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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.
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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
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Khanna A, Vaidya K, Shah D, Ranjan AK, Gulati A. Centhaquine Increases Stroke Volume and Cardiac Output in Patients with Hypovolemic Shock. J Clin Med 2024; 13:3765. [PMID: 38999331 PMCID: PMC11242165 DOI: 10.3390/jcm13133765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/17/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Centhaquine is a resuscitative agent that acts on α2B adrenergic receptors. Its effect on cardiac output in hypovolemic shock patients has not been reported. Methods: This pilot study was conducted in 12 hypovolemic shock patients treated with centhaquine who participated in an open-label phase IV study (NCT05956418). Echocardiography was utilized to measure stroke volume (SV), cardiac output (CO), left ventricular outflow tract velocity time integral (LVOT-VTI) and diameter (LVOTd), heart rate (HR), left ventricular ejection fraction (LVEF) and fractional shortening (LVFS), and inferior vena cava (IVC) diameter before (0 min) and 60, 120, and 300 min after centhaquine (0.01 mg/kg) iv infusion for 60 min. Results: SV was significantly increased after 60, 120, and 300 min. CO increased significantly after 120 and 300 min despite a decrease in HR. IVC diameter and LVOT-VTI at these time points significantly increased, indicating the increased venous return. LVEF and LVFS did not change, while the mean arterial pressure (MAP, mmHg) increased after 120 and 300 min. Positive correlations between IVC diameter and SV (R2 = 0.9556) and between IVC diameter and MAP (R2 = 0.8928) were observed, which indicated the effects of an increase in venous return on SV, CO, and MAP. Conclusions: Centhaquine-mediated increase in venous return is critical in enhancing SV, CO, and MAP in patients with hypovolemic shock; these changes could be pivotal for reducing shock-mediated circulatory failure, promoting tissue perfusion, and improving patient outcomes. Trial Registration: CTRI/2021/01/030263 and NCT05956418.
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Affiliation(s)
- Aman Khanna
- Aman Hospital and Research Centre Organization, Vadodara 390021, GJ, India
| | | | - Dharmesh Shah
- Pharmazz India Private Limited, Greater Noida 201307, UP, India
| | - Amaresh K Ranjan
- Pharmazz Inc., Research and Development, Willowbrook, IL 60527, USA
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL 60527, USA
- Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL 60607, USA
- College of Pharmacy Downers Grove, Midwestern University, Downers Grove, IL 60515, USA
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Sharma V, Sharma A, Sethi A, Pathania J. Diagnostic accuracy of left ventricular outflow tract velocity time integral versus inferior vena cava collapsibility index in predicting post-induction hypotension during general anesthesia: an observational study. Acute Crit Care 2024; 39:117-126. [PMID: 38476064 PMCID: PMC11002618 DOI: 10.4266/acc.2023.00913] [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: 07/18/2023] [Revised: 12/20/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Point of care ultrasound (POCUS) is being explored for dynamic measurements like inferior vena cava collapsibility index (IVC-CI) and left ventricular outflow tract velocity time integral (LVOT-VTI) to guide anesthesiologists in predicting fluid responsiveness in the preoperative period and in treating post-induction hypotension (PIH) with varying accuracy. METHODS In this prospective, observational study on included 100 adult patients undergoing elective surgery under general anesthesia, the LVOT-VTI and IVC-CI measurements were performed in the preoperative room 15 minutes prior to surgery, and PIH was measured for 20 minutes in the post-induction period. RESULTS The incidence of PIH was 24%. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the two techniques at 95% confidence interval was 0.613, 30.4%, 93.3%, 58.3%, 81.4%, 73.6% for IVC-CI and 0.853, 83.3%, 80.3%, 57.1%, 93.8%, 77.4% for LVOT-VTI, respectively. In multivariate analysis, the cutoff value for IVC-CI was >51.5 and for LVOT-VTI it was ≤17.45 for predicting PIH with odd ratio [OR] of 8.491 (P=0.025) for IVCCI and OR of 17.427 (P<0.001) for LVOT. LVOT-VTI assessment was possible in all the patients, while 10% of patients were having poor window for IVC measurements. CONCLUSIONS We recommend the use of POCUS using LVOT-VTI or IVC-CI to predict PIH, to decrease the morbidity of patients undergoing surgery. Out of these, we recommend LVOT-VTI measurements as it has showed a better diagnostic accuracy (77.4%) with no failure rate.
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Affiliation(s)
- Vibhuti Sharma
- Department of Anaesthesia, Indira Gandhi Medical College Shimla, Shimla, India
| | - Arti Sharma
- Department of Anaesthesia, Indira Gandhi Medical College Shimla, Shimla, India
| | - Arvind Sethi
- Department of Anaesthesia, Indira Gandhi Medical College Shimla, Shimla, India
| | - Jyoti Pathania
- Department of Anaesthesia, Indira Gandhi Medical College Shimla, Shimla, India
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Guerrero-Gutiérrez MA, García-Guillén FJ, Adame-Encarnación H, Monera-Martínez F, Ñamendys-Silva SA, Córdova-Sánchez BM. Reliability of point-of-care ultrasound to evaluate fluid tolerance performed by critical care residents. Eur J Med Res 2023; 28:431. [PMID: 37828607 PMCID: PMC10571403 DOI: 10.1186/s40001-023-01397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Patients with hypotension usually receive intravenous fluids, but only 50% will respond to fluid administration. We aimed to assess the intra and interobserver agreement to evaluate fluid tolerance through diverse ultrasonographic methods. METHODS We prospectively included critically ill patients on mechanical ventilation. One trained intensivist and two intensive care residents obtained the left ventricular outflow tract velocity-time integral (VTI) variability, inferior vena cava (IVC) distensibility index, internal jugular vein (IJV) distensibility index, and each component of the venous excess ultrasound (VExUS) system. We obtained the intraclass correlation coefficient (ICC) and Gwet's first-order agreement coefficient (AC1), as appropriate. RESULTS We included 32 patients. In-training observers were unable to assess the VTI-variability in two patients. The interobserver agreement was moderate to evaluate the IJV-distensibility index (AC1 0.54, CI 95% 0.29-0.80), fair to evaluate VTI-variability (AC1 0.39, CI 95% 0.12-0.66), and absent to evaluate the IVC-distensibility index (AC1 0.19, CI 95% - 0.07 to 0.44). To classify patients according to their VExUS grade, the intraobserver agreement was good, and the interobserver agreement was moderate (AC1 0.52, CI 95% 0.34-0.69). CONCLUSIONS Point-of-care ultrasound is frequently used to support decision-making in fluid management. However, we observed that the VTI variability and IVC-distensibility index might require further training of the ultrasound operators to be clinically useful. Our findings suggest that the IJV-distensibility index and the VExUS system have acceptable reproducibility among in-training observers.
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Affiliation(s)
| | | | | | | | - Silvio A Ñamendys-Silva
- Instituto Nacional de Cancerología, San Fernando #22, Tlalpan, Mexico City, Mexico
- Instituto Nacional de Ciencias Medicas y de la Nutricion Salvador Zubiran, Mexico City, Mexico
- Hospital Medica Sur, Mexico City, Mexico
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Roy A, Pachisia AV, Govil D, Kn J, Patel S, Harne R, Pal D, Reddy DM, Tyagi P, Pattajoshi S. Fluid Responsiveness in Critically Ill Patients Using Carotid Peak Systolic Velocity Variability: A New Frontier. Cureus 2023; 15:e42083. [PMID: 37602090 PMCID: PMC10434974 DOI: 10.7759/cureus.42083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Background and objectives A fluid responder is a patient who can increase his stroke volume/ cardiac output by more than 10%-15% after a fluid bolus. Left ventricular outflow tract (LVOT) velocity time integral (VTI) variability is widely used as an adynamic parameter of fluid responsiveness, but a transthoracic echo view of LVOT VTI is often time-consuming and, at times, difficult to achieve. So, in the quest for another parameter that might equally be a good surrogate marker of stroke volume variation, carotid peak systolic velocity (CPSV) variation has been studied. The objective was to assess CPSV variation in patients who are already fluid responders. Methods The sample size was calculated considering a minimum correlation coefficient of 0.5. Adult patients in whom the physician wanted to give a fluid bolus and whose average LVOT VTI was more than 15% over 3 respiratory cycles were included in the study. Demographic variables, along with hemodynamic parameters such as heart rate, blood pressure, the need for vasopressors, mode of breathing (spontaneous or mechanical ventilation), and CPSV variation,were noted and averaged over three respiratory cycles. Fluid bolus (Plasmalyte) 6 ml/kg bolus over 10-15 minutes. Post-fluid hemodynamic variables, along with averaged LVOT VTI over three respiratory cycles and averaged CPSV variation over three respiratory cycles, are noted. Results Thirty adult patients were evaluated in the study. In spontaneously breathing patients (n=12), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight was 14.1 ± 3.4 and 5.4 ± 2.6, respectively (p < 0.05). In mechanically ventilated patients (n=18), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight fluid was 15 ± 5.3 and 6.5 ± 3.1, respectively (p <0.005). Overall, there was a statistically significant positive correlation between LVOT VTI variation and CPSV variation before fluid therapy (correlation coefficient 0.56 and p-value 0.001) and a statistically significant moderate positive correlation post-fluid therapy (correlation coefficient 0.37 and p-value 0.043). Conclusion We found a significant decrease in CPSV variation post-fluid administration in patients who are fluid responders, which mimics a decrease in stroke volume variation after fluid administration in patients who are fluid responsive.
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Affiliation(s)
- Abhinob Roy
- Critical Care Medicine, Paras Hospital, Gurugram, IND
| | | | - Deepak Govil
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | - Jagadeesh Kn
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | - Sweta Patel
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | - Rahul Harne
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | - Divya Pal
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | | | - Pooja Tyagi
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
| | - Swagat Pattajoshi
- Anaesthesiology and Critical Care Medicine, Medanta-The Medicity, Gurugram, IND
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Pérez-Manjarrez A, García-Cruz E, Gopar-Nieto R, Jiménez-Rodríguez GM, Lazcano-Díaz E, Rojas-Velasco G, Manzur-Sandoval D. Usefulness of the velocity-time integral of the left ventricular outflow tract variability index to predict fluid responsiveness in patients undergoing cardiac surgery. Echo Res Pract 2023; 10:9. [PMID: 37381028 DOI: 10.1186/s44156-023-00022-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Haemodynamic monitoring of patients after cardiac surgery using echocardiographic evaluation of fluid responsiveness is both challenging and increasingly popular. We evaluated fluid responsiveness in the first hours after surgery by determining the variability of the velocity-time integral of the left ventricular outflow tract (VTI-LVOT). METHODS We conducted a cross-sectional study of 50 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain VTI-LVOT measurements. We then determined the variability and correlations with our pulse pressure variation (PPV) measurements to predict fluid responsiveness. RESULTS A strong positive correlation was seen between the VTI-LVOT variability index absolute values and PPV for predicting fluid responsiveness in the first hours after cardiac surgery. We also found that the VTI-LVOT variability index has high specificity and a high positive likelihood ratio compared with the gold standard using a cut-off point of ≥ 12%. CONCLUSIONS The VTI-LVOT variability index is a valuable tool for determining fluid responsiveness during the first 6 postoperative hours in patients undergoing cardiac surgery.
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Affiliation(s)
- Aldo Pérez-Manjarrez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Edgar García-Cruz
- Adult Congenital Heart Disease Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Rodrigo Gopar-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Gian Manuel Jiménez-Rodríguez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Emmanuel Lazcano-Díaz
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Gustavo Rojas-Velasco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Daniel Manzur-Sandoval
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico.
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Cheong I, Castro VO, Gómez RA, Merlo PM, Tamagnone FM. A modified subcostal view: a novel method for measuring the LVOT VTI. J Ultrasound 2023; 26:429-434. [PMID: 35449385 PMCID: PMC10247580 DOI: 10.1007/s40477-022-00671-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/21/2022] [Indexed: 01/31/2023] Open
Abstract
PURPOSE The velocity time integral (VTI) of the left ventricular outflow tract (LVOT) obtained in the apical view by echocardiography can be regarded as a surrogate for the stroke volume. In critically ill patients it is often difficult to obtain an appropriate apical view to assess the VTI. The subcostal view is more accessible, but while it allows a qualitative assessment of the heart, is not adequate for estimating a reliable LVOT VTI, given the inappropriate angle between the Doppler signal and the flow through the LVOT. We present a new modified subcostal view that allows a proper LVOT VTI measurement. METHODS This is a single-centre experimental, retrospective, and observational study using data from patients in a tertiary-care centre. We included adult patients admitted to the intensive care unit in the period from June 2020 to January 2022, who were evaluated by echocardiography and whose LVOT VTI was measured aligned with the Doppler signal in both the apical five-chamber view and the modified subcostal view. RESULTS A total of 30 patients were evaluated in the study period by ultrasonography. The Bland-Altman method analysis of the LVOT VTI measured in the apical view compared with that obtained in the subcostal view showed a bias of 0.8 (95% CI 0.39-1.21) with a 95% limit of agreement between - 1.35 (95% CI - 2.06 to - 0.64) and 2.96 (95% CI 2.25-3.67). The percentage error was calculated to be 23%. The Pearson correlation coefficient for the two forms of measurements showed an R value of 0.98 (95% CI 0.96-0.99). CONCLUSION The LVOT VTI measured in a modified subcostal view is useful for estimating the value of the LVOT VTI obtained in an apical view.
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Affiliation(s)
- Issac Cheong
- Department of Critical Care Medicine, Intensive Care Unit, CABA, Sanatorio De los Arcos, Juan B. Justo 909, Buenos Aires, Argentina.
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina.
| | - Victoria Otero Castro
- Department of Critical Care Medicine, Intensive Care Unit, CABA, Sanatorio De los Arcos, Juan B. Justo 909, Buenos Aires, Argentina
| | - Raúl Alejandro Gómez
- Department of Critical Care Medicine, Intensive Care Unit, CABA, Sanatorio De los Arcos, Juan B. Justo 909, Buenos Aires, Argentina
| | - Pablo Martín Merlo
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina
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Weber MD, Lim JKB, Ginsburg S, Conlon T, Nishisaki A. Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians. Crit Care Clin 2023; 39:385-406. [PMID: 36898781 DOI: 10.1016/j.ccc.2022.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.
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Affiliation(s)
- Mark D Weber
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Joel K B Lim
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Sarah Ginsburg
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Conlon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
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Cheong I, Otero Castro V, Brizuela M, Früchtenicht MF, Merlo PM, Tamagnone FM. Passive leg raising test to predict fluid responsiveness using the right ventricle outflow tract velocity-time integral through a subcostal view. J Ultrasound 2022:10.1007/s40477-022-00719-7. [PMID: 36127570 DOI: 10.1007/s40477-022-00719-7] [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: 06/14/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022] Open
Abstract
PURPOSE The passive leg raising test (PLR) produces a reversible increase in venous return and, if the patient's ventricles are preload dependent, in the cardiac output. As this effect occurs in seconds, the transthoracic echocardiography is optimal for its real time assessment. The utility of the PLR for monitoring fluid responsiveness through the measurement of the left ventricle outflow tract velocity-time integral (LVOT VTI) in an apical 5-chamber view is well stablished. To achieve this view in critically ill patients is often challenging. The aim of this study is to explore the accuracy for predicting fluid responsiveness of the change in the right ventricle outflow tract velocity-time integral (RVOT VTI) from a subcostal view during a PLR. METHODS This is a diagnostic accuracy study carried out in two centers in Argentina. We included patients admitted to the intensive care unit from January 2022 to April 2022, that required fluid expansion due to signs of tissular hypoperfusion. We measured the RVOT VTI from a subcostal view in a semi-recumbent position and during the PLR, and the LVOT VTI in an apical 5-chamber view before and after a fluid bolus. If the LVOT VTI increased by 15% after the fluid bolus, the patients were considered fluid responders. RESULTS We included 43 patients. The area under the ROC curve for a change in the RVOT VTI during the PLR was 0.879 (95% CI 0.744-0.959). A change of 15.36% in the RVOT VTI with the PLR predicted fluid responsiveness with a sensitivity of 85.7% (95% CI 57.2%-98.2%) and specificity of 93.1% (95% CI 77.2-99.2). The positive predictive value was 85.7% (95% CI 60.8%-95.9%) and the negative predictive value was 93.1% (95% CI 78.8%-98%). The positive likelihood ratio was 12.43 and the negative predictive value was 0.15. CONCLUSION The RVOT VTI change during a PLR is suitable for the prediction of fluid responsiveness in critically ill patients.
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Affiliation(s)
- Issac Cheong
- Department of Critical Care Medicine, Sanatorio De los Arcos, Juan B. Justo 909, CABA, Buenos Aires, Argentina.
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina.
| | - Victoria Otero Castro
- Department of Critical Care Medicine, Sanatorio De los Arcos, Juan B. Justo 909, CABA, Buenos Aires, Argentina
| | - Matías Brizuela
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina
- Department of Critical Care Medicine, Sanatorio Privado del Interior SRL, Córdoba, Argentina
| | | | - Pablo Martín Merlo
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022; 26:179-184. [PMID: 35712738 PMCID: PMC8857717 DOI: 10.5005/jp-journals-10071-24115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Fluid boluses are used in hemodynamically unstable patients with presumed hypovolemia, to improve tissue perfusion, in the perioperative period. Now less invasive methods, such as pulse pressure variation (PPV) and stroke volume variation (SVV) are increasingly being used. We investigated correlation between carotid and brachial artery velocity time integral (VTI) and compared both with PPV and SVV. Methods We recruited 27 patients undergoing supra-major abdominal surgeries. When indicated (hypotension or increased lactate), a fluid bolus was given after measuring carotid and brachial artery VTI, PPV, and SVV. The change in SV was noted and patients were categorized as responders if the SV increased by >15%. We performed Bland Altman Agreement and calculated best sensitivity and specificity for the parameters. Results Patients were found to be fluid responders on 29 instances. The correlation between PPV, SVV, carotid and brachial artery VTI was poor and the limits of agreement between them were wide. The Area under Curve (AUC) for PPV was 0.69, for SVV was 0.63, while those of Carotid and Brachial artery VTI (TAP and flow) were (0.53 and 0.54 for carotid) and (0.51 and 0.56 for brachial) respectively. Conclusion We found poor agreement and weak correlation between both VTi (TAP and flow) measured at carotid and brachial arteries, suggesting that the readings at brachial vessel cannot be used interchangeably with those at carotid artery. The PPV and SVV were better than these parameters for predicting fluid responsiveness; however, their predictive ability (AUROC), sensitivity and specificity were much lower than previously reported. Further studies in this area are therefore required (CTRI Reg No: CTRI/2017/08/009243). How to cite this article Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022;26(2):179–184.
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Affiliation(s)
- Malini Joshi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Praveen Dhakane
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shilpushp J Bhosale
- Department of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rutuja Phulambrikar
- Department of Community Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Atul P Kulkarni, Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
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Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consult: How Point of Care Ultrasound Helps Guide Medical Decision Making. Int J Gen Med 2021; 14:9789-9806. [PMID: 34938102 PMCID: PMC8685447 DOI: 10.2147/ijgm.s339476] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jake A Rice
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Brewer
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tyler Speaks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Choi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Lahsaei
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Correspondence: Bryan T Romito Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9068, USATel +1 214 648 7674Fax +1 214 648 5461 Email
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