1
|
Chaves RCDF, Barbas CSV, Queiroz VNF, Serpa Neto A, Deliberato RO, Pereira AJ, Timenetsky KT, Silva Júnior JM, Takaoka F, de Backer D, Celi LA, Corrêa TD. Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis. Crit Care 2024; 28:289. [PMID: 39217370 PMCID: PMC11366151 DOI: 10.1186/s13054-024-05078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024] Open
Abstract
IMPORTANCE Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes. OBJECTIVE To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients. REGISTRATION The protocol was registered at PROSPERO: CRD42019146781. INFORMATION SOURCES AND SEARCH PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023. STUDY SELECTION AND DATA COLLECTION Prospective and intervention studies were selected. STATISTICAL ANALYSIS Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed. RESULTS A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89). CONCLUSIONS Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.
Collapse
Affiliation(s)
- Renato Carneiro de Freitas Chaves
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Department of Pneumology, Instituto do Coração (INCOR), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- MIT Critical Data, Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Critical Care Medicine and Anesthesiology, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701, 5° Floor, São Paulo, SP, 05651-901, Brazil.
| | - Carmen Silvia Valente Barbas
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Department of Pneumology, Instituto do Coração (INCOR), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Veronica Neves Fialho Queiroz
- Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Department of Anesthesiology, Takaoka Anestesia, São Paulo, SP, Brazil
| | - Ary Serpa Neto
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, VIC, Australia
- Department of Intensive Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - Rodrigo Octavio Deliberato
- MIT Critical Data, Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Translational Health Intelligence and Knowledge Lab, Department of Biostatistics, Health Informatics and Data Science, University of Cincinnati, Cincinnati, OH, USA
- Division of Biomedical Informatics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Adriano José Pereira
- Department of Intensive Care, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | | - Flávio Takaoka
- Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Department of Anesthesiology, Takaoka Anestesia, São Paulo, SP, Brazil
| | - Daniel de Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Leo Anthony Celi
- MIT Critical Data, Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | |
Collapse
|
2
|
Swathy AS, Jafra A, Bhardwaj N, Kanojia RP, Bawa M. Goal-directed fluid therapy guided by plethysmographic variability index versus conventional liberal fluid therapy in neonates undergoing abdominal surgery: A prospective randomized controlled trial. Paediatr Anaesth 2024; 34:559-567. [PMID: 38348932 DOI: 10.1111/pan.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 01/27/2024] [Accepted: 02/01/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Intraoperative fluid therapy maintains normovolemia, normal tissue perfusion, normal metabolic function, normal electrolytes, and acid-base status. Plethysmographic variability index has been shown to predict fluid responsiveness but its role in guiding intraoperative fluid therapy is still elusive. AIMS The aim of the present study was to compare intraoperative goal-directed fluid therapy based on plethysmographic variability index with liberal fluid therapy in term neonates undergoing abdominal surgeries. METHODS A prospective randomized controlled study was conducted in a tertiary care centre, over a period of 18 months. A total of 30 neonates completed the study out of 132 neonates screened. Neonates with tracheoesophageal fistula, congenital diaphragmatic hernia, congenital heart disease, respiratory disorders, creatinine clearance <90 mL/min and who were hemodynamically unstable were excluded. Neonates were randomized to goal-directed fluid therapy group where the plethysmographic variability index was targeted at <18 or liberal fluid therapy group. Primary outcome was comparison of total amount of fluid infused intraoperatively in both the groups. Secondary outcomes included intraoperative and postoperative arterial blood gas parameters, biochemical parameters, use of vasopressors, number of fluid boluses, complications and duration of hospital stay. RESULTS There was no significant difference in total intraoperative fluid infused [90 (84-117.5 mL) in goal-directed fluid therapy and 105 (85.5-144.5 mL) in liberal fluid therapy group (p = .406)], median difference (95% CI) -15 (-49.1 to 19.1). There was a decrease in serum lactate levels in both groups from preoperative to postoperative 24 h. The amount of fluid infused before dopamine administration was significantly higher in liberal fluid therapy group (58 [50.25-65 mL]) compared to goal-directed fluid therapy group (36 [22-44 mL], p = .008), median difference (95% CI) -22 (-46 to 2). In postoperative period, the total amount of fluid intake over 24 h was comparable in two groups (222 [204-253 mL] in goal-directed fluid therapy group and 224 [179.5-289.5 mL] in liberal fluid therapy group, p = .917) median difference (95% CI) cutoff -2 (-65.3 to 61.2). CONCLUSION Intraoperative plethysmographic variability index-guided goal-directed fluid therapy was comparable to liberal fluid therapy in terms of total volume of fluid infused in neonates during perioperative period. More randomized controlled trials with higher sample size are required. TRIAL REGISTRATION Central Trial Registry of India (CTRI/2020/02/023561).
Collapse
Affiliation(s)
- A S Swathy
- Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neerja Bhardwaj
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi P Kanojia
- Department of Pediatric surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Monika Bawa
- Department of Pediatric surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
3
|
Baucom MR, Wallen TE, Price AD, Caskey C, Schuster RM, Smith MP, Blakeman TC, Strilka R, Goodman MD. Validation of Preload Assessment Technologies at Altitude in a Porcine Model of Hemorrhage. J Surg Res 2024; 295:631-640. [PMID: 38101109 DOI: 10.1016/j.jss.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Dynamic preload assessment measures including pulse pressure variation (PPV), stroke volume variation (SVV), pleth variability index (PVI), and hypotension prediction index (HPI) have been utilized clinically to guide fluid management decisions in critically ill patients. These values aid in the balance of correcting hypotension while avoiding over-resuscitation leading to respiratory failure and increased mortality. However, these measures have not been previously validated at altitude or in those with temporary abdominal closure (TAC). METHODS Forty-eight female swine (39 ± 2 kg) were separated into eight groups (n = 6) including all combinations of flight versus ground, hemorrhage versus no hemorrhage, and TAC versus no TAC. Flight animals underwent simulated aeromedical evacuation via an altitude chamber at 8000 ft. Hemorrhagic shock was induced via stepwise hemorrhage removing 10% blood volume in 15-min increments to a total blood loss of 40% or a mean arterial pressure of 35 mmHg. Animals were then stepwise transfused with citrated shed blood with 10% volume every 15 min back to full blood volume. PPV, SVV, PVI, and HPI were monitored every 15 min throughout the simulated aeromedical evacuation or ground control. Blood samples were collected and analyzed for serum levels of serum IL-1β, IL-6, IL-8, and TNF-α. RESULTS Hemorrhage groups demonstrated significant increases in PPV, SVV, PVI, and HPI at each step compared to nonhemorrhage groups. Flight increased PPV (P = 0.004) and SVV (P = 0.003) in hemorrhaged animals. TAC at ground level increased PPV (P < 0.0001), SVV (P = 0.0003), and PVI (P < 0.0001). When TAC was present during flight, PPV (P = 0.004), SVV (P = 0.003), and PVI (P < 0.0001) values were decreased suggesting a dependent effect between altitude and TAC. There were no significant differences in serum IL-1β, IL-6, IL-8, or TNF-α concentration between injury groups. CONCLUSIONS Based on our study, PPV and SVV are increased during flight and in the presence of TAC. Pleth variability index is slightly increased with TAC at ground level. Hypotension prediction index demonstrated no significant changes regardless of altitude or TAC status, however this measure was less reliable once the resuscitation phase was initiated. Pleth variability index may be the most useful predictor of preload during aeromedical evacuation as it is a noninvasive modality.
Collapse
Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Chelsea Caskey
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Maia P Smith
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Richard Strilka
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | |
Collapse
|
4
|
Mallat J, Lemyze M, Fischer MO. Passive leg raising test induced changes in plethysmographic variability index to assess fluid responsiveness in critically ill mechanically ventilated patients with acute circulatory failure. J Crit Care 2024; 79:154449. [PMID: 37857068 DOI: 10.1016/j.jcrc.2023.154449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/20/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Passive leg raising (PLR) reliably predicts fluid responsiveness but requires a real-time cardiac index (CI) measurement or the presence of an invasive arterial line to achieve this effect. The plethysmographic variability index (PVI), an automatic measurement of the respiratory variation of the perfusion index, is non-invasive and continuously displayed on the pulse oximeter device. We tested whether PLR-induced changes in PVI (ΔPVIPLR) could accurately predict fluid responsiveness in mechanically ventilated patients with acute circulatory failure. METHODS This was a secondary analysis of an observational prospective study. We included 29 mechanically ventilated patients with acute circulatory failure in this study. We measured PVI (Radical-7 device; Masimo Corp., Irvine, CA) and CI (Echocardiography) before and during a PLR test and before and after volume expansion of 500 mL of crystalloid solution. A volume expansion-induced increase in CI of >15% defined fluid responsiveness. To investigate whether ΔPVIPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and gray zones for ΔPVIPLR. RESULTS Of the 29 patients, 27 (93.1%) received norepinephrine. The median tidal volume was 7.0 [IQR: 6.6-7.6] mL/kg ideal body weight. Nineteen patients (65.5%) were classified as fluid responders (increase in CI > 15% after volume expansion). Relative ΔPVIPLR accurately predicted fluid responsiveness with an AUROC of 0.89 (95%CI: 0.72-0.98, p < 0.001). A decrease in PVI ≤ -24.1% induced by PLR detected fluid responsiveness with a sensitivity of 95% (95%CI: 74-100%) and a specificity of 80% (95%CI: 44-97%). Gray zone was acceptable, including 13.8% of patients. The correlations between the relative ΔPVIPLR and changes in CI induced by PLR and by volume expansion were significant (r = -0.58, p < 0.001, and r = -0.65, p < 0.001; respectively). CONCLUSIONS In sedated and mechanically ventilated ICU patients with acute circulatory failure, PLR-induced changes in PVI accurately predict fluid responsiveness with an acceptable gray zone. TRIAL REGISTRATION ClinicalTrials.govNCT03225378.
Collapse
Affiliation(s)
- Jihad Mallat
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Malcolm Lemyze
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France
| | - Marc-Olivier Fischer
- Institut Aquitain du Cœur, Clinique Saint Augustin, ELSAN, 114 Avenue d'Arès, 33 074 Bordeaux Cedex, France
| |
Collapse
|
5
|
Dey A, Bidkar PU, Swaminathan S, M MK, Joy JJ, Balasubramanian M, Bhimsaria S. Comparison of two techniques of goal directed fluid therapy in elective neurosurgical patients - a randomized controlled study. Br J Neurosurg 2023:1-9. [PMID: 36734344 DOI: 10.1080/02688697.2023.2173722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/06/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Goal directed fluid therapy (GDFT) may be a rational approach to adopt in neurosurgical patients, in whom intravascular volume optimization is of utmost importance. Most of the parameters used to guide GDFT are derived invasively. We postulated that the total volume of intraoperative intravenous fluid administered during elective craniotomy for supratentorial brain tumours would be comparable between two groups receiving GDFT guided either by the non-invasively derived plethysmography variability index (PVI) or by stroke volume variation (SVV). METHODS 60 ASA category 1, 2 and 3 patients between 18 and 70 years of age were randomized to receive intraoperative fluid guided either by SVV (SVV group; n = 31) or PVI (PVI group; n = 29). The total volume of fluid administered intraoperatively was recorded. Serum creatinine was measured before the surgery, at the end of the surgery, 24 h after surgery and on the fifth post-operative day. Arterial cannulation was performed before induction in all patients. Serum lactate was measured before induction, once in 2 h intraoperatively, at the end of the surgery and 24 h after the surgery. Brain relaxation score was assessed by the surgeon during dural opening and dural closure. Patients were followed up till discharge or death. The duration of mechanical ventilation and the duration of hospital stay was noted for all patients. RESULTS The volume of fluid given intraoperatively was significantly higher in the SVV group (p = 0.005). The two groups were comparable with respect to serum lactate and serum creatinine measured at pre-determined time intervals. Brain relaxation score was also comparable between the groups. SVV and PVI displayed moderate to strong correlation intraoperatively. The duration of mechanical ventilation and the length of the hospital stay were comparable between the two groups. CONCLUSIONS PVI and SVV are equally effective in guiding GDFT in adults undergoing elective craniotomy for supratentorial brain tumours.
Collapse
Affiliation(s)
- Ankita Dey
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bathinda, India
| | | | | | | | - Jerry Jame Joy
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
| | | | - Sakshi Bhimsaria
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
| |
Collapse
|
6
|
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: 25] [Impact Index Per Article: 12.5] [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.
Collapse
|
7
|
Bhimsaria SK, Bidkar PU, Dey A, Swaminathan S, Joy JJ, T H, Balasubramanian M, Siva P. Clinical utility of ultrasonography, pulse oximetry and arterial line derived hemodynamic parameters for predicting post-induction hypotension in patients undergoing elective craniotomy for excision of brain tumors - A prospective observational study. Heliyon 2022; 8:e11208. [DOI: 10.1016/j.heliyon.2022.e11208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/13/2022] [Accepted: 10/18/2022] [Indexed: 11/28/2022] Open
|
8
|
Ozyurt E. Pleth variability index measured in the sitting position before anesthesia can predict spinal anesthesia-induced hypotension in cesarean section: An observational study. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_97_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
9
|
Sagiroglu G, Baysal A, Karamustafaoglu YA. The use of oxygen reserve index in one-lung ventilation and its impact on peripheral oxygen saturation, perfusion index and, pleth variability index. BMC Anesthesiol 2021; 21:319. [PMID: 34930139 PMCID: PMC8685494 DOI: 10.1186/s12871-021-01539-8] [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: 10/18/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Background Our goal is to investigate the use of the oxygen reserve index (ORi) to detect hypoxemia and its relation with parameters such as; peripheral oxygen saturation, perfusion index (PI), and pleth variability index (PVI) during one-lung ventilation (OLV). Methods Fifty patients undergoing general anesthesia and OLV for elective thoracic surgeries were enrolled in an observational cohort study in a tertiary care teaching hospital. All patients required OLV after a left-sided double-lumen tube insertion during intubation. The definition of hypoxemia during OLV is a peripheral oxygen saturation (SpO2) value of less than 95%, while the inspired oxygen fraction (FiO2) is higher than 50% on a pulse oximetry device. ORi, pulse oximetry, PI, and PVI values were measured continuously. Sensitivity, specificity, positive and negative predictive values, likelihood ratios, and accuracy were calculated for ORi values equal to zero in different time points during surgery to predict hypoxemia. At Clinicaltrials.gov registry, the Registration ID is NCT05050552. Results Hypoxemia was observed in 19 patients (38%). The accuracy for predicting hypoxemia during anesthesia induction at ORi value equals zero at 5 min after intubation in the supine position (DS5) showed a sensitivity of 92.3% (95% CI 84.9–99.6), specificity of 81.1% (95% CI 70.2–91.9), and an accuracy of 84.0% (95% CI 73.8–94.2). For predicting hypoxemia, ORi equals zero show good sensitivity, specificity, and statistical accuracy values for time points of DS5 until OLV30 where the sensitivity of 43.8%, specificity of 64%, and an accuracy of 56.1% were recorded. ORi and SpO2 correlation was found at DS5, 5 min after lateral position with two-lung ventilation (DL5) and at 10 min after OLV (OLV10) (p = 0.044, p = 0.039, p = 0.011, respectively). Time-dependent correlations also showed that; at a time point of DS5, ORi has a significant negative correlation with PI whereas, no correlations with PVI were noted. Conclusions During the use of OLV for thoracic surgeries, from 5 min after intubation (DS5) up to 30 min after the start of OLV, ORi provides valuable information in predicting hypoxemia defined as SpO2 less than 95% on pulse oximeter at FiO2 higher than 50%.
Collapse
Affiliation(s)
- Gonul Sagiroglu
- Department of Anesthesiology and Reanimation, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Ayse Baysal
- Pendik District Hospital, Clinic of Anesthesiology and Reanimation, Pendik, 34980, Istanbul, Turkey.
| | | |
Collapse
|
10
|
Ramsingh D, Staab J, Flynn B. Application of perioperative hemodynamics today and potentials for tomorrow. Best Pract Res Clin Anaesthesiol 2021; 35:551-564. [PMID: 34801217 DOI: 10.1016/j.bpa.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Hemodynamic (HD) monitoring remains integral to the assessment and management of perioperative and critical care patients. This review article seeks to provide an update on the different types of flow-guided HD monitoring technologies available, highlight their limitations, and review the therapies associated with the application of these technologies. Additionally, we will also comment on the expanding roles of HD monitoring in the future.
Collapse
Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology Loma Linda University Medical Center, Loma Linda, CA, USA; VP for Clinical and Medical Affairs, Edwards Lifesciences Critical Care Division, USA.
| | - Jared Staab
- Director of Perioperative Ultrasound, Program Director Critical Care Anesthesiology Fellowship, Department of Anesthesiology, University of Kansas Medical Center, USA.
| | - Brigid Flynn
- Chief, Division of Critical Care, Co-Director Cardiothoracic ICUChair Anesthesia Research Committee, Department of Anesthesiology, University of Kansas Medical, USA.
| |
Collapse
|
11
|
Song LL, Geng ZY, Ma W, Liu YF, Wang DX. Dynamic variables predict fluid responsiveness in pre-school and school children undergoing neurosurgery: a prospective observational study. Transl Pediatr 2021; 10:2972-2984. [PMID: 34976763 PMCID: PMC8649593 DOI: 10.21037/tp-21-281] [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: 06/17/2021] [Accepted: 08/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The evidence that plethysmographic variability index (PVI), pulse pressure variation (PPV), FloTrac/Vigileo-derived stroke volume variation (SVV), and Eadyn (dynamic arterial elastance) predict fluid responsiveness in children is limited by conflicting results. We aim to evaluate their accuracy and reliability to predict fluid responsiveness after induction in children aged 4-9 years undergoing major neurosurgery. METHODS Children aged 4-9 years undergoing intracranial epileptic foci excision were enrolled. After the induction of anesthesia, fluid loading with 10 mL/kg of Ringer's solution over 10 min was administered before surgical incision. PVI, PPV, SVV, and Eadyn were measured before and within 5 min after fluid loading. Respiratory variation in aortic blood flow peak velocity (∆Vpeak) >15% at baseline, measured using transthoracic echocardiography, identified fluid "responders". The abilities of dynamic variables to predict an increase in mean arterial pressure (MAP) of >10% following fluid loading were also assessed. RESULTS Fourteen (31.8%) of forty-four patients were responders defined by a baseline ∆Vpeak >15%. Before fluid loading, only the PVI value was significantly different between R and NR (P=0.017). Baseline PVI showed fair diagnostic accuracy for fluid responsiveness, with an area under the curve (AUROC) of 0.735 and the cutoff value of 13%. The R group showed a significantly greater absolute change in PPV and SVV after fluid loading from baseline compared with the NR group (P=0.021 and 0.040, respectively). The absolute change in the PPV and SVV values from baseline was greater in R than those in NR (P=0.021 and 0.040, respectively). Twenty (45.5%) showed a MAP increase of >10% following fluid loading and were defined as responders. Baseline ∆Vpeak and SVV showed fair predictive values for a MAP increase of >10% (AUROC =0.758 and 0.715, respectively). CONCLUSIONS PVI at baseline showed fair reliability to predict fluid responsiveness after anesthesia induction in mechanically ventilated children aged 4-9 years undergoing neurosurgery. Baseline ∆Vpeak and SVV were fairly predictive for an increase in MAP following fluid loading.
Collapse
Affiliation(s)
- Lin-Lin Song
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Zhi-Yu Geng
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Ya-Fei Liu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| |
Collapse
|
12
|
Ravi C, Johnson DW. Optimizing Fluid Resuscitation and Preventing Fluid Overload in Patients with Septic Shock. Semin Respir Crit Care Med 2021; 42:698-705. [PMID: 34544187 DOI: 10.1055/s-0041-1733898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravenous fluid administration remains an important component in the care of patients with septic shock. A common error in the treatment of septic shock is the use of excessive fluid in an effort to overcome both hypovolemia and vasoplegia. While fluids are necessary to help correct the intravascular depletion, vasopressors should be concomitantly administered to address vasoplegia. Excessive fluid administration is associated with worse outcomes in septic shock, so great care should be taken when deciding how much fluid to give these vulnerable patients. Simple or strict "recipes" which mandate an exact amount of fluid to administer, even when weight based, are not associated with better outcomes and therefore should be avoided. Determining the correct amount of fluid requires the clinician to repeatedly assess and consider multiple variables, including the fluid deficit, organ dysfunction, tolerance of additional fluid, and overall trajectory of the shock state. Dynamic indices, often involving the interaction between the cardiovascular and respiratory systems, appear to be superior to traditional static indices such as central venous pressure for assessing fluid responsiveness. Point-of-care ultrasound offers the bedside clinician a multitude of applications which are useful in determining fluid administration in septic shock. In summary, prevention of fluid overload in septic shock patients is extremely important, and requires the careful attention of the entire critical care team.
Collapse
Affiliation(s)
- Chandni Ravi
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Daniel W Johnson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| |
Collapse
|
13
|
García-de-Acilu M, Pacheco A, Santafé M, Ramos FJ, Ruiz-Rodríguez JC, Ferrer R, Roca O. Pleth variability index may predict preload responsiveness in patients treated with nasal high flow: a physiological study. J Appl Physiol (1985) 2021; 130:1660-1667. [PMID: 33856256 DOI: 10.1152/japplphysiol.00614.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to determine whether the plethysmographic variability index ("PVi") can predict preload responsiveness in patients with nasal high flow (NHF) (≥30 L/min) with any sign of hypoperfusion. "Preload responsiveness" was defined as a ≥10% increase in stroke volume (SV), measured by transthoracic echocardiography, after passive leg raising. SV and PVi were reassessed in preload responders after receiving a 250-mL fluid challenge. Twenty patients were included and 12 patients (60%) were preload responders. Responders showed higher baseline mean PVi (24% vs. 13%; P = 0.001) and higher mean PVi variation (ΔPVi) after passive leg raising (6.8% vs. -1.7%; P < 0.001). No differences between mean ΔPVi after passive leg raising and mean ΔPVi after fluid challenge were observed (6.8% vs. 7.4%; P = 0.24); and both values were strongly correlated (r = 0.84; P < 0.001). Baseline PVi and ΔPVi after passive leg raising showed excellent diagnostic accuracy identifying preload responders (AUROC 0.92 and 1.00, respectively). Baseline PVi ≥ 16% had a sensitivity of 91.7% and a specificity of 87.5% for detecting preload responders. Similarly, ΔPVi after passive leg raising ≥2% had a 100% of both sensitivity and specificity. Thus, PVi might predict "preload responsiveness" in patients treated with NHF, suggesting that it may guide fluid administration in these patients.NEW & NOTEWORTHY This is the first study that analyzes the use of noninvasive plethysmographic variability index (PVi) for preload assessment in patients treated with nasal high flow (NHF). Its results showed that PVi might identify preload responders. Therefore, PVi may be used in the day-to-day clinical decision-making process in critically ill patients treated with NHF, helping to provide adequate resuscitation volume.
Collapse
Affiliation(s)
- Marina García-de-Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Andrés Pacheco
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Manel Santafé
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Francisco-Javier Ramos
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Juan C Ruiz-Rodríguez
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Ricard Ferrer
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
14
|
Yüksek A. Utility of the Pleth Variability Index in predicting anesthesia-induced hypotension in geriatric patients. Turk J Med Sci 2021; 51:134-139. [PMID: 32892541 PMCID: PMC7991892 DOI: 10.3906/sag-1912-132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 08/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background/aim Anesthesia-induced hypotension may have negative consequences in geriatric patients. Therefore, predicting hypotension remains an important topic for anesthesiologists. Pleth Variability Index (PVI) measurement provides information about the fluid status and vascular tonus of patients. In this study, the ability of the Pleth Variability Index to predict hypotension after general anesthesia induction was evaluated. Materials and methods PVI values obtained from pulse oximetry were recorded, in addition to preoperative standard anesthesia monitoring. The correlation between the PVI value and mean arterial pressure (MAP), systolic arterial blood pressure (SAP) changes, and the power of PVI values to predict the incidence of hypotension after anesthesia induction (>20% MAP decrease) was tested. Results Eighty patients over 65 years of age who were operated under general anesthesia were included in the study. Hypotension was observed in 20 patients (25%). PVI values were mild and positively correlated with MAP changes (r = 0.195 and P = 0.041). According to receiver operating characteristic (ROC) analysis, the incidence of hypotension increased in patients with PVI values above 15.45%. We also found the following diagnostic results for PVI value for predicting hypotension: P = 0.044 and area under the ROC curve of 0.651 ± 0.073 (95% confidence interval (CI): 0.507–0.794), 40% sensitivity, 80% specificity, a PPV of 40%, an NPV of 80%, a cut-off value of 15.45, a positive likelihood ratio of 2, a negative likelihood ratio of 0.75, and a Youden Index of 0.2. Conclusion Predicting hypotension in geriatric patients is an important issue for anesthesiologists. As an easily applicable test, the Pleth Variability Index is useful in predicting MAP reduction in patients. This practical technique can be used routinely in all geriatric patient groups.
Collapse
Affiliation(s)
- Ahmet Yüksek
- Department of Anesthesiology and Reanimation, Bozok University, Yozgat, Turkey
| |
Collapse
|
15
|
Emektar E, Dagar S, Uzunosmanoğlu H, Çıkrıkçı Işık G, Çorbacıoğlu ŞK, Çevik Y. The role of perfusion index and plethysmography variability index for predicting dehydration severity in patients with acute gastroenteritis. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919889488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Acute gastroenteritis is a clinical syndrome that may cause severe dehydration in affected individuals and a reason of mortality and morbidity in all age groups. Measurement of perfusion index and plethysmography variability index may provide emergency physicians valuable information about hemodynamics of the patient. Objectives: Our study aimed to investigate the role of perfusion index and plethysmography variability index measurement at admission for estimating dehydration severity and determiningthe possible change in those parameters after fluid replacement among patients presenting to emergency department with acute gastroenteritis. Methods: This was a prospective cross-sectional study. Patients diagnosed with acute gastroenteritis at the emergency department were consecutively enrolled. The two groups were defined according to the severity of dehydration: mild and moderate/severe dehydration groups. The values of perfusion index and plethysmography variability index of all patients were measured. Results: A total of 180 patients were included in the study. As compared with the mild dehydration group, moderate/severe dehydration group had a significantly lower perfusion index value and significantly higher plethysmography variability index value on admission (p < 0.001 for both comparisons). Among moderate/severe dehydration patients, perfusion index value significantly increased and plethysmography variability index significantly decreased after treatment (p < 0.001). There was a significant positive correlation between osmolarity and plethysmography variability index (r = 0.298; p = 0.007) and a significant negative correlation between osmolality and perfusion index (r = −0.259; p = 0.019) in the patients with moderate/severe dehydration. Conclusion: The study show that perfusion index and plethysmography variability index may be useful for determining the severity of dehydration in acute gastroenteritis and may be use for assessing the response to fluid replacement especially in patients with severe dehydration at emergency department.
Collapse
Affiliation(s)
- Emine Emektar
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Seda Dagar
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Hüseyin Uzunosmanoğlu
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Gülşah Çıkrıkçı Işık
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | | | - Yunsur Çevik
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
16
|
Pena-Hernandez C, Nugent K. One approach to circulation and blood flow in the critical care unit. World J Crit Care Med 2019; 8:36-48. [PMID: 31667132 PMCID: PMC6817932 DOI: 10.5492/wjccm.v8.i4.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/24/2019] [Accepted: 06/12/2019] [Indexed: 02/06/2023] Open
Abstract
Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine. Understanding the applicability of some of the basic but, at the same time, complex physiological processes occurring during a state of illness is sometimes neglected and/or presented to the practitioners as point-of-care protocols to follow. Furthermore, managing hemodynamic shock has shown us that the human body is designed to fight to sustain life and that the compensatory mechanisms within organ systems are extraordinary. In this review article, we have created a minimalistic guide to the clinical information relevant when assessing critically ill patients with failing circulation. Measures such as organ blood flow, circulating volume, and hemodynamic biomarkers of shock are described. In addition, we will describe historical scientific events that led to some of our current medical practices and its validation for clinical decision making, and we present clinical advice for patient care and medical training.
Collapse
Affiliation(s)
- Camilo Pena-Hernandez
- Department of Internal Medicine, Division of Nephrology and Hypertension, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| | - Kenneth Nugent
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, United States
| |
Collapse
|
17
|
Disturbed fluid responsiveness and lactate/pyruvate ratio as predictors for mortality of septic shock patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
|
18
|
Liu T, Xu C, Wang M, Niu Z, Qi D. Reliability of pleth variability index in predicting preload responsiveness of mechanically ventilated patients under various conditions: a systematic review and meta-analysis. BMC Anesthesiol 2019; 19:67. [PMID: 31068139 PMCID: PMC6507157 DOI: 10.1186/s12871-019-0744-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022] Open
Abstract
Background Goal-directed volume expansion is increasingly used for fluid management in mechanically ventilated patients. The Pleth Variability Index (PVI) has been shown to reliably predict preload responsiveness; however, a lot of research on PVI has been published recently, and update of the meta-analysis needs to be completed. Methods We searched PUBMED, EMBASE, Cochrane Library, Web of Science (updated to November 7, 2018) and the associated references. Relevant authors and researchers had been contacted for complete data. Results Twenty-five studies with 975 mechanically ventilated patients were included in this meta-analysis. The area under the curve (AUC) of receiver operating characteristics (ROC) to predict preload responsiveness was 0.82 (95% confidence interval (CI) 0.79–0.85). The pooled sensitivity was 0.77 (95% CI 0.67–0.85) and the pooled specificity was 0.77 (95% CI 0.71–0.82). The results of subgroup of patients without undergoing surgery (AUC =0.86, Youden index =0.65) and the results of subgroup of patients in ICU (AUC =0.89, Youden index =0.67) were reliable. Conclusion The reliability of the PVI is limited, but the PVI can play an important role in bedside monitoring for mechanically ventilated patients who are not undergoing surgery. Patients who are expanded with colloid may be more suitable for PVI. Electronic supplementary material The online version of this article (10.1186/s12871-019-0744-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tianyu Liu
- Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China.,Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Chao Xu
- Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China.,Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Min Wang
- Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China.,Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Zheng Niu
- Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China.,Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China
| | - Dunyi Qi
- Key Laboratory of Anesthesia and Analgesia, Xuzhou Medical University, Xuzhou, Jangsu, China. .,Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jangsu, China.
| |
Collapse
|
19
|
Bennett VA, Aya HD, Cecconi M. Evaluation of cardiac function using heart-lung interactions. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:356. [PMID: 30370283 DOI: 10.21037/atm.2018.08.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Heart lung interactions can be used clinically to assist in the evaluation of cardiac function. Application of these interactions and understanding of the physiology underlying them has formed a focus of research over a number of years. The changes in preload induced by changes in intrathoracic pressure (ITP) with the respiratory cycle, have been applied to form dynamic tests of fluid responsiveness. Pulse pressure variation (PPV), stroke volume variation (SVV), end expiratory occlusion test, pleth variability index (PVI) and use of echocardiography are all clinical assessments that can be made at the bedside. However, there are limitations and pitfalls to each that restrict their use to specific situations. The haemodynamic response to treatment with continuous positive airway pressure (CPAP) in left ventricular failure is explained by the presence of heart lung interactions, and works predominately through afterload reduction. Similarly, in other disease states such as acute respiratory distress syndrome (ARDS), the effects of a change in ventilation can provide information about both the cardiac and respiratory system. This review aims to summarise how assessment of cardiac function using heart lung interactions can be performed. It introduces the underlying physiology and some of the clinical applications that are further explored in other articles within the series.
Collapse
Affiliation(s)
- Victoria A Bennett
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, Blackshaw Road, London, UK
| | - Hollmann D Aya
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, Blackshaw Road, London, UK
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
20
|
Kim DH, Shin S, Kim JY, Kim SH, Jo M, Choi YS. Pulse pressure variation and pleth variability index as predictors of fluid responsiveness in patients undergoing spinal surgery in the prone position. Ther Clin Risk Manag 2018; 14:1175-1183. [PMID: 30013353 PMCID: PMC6038863 DOI: 10.2147/tcrm.s170395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study investigated the ability of pulse pressure variation (PPV) and pleth variability index (PVI) to predict fluid responsiveness of patients undergoing spinal surgery in the prone position. Patients and methods A total of 53 patients undergoing posterior lumbar spinal fusion in the prone position on a Jackson table were studied. PPV, PVI, and hemodynamic and respiratory variables were measured both before and after the administration of 6 mL/kg colloid in both the supine and prone positions. Fluid responsiveness was defined as a 15% or greater increase in stroke volume index, as assessed by esophageal Doppler monitor after fluid loading. Results In the supine position, 40 patients were responders. The areas under the receiver operating characteristic (ROC) curves for PPV and PVI were 0.783 [95% CI 0.648–0.884, P<0.001] and 0.814 (95% CI 0.684–0.908, P<0.001), respectively. The optimal cut-off values of PPV and PVI were 10% (sensitivity 75%, specificity 62%) and 8% (sensitivity 78%, specificity 77%), respectively. In the prone position, 27 patients were responders. The areas under the ROC curves for PPV and PVI were 0.781 (95% CI 0.646–0.883, P<0.001) and 0.756 (95% CI 0.618–0.863, P<0.001), respectively. The optimal cut-off values of PPV and PVI were 7% (sensitivity 82%, specificity 62%) and 8% (sensitivity 67%, specificity 69%), respectively. Conclusion Both PPV and PVI were able to predict fluid responsiveness; their predictive abilities were maintained in the prone position.
Collapse
Affiliation(s)
- Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Minju Jo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| |
Collapse
|
21
|
Sano H, Seo J, Wightman P, Cave NJ, Gieseg MA, Johnson CB, Chambers P. Evaluation of pulse pressure variation and pleth variability index to predict fluid responsiveness in mechanically ventilated isoflurane-anesthetized dogs. J Vet Emerg Crit Care (San Antonio) 2018; 28:301-309. [PMID: 29898246 DOI: 10.1111/vec.12728] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/29/2016] [Accepted: 08/19/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether pulse pressure variation (PPV) and pleth variability index (PVI) are more accurate than central venous pressure (CVP) for predicting fluid responsiveness in mechanically ventilated isoflurane-anesthetized dogs after premedication with acepromazine. DESIGN Prospective experimental trial. SETTING University teaching hospital. ANIMALS Twelve Harrier hound dogs. INTERVENTIONS Each dog was anesthetized and had a fluid challenge performed. This was repeated 4 weeks later for a total of 24 fluid challenges. After premedication with intramuscular acepromazine, anesthesia was induced with propofol and maintained with isoflurane. The dogs were mechanically ventilated with constant settings. The fluid challenge consisted of 10 mL/kg of 6% hydroxyethyl starch intravenously over 13 minutes. MEASUREMENTS AND MAIN RESULTS Before and after the fluid challenge, PPV, PVI, CVP, and other hemodynamics were recorded. Change in velocity time integral of pulmonary arterial blood flow by echocardiography was calculated as an indication of change in stroke volume. A fluid responder was defined as an increase in velocity time integral ≥ 15%. Receiver operator characteristic (ROC) curves were used to determine cutoff values. Areas under ROC curve were calculated and compared. Dogs responded on 14 fluid challenges and did not on 10. Cutoff values for PPV and PVI were 11% (sensitivity 79%; specificity 80%) and 9.3% (sensitivity 86%; specificity 70%), respectively. The areas under the ROC curve of PPV [0.85, 95% confidence interval (CI): 0.70-1.00, P = 0.038] and PVI (0.84, 95% CI: 0.68-1.00, P = 0.043) were significantly higher than CVP (0.56, 95% CI: 0.32-0.81). CONCLUSIONS PPV and PVI predicted fluid responsiveness more accurately than CVP and may be useful to guide fluid administration in mechanically ventilated isoflurane-anesthetized dogs after premedication with acepromazine.
Collapse
Affiliation(s)
- Hiroki Sano
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| | - Joonbum Seo
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| | - Paul Wightman
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| | - Nick J Cave
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| | - Mike A Gieseg
- Veterinary Health Research NZ, Hamilton 3240, New Zealand
| | - Craig B Johnson
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| | - Paul Chambers
- Institute of Veterinary, Animal and Biomedical Sciences, College of Sciences, Massey University, Palmerston North 4442
| |
Collapse
|
22
|
Le Guen M, Follin A, Gayat E, Fischler M. The plethysmographic variability index does not predict fluid responsiveness estimated by esophageal Doppler during kidney transplantation: A controlled study. Medicine (Baltimore) 2018; 97:e10723. [PMID: 29768341 PMCID: PMC5976303 DOI: 10.1097/md.0000000000010723] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Research is ongoing to find a noninvasive method of monitoring, which can predict fluid responsiveness in patients undergoing kidney transplantation.To compare the responses to fluid challenges with the Pleth Variability Index, a noninvasive dynamic index derived from plethysmographic variability (Radical 7 pulse oximeter; Masimo Corporation, Irvine, CA), and the esophageal Doppler, the criterion standard.Observational study.University hospital; study from May 2011 and May 2012.Forty-eight patients with end-renal function were included and 44 analyzed. Patients with cardiac failure were not eligible.Fluid challenges were administered during maintenance of general anesthesia but before skin incision and repeated if the patient was deemed to be a "responder" (increase in stroke volume ≥10%).The primary endpoint was to assess if the Pleth Variability Index is an accurate predictor of fluid responsiveness.Among 76 fluid challenges, 38 were considered as positive (increase in stroke volume measured by Doppler ≥10%). Pleth Variability Index was similar at baseline between responders and nonresponder patients. Fluid challenges were associated with a significant decrease in Pleth Variability Index in overall cases (12 [8-14] vs 10 [6-17], P = .050), but it was not able to discriminate between responders (12 [8-15] vs 10 [5-15], P = .650) and nonresponders (11 [6-16] vs 8 [5-14], P = .047). The area under the Receiver Operating Characteristic curve for Pleth Variability Index was 0.49 (0.36-0.62).Pleth Variability Index is not an accurate predictor of fluid responsiveness during kidney transplantation.
Collapse
Affiliation(s)
- Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
| | - Arnaud Follin
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière-Fernand Widal
- UMR-S 942, INSERM, University Paris 7 Diderot, Paris, France
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch
- Université Versailles Saint-Quentin en Yvelines, Suresnes
| |
Collapse
|
23
|
Esmolol hypotension maintains tissue perfusion during myomectomy judged by Masimo monitoring of regional cerebral oxygen saturation and pleth variability index. EGYPTIAN JOURNAL OF ANAESTHESIA 2018. [DOI: 10.1016/j.egja.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
24
|
Roederer A, Weimer J, DiMartino J, Gutsche J. Robust monitoring of hypovolemia in intensive care patients using photoplethysmogram signals. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2015:1504-7. [PMID: 26736556 DOI: 10.1109/embc.2015.7318656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The paper presents a fingertip photoplethysmography based technique to assess patient fluid status that is robust to waveform artifacts and health variability in the underlying patient population. The technique is intended for use in intensive care units, where patients are at risk for hypovolemia, and signal artifacts and inter-patient variations in health are common. Input signals are preprocessed to remove artifact, then a parameter-invariant statistic is calculated to remove effects of patient-specific physiology. Patient data from the Physionet MIMICII database was used to evaluate the performance of this technique. The proposed method was able to detect hypovolemia within 24 hours of onset in all hypovolemic patients tested, while producing minimal false alarms over non-hypovolemic patients.
Collapse
|
25
|
Kuwata S, Suehiro K, Juri T, Tsujimoto S, Mukai A, Tanaka K, Yamada T, Mori T, Nishikawa K. Pleth variability index can predict spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. Acta Anaesthesiol Scand 2018; 62:75-84. [PMID: 29034983 DOI: 10.1111/aas.13012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery. METHODS Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed. RESULTS Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597-0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655-0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570-0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041). CONCLUSIONS Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension.
Collapse
Affiliation(s)
- S. Kuwata
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - K. Suehiro
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - T. Juri
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - S. Tsujimoto
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - A. Mukai
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - K. Tanaka
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - T. Yamada
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - T. Mori
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - K. Nishikawa
- Department of Anaesthesiology; Osaka City University Graduate School of Medicine; Osaka Japan
| |
Collapse
|
26
|
Pişkin Ö, Öz İİ. Accuracy of pleth variability index compared with inferior vena cava diameter to predict fluid responsiveness in mechanically ventilated patients. Medicine (Baltimore) 2017; 96:e8889. [PMID: 29382017 PMCID: PMC5709016 DOI: 10.1097/md.0000000000008889] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In the intensive care unit (ICU), stable hemodynamics are very important. Hemodynamic intervention is often effective against multiple organ failure, such as in tissue hypoxia and shock. The administration of intravenous fluids is the first step in regulating tissue perfusion.The main objective of this study is to compare the performance between 2 methods namely pleth variability index (PVI) and IVC distensibily index (dIVC).In this study, the hemodynamic measurements were performed before and after passive leg raising (PLR). Measurements were obtained, including, PVI, dIVC, and cardiac index (CI). Both CI and dIVC measurements were evaluated by transesophageal probe and convex probe respectively. The dIVC measurements were taken using M-mode, 2 cm from junction between the right atrium and the inferior vena cava. The PVI was measured by Masimo Radical-7 monitor, Masimo.A total of 72 patients were included. The dIVC at a threshold value of >23.8% provided 80% sensitivity and 87.5% specificity to predict fluid responsiveness and was statistically significant (P < .001), with an AUC 0.928 (0.842-0.975). The PVI at a threshold value of >14% provided 95% sensitivity and 81.2% specificity to predict fluid responsiveness and was statistically significant (P < .001), with an AUC 0.939 (0.857-0.982).Both PVI and dIVC can be used as a noninvasive method that can be easily applied at the bedside in determining fluid responsiveness in all patients with mechanical ventilation in intensive care.
Collapse
Affiliation(s)
| | - İbrahim İlker Öz
- Department of Radiology, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| |
Collapse
|
27
|
|
28
|
den Boogert WJ, van Elteren HA, Goos TG, Reiss IKM, de Jonge RCJ, van den Berg VJ. Reproducibility of the Pleth Variability Index in premature infants. J Clin Monit Comput 2017; 32:457-464. [PMID: 28861669 PMCID: PMC5943392 DOI: 10.1007/s10877-017-0058-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/23/2017] [Indexed: 11/26/2022]
Abstract
The aim was to assess the reproducibility of the Pleth Variability Index (PVI), developed for non-invasive monitoring of peripheral perfusion, in preterm neonates below 32 weeks of gestational age. Three PVI measurements were consecutively performed in stable, comfortable preterm neonates in the first 48 h of life. On each occasion, pulse oximeter sensors were attached to two different limbs for 5 min. Reproducibility was assessed with the intra-class correlation coefficient (ICC) and Bland–Altman analysis. A total of 25 preterm neonates were included. Inter-limb comparison showed fair to moderate ICC’s with 95%-confidence intervals (95%-CI). Left hand–right hand ICC = 0.498, 95%-CI (0.119–0.753); right foot–right hand ICC = 0.314 (−0.088–0.644); right foot–left foot ICC = 0.315 (−0.089–0.628). Intra-limb comparison showed fair to moderate ICC for right foot–right foot ICC = 0.380 (−0.014–0.677); and good ICC for right hand–right hand ICC = 0.646 (0.194–0.852). Bland–Altman plots showed moderate reproducibility of measurements between different limbs and of the same limb in consecutive time periods, with large biases and wide limits of agreement. The findings from this study indicate that PVI measurement is poorly reproducible when measured on different limbs and on the same limb in stable and comfortable preterm neonates.
Collapse
Affiliation(s)
- Wilhelmina J. den Boogert
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Hugo A. van Elteren
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Tom G. Goos
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
- Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Rogier C. J. de Jonge
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Victor J. van den Berg
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Room Sp-3434, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| |
Collapse
|
29
|
Endo Y, Kawase K, Miyasho T, Sano T, Yamashita K, Muir WW. Plethysmography variability index for prediction of fluid responsiveness during graded haemorrhage and transfusion in sevoflurane-anaesthetized mechanically ventilated dogs. Vet Anaesth Analg 2017; 44:1303-1312. [PMID: 29113716 DOI: 10.1016/j.vaa.2017.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/29/2017] [Accepted: 07/29/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the accuracy of plethysmography variability index (PVI) as a noninvasive indicator of fluid responsiveness in hypovolaemic dogs. STUDY DESIGN Prospective experimental study. ANIMALS Six adult healthy sevoflurane-anaesthetized Beagle dogs. METHODS Dogs were anaesthetized with 1.3-fold their individual minimum alveolar concentration of sevoflurane. The lungs were mechanically ventilated after neuromuscular blockade with vecuronium bromide. Cardiopulmonary variables including mean arterial blood pressure (MAP), central venous pressure (CVP), transpulmonary thermodilution cardiac output (TPTDCO), stroke volume (SV), perfusion index (PI), pulse pressure variation (PPV), stroke volume variation (SVV) and PVI were determined during six stages of graded venous blood withdrawal (5 mL kg-1 increments) and six stages of graded blood infusion (5 mL kg-1 increments). The cardiopulmonary variables were analysed using paired t test or Wilcoxon signed rank test. Correlations between PPV and SVV or PVI were analysed by linear regression. The accuracy of PPV, SVV and PVI for predicting fluid responsiveness was examined by using receiver operating characteristic curve analysis. A value of p < 0.05 was considered statistically significant. RESULTS Blood withdrawal resulted in significant increases in PPV and PVI and decreases in MAP, CVP, TPTDCO, SV and PI. Blood infusion resulted in significant increases in MAP, CVP, TPTDCO, SV and PI and decreases in PPV and PVI. PPV and PVI showed a relevant correlation (p < 0.001, r2 = 0.62) and threshold values of PPV ≥ 16% (sensitivity 71%, specificity 82%) and PVI ≥ 12% (sensitivity 78%, specificity 72%) for identifying fluid responsiveness. SVV did not change. CONCLUSIONS AND CLINICAL RELEVANCE Noninvasive measurement of PVI predicted fluid responsiveness with moderate accuracy equal to PPV in sevoflurane-anaesthetized mechanically ventilated dogs. Provisional threshold values for identification of fluid responsiveness were PPV ≥ 16% and PVI ≥ 12%. Clinical trials are needed to confirm these threshold values in dogs.
Collapse
Affiliation(s)
- Yusuke Endo
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido, Japan
| | - Koudai Kawase
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido, Japan
| | - Taku Miyasho
- Department of Veterinary Nursing Science, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido, Japan
| | - Tadashi Sano
- Department of Veterinary Nursing Science, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido, Japan
| | - Kazuto Yamashita
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido, Japan.
| | - William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, USA
| |
Collapse
|
30
|
Toscani L, Aya HD, Antonakaki D, Bastoni D, Watson X, Arulkumaran N, Rhodes A, Cecconi M. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:207. [PMID: 28774325 PMCID: PMC5543539 DOI: 10.1186/s13054-017-1796-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Background The fluid challenge is considered the gold standard for diagnosis of fluid responsiveness. The objective of this study was to describe the fluid challenge techniques reported in fluid responsiveness studies and to assess the difference in the proportion of ‘responders,’ (PR) depending on the type of fluid, volume, duration of infusion and timing of assessment. Methods Searches of MEDLINE and Embase were performed for studies using the fluid challenge as a test of cardiac preload with a description of the technique, a reported definition of fluid responsiveness and PR. The primary outcome was the mean PR, depending on volume of fluid, type of fluids, rate of infusion and time of assessment. Results A total of 85 studies (3601 patients) were included in the analysis. The PR were 54.4% (95% CI 46.9–62.7) where <500 ml was administered, 57.2% (95% CI 52.9–61.0) where 500 ml was administered and 60.5% (95% CI 35.9–79.2) where >500 ml was administered (p = 0.71). The PR was not affected by type of fluid. The PR was similar among patients administered a fluid challenge for <15 minutes (59.2%, 95% CI 54.2–64.1) and for 15–30 minutes (57.7%, 95% CI 52.4–62.4, p = 1). Where the infusion time was ≥30 minutes, there was a lower PR of 49.9% (95% CI 45.6–54, p = 0.04). Response was assessed at the end of fluid challenge, between 1 and 10 minutes, and >10 minutes after the fluid challenge. The proportions of responders were 53.9%, 57.7% and 52.3%, respectively (p = 0.47). Conclusions The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1796-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Toscani
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cristo Re Hospital, Via delle Calasanziane 25, 00167, Rome, Italy
| | - Hollmann D Aya
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK. .,Anaesthetic Department, East Surrey Hospital, Surrey & Sussex Healthcare Trust, Canada Avenue, Redhill, Surrey, RH1 5 RH, UK.
| | - Dimitra Antonakaki
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cardiology Department, Broomfield Hospital, Mid-Essex Healthcare Trust, Court Road, Broomfield, Chelmsford, CM1 7ET, UK
| | - Davide Bastoni
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Dipartimento di Medicina Sperimentale, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ximena Watson
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Nish Arulkumaran
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Andrew Rhodes
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| |
Collapse
|
31
|
Klein AV, Teixeira-Neto FJ, Garofalo NA, Lagos-Carvajal AP, Diniz MS, Becerra-Velásquez DR. Changes in pulse pressure variation and plethysmographic variability index caused by hypotension-inducing hemorrhage followed by volume replacement in isoflurane-anesthetized dogs. Am J Vet Res 2016; 77:280-7. [PMID: 26919599 DOI: 10.2460/ajvr.77.3.280] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare changes in pulse pressure variation (PPV) and plethysmographic variability index (PVI) induced by hemorrhage followed by volume replacement (VR) in isoflurane-anesthetized dogs. ANIMALS 7 healthy adult dogs. PROCEDURE Each dog was anesthetized with isoflurane and mechanically ventilated. End-tidal isoflurane concentration was adjusted to maintain mean arterial pressure (MAP) at 60 to 70 mm Hg before hemorrhage. Controlled hemorrhage was initiated and continued until the MAP decreased to 40 to 50 mm Hg, then autologous blood removed during hemorrhage was retransfused during VR. Various physiologic variables including PPV and PVI were recorded immediately before (baseline) and after controlled hemorrhage and immediately after VR. RESULTS Mean ± SD PPV and PVI were significantly increased from baseline after hemorrhage (PPV, 20 ± 6%; PVI, 18 ± 4%). After VR, the mean PPV (7 ± 3%) returned to a value similar to baseline, whereas the mean PVI (10 ± 3%) was significantly lower than that at baseline. Cardiac index (CI) and stroke index (SI) were significantly decreased from baseline after hemorrhage (CI, 2.07 ± 0.26 L/min/m(2); SI, 20 ± 3 mL/beat/m(2)) and returned to values similar to baseline after VR (CI, 4.25 ± 0.63 L/min/m(2); SI, 36 ± 6 mL/beat/m(2)). There was a significant positive correlation (r(2) = 0.77) between PPV and PVI after hemorrhage. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that both PPV and PVI may be useful for identification of dogs that respond to VR with increases in SI and CI (ie, dogs in the preload-dependent limb of the Frank-Starling curve).
Collapse
|
32
|
|
33
|
Zhou J, Han Y. Pleth variability index and respiratory system compliance to direct PEEP settings in mechanically ventilated patients, an exploratory study. SPRINGERPLUS 2016; 5:1371. [PMID: 27606159 PMCID: PMC4992479 DOI: 10.1186/s40064-016-3008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 08/05/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To analyze the ability of pleth variability index (PVI) and respiratory system compliance (RSC) on evaluating the hemodynamic and respiratory effects of positive end expiratory pressure (PEEP), then to direct PEEP settings in mechanically ventilated critical patients. METHODS We studied 22 mechanically ventilated critical patients in the intensive care unit. Patients were monitored with classical monitor and a pulse co-oximeter, with pulse sensors attached to patients' index fingers. Hemodynamic data [heart rate (HR), perfusion index (PI), PVI, central venous pressure (CVP), mean arterial pressure (MAP), peripheral blood oxygen saturation (SPO2), peripheral blood oxygen content (SPOC) and peripheral blood hemoglobin (SPHB)] as well as the respiratory data [respiratory rate (RR), tidal volume (VT), RSC and controlled airway pressure] were recorded for 15 min each at 3 different levels of PEEP (0, 5 and 10 cmH2O). RESULTS Different levels of PEEP (0, 5 and 10 cmH2O) had no obvious effect on RR, HR, MAP, SPO2 and SPOC. However, 10 cmH2O PEEP induced significant hemodynamic disturbances, including decreases of PI, and increases of both PVI and CVP. Meanwhile, 5 cmH2O PEEP induced no significant changes on hemodynamics such as CVP, PI and PVI, but improved the RSC. CONCLUSIONS RSC and PVI may be useful in detecting the hemodynamic and respiratory effects of PEEP, thus may help clinicians individualize PEEP settings in mechanically ventilated patients.
Collapse
Affiliation(s)
- Jing Zhou
- Intensive Care Unit, Department of Geriatrics, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029 China
| | - Yi Han
- Intensive Care Unit, Department of Geriatrics, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029 China
| |
Collapse
|
34
|
Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Konur H, Erdogan Kayhan G, Toprak HI, Bucak N, Aydogan MS, Yologlu S, Durmus M, Yılmaz S. Evaluation of pleth variability index as a predictor of fluid responsiveness during orthotopic liver transplantation. Kaohsiung J Med Sci 2016; 32:373-80. [PMID: 27450027 DOI: 10.1016/j.kjms.2016.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/18/2016] [Accepted: 05/25/2016] [Indexed: 11/17/2022] Open
Abstract
Fluid management is challenging and still remains controversial in orthotopic liver transplantation (OLT). The pleth variability index (PVI) has been shown to be a reliable predictor of fluid responsiveness of perioperative and critically ill patients; however, it has not been evaluated in OLT. This study was designed to examine whether the PVI can reliably predict fluid responsiveness in OLT and to compare PVI with other hemodynamic indexes that are measured using the PiCCO2 monitoring system. Twenty-five patients were enrolled in this study. Each patient was monitored using the noninvasive Masimo and PiCCO2 monitoring system. PVI was obtained with a Masimo pulse oximeter. Cardiac index was obtained using a transpulmonary thermodilution technique (CITPTD). Stroke volume variation (SVV), pulse pressure variation, and systemic vascular resistance index were measured using the PiCCO2 system. Fluid loading (10 mL/kg colloid) was performed at two different phases during the operation, and fluid responsiveness was defined as an increase in CITPTD ≥ 15%. During the dissection phase and the anhepatic phase, respectively, 14 patients (56%) and 18 patients (75%) were classified as responders. There were no differences between the baseline values of the PVI of responders and nonresponders. Area under the curve for PVI was 0.56 (sensitivity 35%, specificity 90%, p = 0.58) at dissection phase, and was 0.55 (sensitivity 55%, specificity 66%, p = 0.58) at anhepatic phase. Of the parameters, a higher area under the curve value was found for SVV. We conclude that PVI was unable to predict fluid responsiveness with sufficient accuracy in patients undergoing OLT, but the SVV parameter was reliable.
Collapse
Affiliation(s)
- Huseyin Konur
- Department of Anesthesiology and Reanimation, Goztepe Education and Research Hospital, Medeniyet University, Istanbul, Turkey
| | - Gulay Erdogan Kayhan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey.
| | - Huseyin Ilksen Toprak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Nizamettin Bucak
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Mustafa Said Aydogan
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Saim Yologlu
- Department of Biostatistics, Inonu University Medical Faculty, Malatya, Turkey
| | - Mahmut Durmus
- Department of Anesthesiology and Reanimation, Inonu University Medical Faculty, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery, Inonu University Medical Faculty, Malatya, Turkey
| |
Collapse
|
36
|
Biais M, Stecken L, Martin A, Roullet S, Quinart A, Sztark F. Automated, continuous and non-invasive assessment of pulse pressure variations using CNAP ® system. J Clin Monit Comput 2016; 31:685-692. [PMID: 27312841 DOI: 10.1007/s10877-016-9899-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
Abstract
Non-invasive respiratory variations in arterial pulse pressure using infrared-plethysmography (PPVCNAP) are able to predict fluid responsiveness in mechanically ventilated patients. However, they cannot be continuously monitored. The present study evaluated a new algorithm allowing continuous measurements of PPVCNAP (PPVCNAPauto) (CNSystem, Graz, Austria). Thirty-five patients undergoing vascular surgery were studied after induction of general anaesthesia. Stroke volume was measured using the VigileoTM/FloTracTM. Invasive pulse pressure variations were manually calculated using an arterial line (PPVART) and PPVCNAPauto was continuously displayed. PPVART and PPVCNAPauto were simultaneously recorded before and after volume expansion (500 ml hydroxyethylstarch). Subjects were defined as responders if stroke volume increased by ≥15 %. Twenty-one patients were responders. Before volume expansion, PPVART and PPVCNAPauto exhibited a bias of 0.1 % and limits of agreement from -7.9 % to 7.9 %. After volume expansion, PPVART and PPVCNAPauto exhibited a bias of -0.4 % and limits of agreement from -5.3 % to 4.5 %. A 14 % baseline PPVART threshold discriminated responders with a sensitivity of 86 % (95 % CI 64-97 %) and a specificity of 100 % (95 % CI 77-100 %). Area under the receiver operating characteristic (ROC) curve for PPVART was 0.93 (95 % CI 0.79-0.99). A 15 % baseline PPVCNAPauto threshold discriminated responders with a sensitivity of 76% (95 % CI 53-92 %) and a specificity of 93 % (95 % CI 66-99 %). Area under the ROC curves for PPVCNAPauto was 0.91 (95 % CI 0.76-0.98), which was not different from that for PPVART. When compared with PPVART, PPVCNAPauto performs satisfactorily in assessing fluid responsiveness in hemodynamically stable surgical patients.
Collapse
Affiliation(s)
- Matthieu Biais
- Service d'Anesthésie Réanimation 3, CFXM, CHU de Bordeaux, 33076, Bordeaux Cedex, France. .,Adaptation cardiovasculaire à l'ischémie, U1034, INSERM, 33600, Pessac, France. .,Adaptation cardiovasculaire à l'ischémie, U1034, Univ. Bordeaux, 33600, Pessac, France.
| | - Laurent Stecken
- Service d'Anesthésie réanimation 1, CHU de Bordeaux, 33000, Bordeaux, France
| | - Aurélie Martin
- Service d'Anesthésie réanimation 1, CHU de Bordeaux, 33000, Bordeaux, France
| | - Stéphanie Roullet
- Service d'Anesthésie réanimation 1, CHU de Bordeaux, 33000, Bordeaux, France
| | - Alice Quinart
- Service d'Anesthésie réanimation 1, CHU de Bordeaux, 33000, Bordeaux, France
| | - François Sztark
- Adaptation cardiovasculaire à l'ischémie, U1034, INSERM, 33600, Pessac, France.,Adaptation cardiovasculaire à l'ischémie, U1034, Univ. Bordeaux, 33600, Pessac, France.,Service d'Anesthésie réanimation 1, CHU de Bordeaux, 33000, Bordeaux, France
| |
Collapse
|
37
|
Ventilation-Induced Modulation of Pulse Oximeter Waveforms: A Method for the Assessment of Early Changes in Intravascular Volume During Spinal Fusion Surgery in Pediatric Patients. Anesth Analg 2016; 123:346-56. [PMID: 27284998 DOI: 10.1213/ane.0000000000001377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Scoliosis surgery is often associated with substantial blood loss, requiring fluid resuscitation and blood transfusions. In adults, dynamic preload indices have been shown to be more reliable for guiding fluid resuscitation, but these indices have not been useful in children undergoing surgery. The aim of this study was to introduce frequency-analyzed photoplethysmogram (PPG) and arterial pressure waveform variables and to study the ability of these parameters to detect early bleeding in children during surgery. METHODS We studied 20 children undergoing spinal fusion. Electrocardiogram, arterial pressure, finger pulse oximetry (finger PPG), and airway pressure waveforms were analyzed using time domain and frequency domain methods of analysis. Frequency domain analysis consisted of calculating the amplitude density of PPG and arterial pressure waveforms at the respiratory and cardiac frequencies using Fourier analysis. This generated 2 measurements: The first is related to slow mean arterial pressure modulation induced by ventilation (also known as DC modulation when referring to the PPG), and the second corresponds to pulse pressure modulation (AC modulation or changes in the amplitude of pulse oximeter plethysmograph when referring to the PPG). Both PPG and arterial pressure measurements were divided by their respective cardiac pulse amplitude to generate DC% and AC% (normalized values). Standard hemodynamic data were also recorded. Data at baseline and after bleeding (estimated blood loss about 9% of blood volume) were presented as median and interquartile range and compared using Wilcoxon signed-rank tests; a Bonferroni-corrected P value <0.05 was considered statistically significant. RESULTS There were significant increases in PPG DC% (median [interquartile range] = 359% [210 to 541], P = 0.002), PPG AC% (160% [87 to 251], P = 0.003), and arterial DC% (44% [19 to 84], P = 0.012) modulations, respectively, whereas arterial AC% modulations showed nonsignificant increase (41% [1 to 85], P = 0.12). The change in PPG DC% was significantly higher than that in PPG AC%, arterial DC%, arterial AC%, and systolic blood pressure with P values of 0.008, 0.002, 0.003, and 0.002, respectively. Only systolic blood pressure showed significant changes (11% [4 to 21], P = 0.003) between bleeding phase and baseline. CONCLUSIONS Finger PPG and arterial waveform parameters (using frequency analysis) can track changes in blood volume during the bleeding phase, suggesting the potential for a noninvasive monitor for tracking changes in blood volume in pediatric patients. PPG waveform baseline modulation (PPG DC%) was more sensitive to changes in venous blood volume when compared with respiration-induced modulation seen in the arterial pressure waveform.
Collapse
|
38
|
Lee HC, Tsai YF, Tsai HI, Chung PH, Yu HP, Lee WC, Lin CC. Pulse Oximeter–Derived Pleth Variability Index is a Reliable Indicator of Cardiac Preload in Patients Undergoing Liver Transplantation. Transplant Proc 2016; 48:1055-8. [DOI: 10.1016/j.transproceed.2015.12.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/30/2015] [Indexed: 11/17/2022]
|
39
|
DeBarros M, Causey MW, Chesley P, Martin M. Reliability of Continuous Non-Invasive Assessment of Hemoglobin and Fluid Responsiveness: Impact of Obesity and Abdominal Insufflation Pressures. Obes Surg 2016; 25:1142-8. [PMID: 25399349 DOI: 10.1007/s11695-014-1505-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND During surgery, proper fluid resuscitation and hemostatic control is critical. Pleth variability index (PVI) is advocated as a reliable way of optimizing intraoperative fluid resuscitation. PVI is a measure of dynamic change in perfusion index during a complete respiratory cycle. Non-invasive monitoring of total hemoglobin could provide a reliable means to determine need for transfusion. We analyzed the impact of insufflation and obesity on non-invasive measurements of hemoglobin and PVI in laparoscopic procedures to validate reliability of fluid responsiveness and hemoglobin levels. METHODS A non-invasive hemoglobin and PVI monitoring device was prospectively analyzed in patients undergoing abdominal operations. Patients were stratified by open and laparoscopic approach and obesity (body mass index (BMI) ≥35). PVI and hemoglobin values were assessed before, during, and after insufflation and compared to control patients undergoing open surgery. RESULTS Sixty-three patients were enrolled (mean age 42 years; 71 % male; mean BMI 36) with 24 patients laparoscopic non-obese (LNO), 20 laparoscopic obese (LO), and 19 undergoing open operations. There was no significant blood loss. Hemoglobin did not change significantly before or after insufflation. There was false elevation of PVI with insufflation and more pronounced in obese patients. CONCLUSIONS Insufflation or obesity was not associated with significant variations in hemoglobin. Non-invasive monitoring of hemoglobin is useful in laparoscopic procedures in obese and non-obese patients. PVI values should be used cautiously during laparoscopic procedures, particularly in obese patients.
Collapse
Affiliation(s)
- Mia DeBarros
- Department of Surgery, Madigan Army Medical Center, 9040a Fitzsimmons Drive, Tacoma, WA, 98431, USA,
| | | | | | | |
Collapse
|
40
|
Fischer MO, Daccache G, Lemoine S, Tavernier B, Compère V, Hulet C, Bouchakour CE, Canevet C, Gérard JL, Guittet L, Lorne E, Hanouz JL, Parienti JJ. The OPVI trial - perioperative hemodynamic optimization using the plethysmographic variability index in orthopedic surgery: study protocol for a multicenter randomized controlled trial. Trials 2015; 16:503. [PMID: 26537815 PMCID: PMC4634899 DOI: 10.1186/s13063-015-1020-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 10/20/2015] [Indexed: 11/13/2022] Open
Abstract
Background Hemodynamic optimization during surgery is of major importance to decrease postoperative morbidity and length of hospital stay. However, conventional cardiac output monitoring is rarely used at the bedside. Recently, the plethysmographic variability index (PVI) was described as a simplified alternative, using plug-and-play noninvasive technology, but its clinical utility remains to be established. Methods/design The hemodynamic optimization using the PVI (OPVI) trial is a multicenter randomized controlled two-arm trial, randomizing 440 patients at intermediate risk of postoperative complications after orthopedic surgery. Hemodynamic optimization was conducted using either the PVI (PVI group) or conventional mean arterial pressure (control group). The anesthesiologist performed the randomization the day before surgery using an interactive web response system, available 24 hours a day, 7 days a week. The randomization sequence was generated using permutated blocks and stratified by center and type of surgery (knee or hip arthoplasty). Patients and surgeons, but not anesthesiology staff, were blinded to the allocation group. The primary outcome measure is the length of hospital stay following surgery. The attending surgeon, who was blinded to group assessment, determined hospital discharge. Secondary outcome measures are theoretical length of hospital stay, determined using a dedicated discharge-from-hospital checklist, postoperative arterial lactate level in the recovery room, postoperative troponin level, presence of serious postoperative cardiac complications, and postoperative acute kidney insufficiency. Discussion The OPVI trial is the first multicenter randomized controlled study to investigate whether perioperative hemodynamic optimization using PVI during orthopedic surgery could decrease the length of hospital stay and postoperative morbidity. Trial registration ClinicalTrials.gov NCT02207296. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1020-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Marc-Olivier Fischer
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France. .,EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS 14 032, F-14 000, Caen, France.
| | - Georges Daccache
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France.
| | - Sandrine Lemoine
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France.
| | - Benoît Tavernier
- Service d'Anesthésie Réanimation, CHRU de Lille, Hôpital Roger Salengro, Rue Emile Laine, 59 037, Lille, France.
| | - Vincent Compère
- Service d'Anesthésie Réanimation, CHU de Rouen, Hôpital Charles Nicolle, 1 rue de Germont, 76 031, Rouen, France.
| | - Christophe Hulet
- Department of Orthopedic Surgery, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France.
| | - Chems Eddine Bouchakour
- Service d'Anesthésie, Hôpital Saint Philibert, 115 rue du Grand But, F-59462, Lomme, France.
| | - Christophe Canevet
- Service d'Anesthésie, Hôpital Saint Philibert, 115 rue du Grand But, F-59462, Lomme, France.
| | - Jean-Louis Gérard
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France.
| | - Lydia Guittet
- Department of Public Health, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France. .,INSERM1086, Faculty of Medicine, Caen University Hospital, Avenue de la Côte de Nacre, F-14032, Caen, France.
| | - Emmanuel Lorne
- Anesthesiology and Critical Care Department, Amiens University Hospital, Place Victor Pauchet, F-80 054, Amiens, France. .,INSERM ERI12, Jules Vernes University of Picardy, 12 rue des Louvels, F-80 000, Amiens, France.
| | - Jean-Luc Hanouz
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France. .,EA 4650, Université de Caen Basse-Normandie, Esplanade de la Paix, CS 14 032, F-14 000, Caen, France.
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000, Caen, France.
| |
Collapse
|
41
|
Perel A. Non-invasive monitoring of oxygen delivery in acutely ill patients: new frontiers. Ann Intensive Care 2015; 5:24. [PMID: 26380992 PMCID: PMC4573965 DOI: 10.1186/s13613-015-0067-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 09/06/2015] [Indexed: 12/15/2022] Open
Abstract
Hypovolemia, anemia and hypoxemia may cause critical deterioration in the oxygen delivery (DO2). Their early detection followed by a prompt and appropriate intervention is a cornerstone in the care of critically ill patients. And yet, the remedies for these life-threatening conditions, namely fluids, blood and oxygen, have to be carefully titrated as they are all associated with severe side-effects when administered in excess. New technological developments enable us to monitor the components of DO2 in a continuous non-invasive manner via the sensor of the traditional pulse oximeter. The ability to better assess oxygenation, hemoglobin levels and fluid responsiveness continuously and simultaneously may be of great help in managing the DO2. The non-invasive nature of this technology may also extend the benefits of advanced monitoring to wider patient populations.
Collapse
Affiliation(s)
- Azriel Perel
- Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, 52621, Tel Aviv, Israel.
| |
Collapse
|
42
|
Bartels K, Thiele RH. Advances in photoplethysmography: beyond arterial oxygen saturation. Can J Anaesth 2015; 62:1313-28. [PMID: 26286382 DOI: 10.1007/s12630-015-0458-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 07/03/2015] [Accepted: 08/11/2015] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Photoplethysmography permits continuous measurement of heart rate and peripheral oxygen saturation and has been widely used to inform clinical decisions. Recently, a myriad of noninvasive hemodynamic monitoring devices using this same technology have been increasingly available. This narrative review aims to summarize the principles that form the basis for the function of these devices as well as to comment on trials evaluating their accuracy and clinical application. PRINCIPAL FINDINGS Advanced monitoring devices extend photoplethysmography technology beyond measuring oxygen concentration and heart rate. Quantification of respiratory variation of the photoplethysmographic waveform reflects respiratory variation of the arterial pressure waveform and can be used to gauge volume responsiveness. Both the volume-clamp and physiocal techniques are extensions of conventional photoplethysmography and permit continuous measurement of finger arterial blood pressure. Finger arterial pressure waveforms can subsequently inform estimations of cardiac output. CONCLUSIONS Although respiratory variations of the plethysmographic waveform correlate only modestly with the arterial blood pressure waveform, fluid responsiveness can be relatively consistently assessed using both approaches. Continuous blood pressure measurements obtained using the volume-clamp technique may be as accurate as conventional brachial noninvasive blood pressure measurements. Most importantly, clinical comparative effectiveness studies are still needed in order to determine if these technologies can be translated into improvement of relevant patient outcomes.
Collapse
Affiliation(s)
- Karsten Bartels
- Departments of Anesthesiology and Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Robert H Thiele
- Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, VA, USA.
| |
Collapse
|
43
|
Chu H, Wang Y, Sun Y, Wang G. Accuracy of pleth variability index to predict fluid responsiveness in mechanically ventilated patients: a systematic review and meta-analysis. J Clin Monit Comput 2015; 30:265-74. [PMID: 26242233 DOI: 10.1007/s10877-015-9742-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 07/21/2015] [Indexed: 11/25/2022]
Abstract
To systemically evaluate the accuracy of pleth variability index to predict fluid responsiveness in mechanically ventilated patients. A literature search of PUBMED, OVID, CBM, CNKI and Wanfang Data for clinical studies in which the accuracy of pleth variability index to predict fluid responsiveness was performed (last update 5 April 2015). Related journals were also searched manually. Two reviewers independently assessed trial quality according to the modified QUADAS items. Heterogeneous studies and meta-analysis were conducted by Meta-Disc 1.4 software. A subgroup analysis in the operating room (OR) and in intensive care unit (ICU) was also performed. Differences between subgroups were analyzed using the interaction test. A total of 18 studies involving 665 subjects were included. The pooled area under the receiver operating characteristic curve (AUC) to predict fluid responsiveness in mechanically ventilated patients was 0.88 [95 % confidence interval (CI) 0.84-0.91]. The pooled sensitivity and specificity were 0.73 (95 % CI 0.68-0.78) and 0.82 (95 % CI 0.77-0.86), respectively. No heterogeneity was found within studies nor between studies. And there was no significant heterogeneity within each subgroup. No statistical differences were found between OR subgroup and ICU subgroup in the AUC [0.89 (95 % CI 0.85-0.92) versus 0.90 (95 % CI 0.82-0.94); P = 0.97], and in the specificity [0.84 (95 % CI 0.75-0.86) vs. 0.84 (95 % CI 0.75-0.91); P = 1.00]. Sensitivity was higher in the OR subgroup than the ICU subgroup [0.84 (95 % CI 0.78-0.88) vs. 0.56 (95 % CI 0.47-0.64); P = 0.00004]. The pleth variability index has a reasonable ability to predict fluid responsiveness.
Collapse
Affiliation(s)
- Haitao Chu
- The First Hospital of China Medical University, Shenyang, China
| | - Yong Wang
- The First Hospital of China Medical University, Shenyang, China
| | - Yanfei Sun
- The First Hospital of China Medical University, Shenyang, China
| | - Gang Wang
- The First Hospital of China Medical University, Shenyang, China.
| |
Collapse
|
44
|
Sakka SG. Hemodynamic Monitoring in the Critically Ill Patient - Current Status and Perspective. Front Med (Lausanne) 2015; 2:44. [PMID: 26284244 PMCID: PMC4522558 DOI: 10.3389/fmed.2015.00044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/26/2015] [Indexed: 01/20/2023] Open
Abstract
In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient's outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations.
Collapse
Affiliation(s)
- Samir G Sakka
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Center Cologne Merheim, University Witten/Herdecke , Cologne , Germany
| |
Collapse
|
45
|
Stens J, de Wolf SP, van der Zwan RJ, Koning NJ, Dekker NA, Hering JP, Boer C. Microcirculatory Perfusion During Different Perioperative Hemodynamic Strategies. Microcirculation 2015; 22:267-75. [DOI: 10.1111/micc.12194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/11/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Jurre Stens
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Steven P. de Wolf
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - René J. van der Zwan
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nick J. Koning
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | - Nicole A.M. Dekker
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| | | | - Christa Boer
- Departments of Anaesthesiology of the VU University Medical Centre; Institute for Cardiovascular Research; Amsterdam the Netherlands
| |
Collapse
|
46
|
Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015; 220:430-43. [DOI: 10.1016/j.jamcollsurg.2014.12.042] [Citation(s) in RCA: 283] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 12/12/2022]
|
47
|
Siswojo AS, Wong DMY, Phan TD, Kluger R. Pleth Variability Index Predicts Fluid Responsiveness in Mechanically Ventilated Adults During General Anesthesia for Noncardiac Surgery. J Cardiothorac Vasc Anesth 2014; 28:1505-9. [DOI: 10.1053/j.jvca.2014.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Indexed: 02/04/2023]
|
48
|
Yang X, Du B. Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:650. [PMID: 25427970 PMCID: PMC4258282 DOI: 10.1186/s13054-014-0650-6] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 11/06/2014] [Indexed: 02/08/2023]
Abstract
Introduction Fluid resuscitation is crucial in managing hemodynamically unstable patients. The last decade witnessed the use of pulse pressure variation (PPV) to predict fluid responsiveness. However, as far as we know, no systematic review and meta-analysis has been carried out to evaluate the value of PPV in predicting fluid responsiveness specifically upon patients admitted into intensive care units. Methods We searched MEDLINE and EMBASE and included clinical trials that evaluated the association between PPV and fluid responsiveness after fluid challenge in mechanically ventilated patients in intensive care units. Data were synthesized using an exact binomial rendition of the bivariate mixed-effects regression model modified for synthesis of diagnostic test data. Result Twenty-two studies with 807 mechanically ventilated patients with tidal volume more than 8 ml/kg and without spontaneous breathing and cardiac arrhythmia were included, and 465 were responders (58%). The pooled sensitivity was 0.88 (95% confidence interval (CI) 0.81 to 0.92) and pooled specificity was 0.89 (95% CI 0.84 to 0.92). A summary receiver operating characteristic curve yielded an area under the curve of 0.94 (95% CI 0.91 to 0.95). A significant threshold effect was identified. Conclusions PPV predicts fluid responsiveness accurately in mechanically ventilated patients with relative large tidal volume and without spontaneous breathing and cardiac arrhythmia. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0650-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Xiaobo Yang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, PR China.
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, PR China.
| |
Collapse
|
49
|
Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2014; 62:169-81. [PMID: 25391734 DOI: 10.1007/s12630-014-0265-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy. PRINCIPAL FINDINGS The focus of many devices used for advanced hemodynamic monitoring is on providing measurements of cardiac output, while other, more recent, devices include estimates of fluid responsiveness based on dynamic indices that better predict an individual's response to a fluid bolus. Currently available technologies include the pulmonary artery catheter, esophageal Doppler, arterial waveform analysis, photoplethysmography, venous oxygen saturation, as well as bioimpedance and bioreactance. The underlying mechanistic principles for each device are presented as well as their performance in clinical trials relevant for goal-directed therapy in ERAS. CONCLUSIONS The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.
Collapse
Affiliation(s)
- Robert H Thiele
- Technology in Anesthesia & Critical Care Group, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, P.O. Box 800710-0710, Charlottesville, VA, 22908-0710, USA,
| | | | | |
Collapse
|
50
|
Fischer MO, Pellissier A, Saplacan V, Gérard JL, Hanouz JL, Fellahi JL. Cephalic versus digital plethysmographic variability index measurement: a comparative pilot study in cardiac surgery patients. J Cardiothorac Vasc Anesth 2014; 28:1510-5. [PMID: 25263772 DOI: 10.1053/j.jvca.2014.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Noninvasive measurement of digital plethysmographic variability index (PVI(digital)) has been proposed to predict fluid responsiveness, with conflicting results. The authors tested the hypothesis that cephalic sites of PVI measurement (namely PVI(ear) and PVI(forehead)) could be more discriminant than PVI(digital) to predict fluid responsiveness after cardiac surgery. DESIGN A prospective observational study. SETTING A cardiac surgical intensive care unit of a university hospital. PARTICIPANTS Fifty adult patients. INTERVENTIONS Investigation before and after fluid challenge. MEASUREMENT AND MAIN RESULTS Patients were prospectively included within the first 6-hour postoperative period and investigated before and after fluid challenge. A positive response to fluid challenge was defined as a 15% increase in cardiac index. PVI(digital), PVI(ear), PVI(forehead), and invasive arterial pulse-pressure variation (PPV) measurements were recorded simultaneously, and receiver operating characteristic (ROC) curves were built. Forty-one (82%) patients were responders and 9 (18%) patients were nonresponders to fluid challenge. ROCAUC were 0.74 (95% confidence interval [95% CI]: 0.60-0.86), 0.81 (95% CI: 0.68-0.91), 0.88 (95% CI: 0.75-0.95) and 0.87 (95% CI: 0.75-0.95) for PVI(digital), PVI(ear), PVI(forehead), and PPV, respectively. Significant differences were observed between PVI(forehead) and PVI(digital) (absolute difference in ROCAUC = 0.134 [95% CI: 0.003-0.265], p = 0.045) and between PPV and PVI(digital) (absolute difference in ROCAUC = 0.129 [95% CI: 0.011-0.247], p = 0.033). The percentage of patients within the inconclusive class of response was 46%, 70%, 44%, and 26% for PVI(digital), PVI(ear), PVI(forehead), and PPV, respectively. CONCLUSIONS PVI(forehead) was more discriminant than PVI(digital) and could be a valuable alternative to arterial PPV in predicting fluid responsiveness.
Collapse
Affiliation(s)
- Marc-Olivier Fischer
- Departments of *Anesthesia and Critical Care Medicine; University of Caen, Caen, France.
| | | | | | - Jean-Louis Gérard
- Departments of *Anesthesia and Critical Care Medicine; University of Caen, Caen, France
| | - Jean-Luc Hanouz
- Departments of *Anesthesia and Critical Care Medicine; University of Caen, Caen, France
| | - Jean-Luc Fellahi
- Departments of *Anesthesia and Critical Care Medicine; University of Caen, Caen, France
| |
Collapse
|