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Aneman A, Skrifvars MB, Ameloot K. Venous return physiology applied to post-cardiac arrest haemodynamic management: a post hoc analysis of the NEUROPROTECT trial. Intensive Care Med Exp 2024; 12:70. [PMID: 39138823 PMCID: PMC11322455 DOI: 10.1186/s40635-024-00657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups. RESULTS Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01). CONCLUSIONS Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.
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Affiliation(s)
- Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District and South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
- The Ingham Institute for Applied Medical Research, Sydney, Australia.
- Faculty of Health Sciences, Macquarie University, Sydney, Australia.
| | - Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Louvain, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
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Bachmann KF, Moller PW, Hunziker L, Maggiorini M, Berger D. Mechanisms maintaining right ventricular contractility-to-pulmonary arterial elastance ratio in VA ECMO: a retrospective animal data analysis of RV-PA coupling. J Intensive Care 2024; 12:19. [PMID: 38734616 PMCID: PMC11088130 DOI: 10.1186/s40560-024-00730-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/14/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND To optimize right ventricular-pulmonary coupling during veno-arterial (VA) ECMO weaning, inotropes, vasopressors and/or vasodilators are used to change right ventricular (RV) function (contractility) and pulmonary artery (PA) elastance (afterload). RV-PA coupling is the ratio between right ventricular contractility and pulmonary vascular elastance and as such, is a measure of optimized crosstalk between ventricle and vasculature. Little is known about the physiology of RV-PA coupling during VA ECMO. This study describes adaptive mechanisms for maintaining RV-PA coupling resulting from changing pre- and afterload conditions in VA ECMO. METHODS In 13 pigs, extracorporeal flow was reduced from 4 to 1 L/min at baseline and increased afterload (pulmonary embolism and hypoxic vasoconstriction). Pressure and flow signals estimated right ventricular end-systolic elastance and pulmonary arterial elastance. Linear mixed-effect models estimated the association between conditions and elastance. RESULTS At no extracorporeal flow, end-systolic elastance increased from 0.83 [0.66 to 1.00] mmHg/mL at baseline by 0.44 [0.29 to 0.59] mmHg/mL with pulmonary embolism and by 1.36 [1.21 to 1.51] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Pulmonary arterial elastance increased from 0.39 [0.30 to 0.49] mmHg/mL at baseline by 0.36 [0.27 to 0.44] mmHg/mL with pulmonary embolism and by 0.75 [0.67 to 0.84] mmHg/mL with hypoxic pulmonary vasoconstriction (p < 0.001). Coupling remained unchanged (2.1 [1.8 to 2.3] mmHg/mL at baseline; - 0.1 [- 0.3 to 0.1] mmHg/mL increase with pulmonary embolism; - 0.2 [- 0.4 to 0.0] mmHg/mL with hypoxic pulmonary vasoconstriction, p > 0.05). Extracorporeal flow did not change coupling (0.0 [- 0.0 to 0.1] per change of 1 L/min, p > 0.05). End-diastolic volume increased with decreasing extracorporeal flow (7.2 [6.6 to 7.8] ml change per 1 L/min, p < 0.001). CONCLUSIONS The right ventricle dilates with increased preload and increases its contractility in response to afterload changes to maintain ventricular-arterial coupling during VA extracorporeal membrane oxygenation.
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Affiliation(s)
- Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Per Werner Moller
- Department of Anesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Furst B, González-Alonso J. The heart, a secondary organ in the control of blood circulation. Exp Physiol 2023. [PMID: 38126953 DOI: 10.1113/ep091387] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
Circulation of the blood is a fundamental physiological function traditionally ascribed to the pressure-generating function of the heart. However, over the past century the 'cardiocentric' view has been challenged by August Krogh, Ernst Starling, Arthur Guyton and others, based on haemodynamic data obtained from isolated heart preparations and organ perfusion. Their research brought forth experimental evidence and phenomenological observations supporting the concept that cardiac output occurs primarily in response to the metabolic demands of the tissues. The basic tenets of Guyton's venous return model are presented and juxtaposed with their critiques. Developmental biology of the cardiovascular system shows that the blood circulates before the heart has achieved functional integrity and that its movement is intricately connected with the metabolic demands of the tissues. Long discovered, but as yet overlooked, negative interstitial pressure may play a role in assisting the flow returning to the heart. Based on these phenomena, an alternative circulation model has been proposed in which the heart functions like a hydraulic ram and maintains a dynamic equilibrium between the arterial (centrifugal) and venous (centripetal) forces which define the blood's circular movement. In this focused review we introduce some of the salient arguments in support of the proposed circulation model. Finally, we present evidence that exercising muscle blood flow is subject to local metabolic control which upholds optimal perfusion in the face of a substantive rise in muscle vascular conductance, thus lending further support to the permissive role of the heart in the overall control of blood circulation.
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Affiliation(s)
- Branko Furst
- Department of Anesthesiology, Albany Medical Center, Albany, New York, USA
| | - José González-Alonso
- Sport, Health and Exercise Sciences, Department of Life Sciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK
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Bachmann KF, Berger D, Moller PW. Interactions between extracorporeal support and the cardiopulmonary system. Front Physiol 2023; 14:1231016. [PMID: 37772062 PMCID: PMC10523013 DOI: 10.3389/fphys.2023.1231016] [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] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.
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Affiliation(s)
- Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Berger D, Werner Moller P, Bachmann KF. Cardiopulmonary interactions-which monitoring tools to use? Front Physiol 2023; 14:1234915. [PMID: 37621761 PMCID: PMC10445648 DOI: 10.3389/fphys.2023.1234915] [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] [Received: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
Heart-lung interactions occur due to the mechanical influence of intrathoracic pressure and lung volume changes on cardiac and circulatory function. These interactions manifest as respiratory fluctuations in venous, pulmonary, and arterial pressures, potentially affecting stroke volume. In the context of functional hemodynamic monitoring, pulse or stroke volume variation (pulse pressure variation or stroke volume variability) are commonly employed to assess volume or preload responsiveness. However, correct interpretation of these parameters requires a comprehensive understanding of the physiological factors that determine pulse pressure and stroke volume. These factors include pleural pressure, venous return, pulmonary vessel function, lung mechanics, gas exchange, and specific cardiac factors. A comprehensive knowledge of heart-lung physiology is vital to avoid clinical misjudgments, particularly in cases of right ventricular (RV) failure or diastolic dysfunction. Therefore, when selecting monitoring devices or technologies, these factors must be considered. Invasive arterial pressure measurements of variations in breath-to-breath pressure swings are commonly used to monitor heart-lung interactions. Echocardiography or pulmonary artery catheters are valuable tools for differentiating preload responsiveness from right ventricular failure, while changes in diastolic function should be assessed alongside alterations in airway or pleural pressure, which can be approximated by esophageal pressure. In complex clinical scenarios like ARDS, combined forms of shock or right heart failure, additional information on gas exchange and pulmonary mechanics aids in the interpretation of heart-lung interactions. This review aims to describe monitoring techniques that provide clinicians with an integrative understanding of a patient's condition, enabling accurate assessment and patient care.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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Kenny JES. A framework for heart-lung interaction and its application to prone position in the acute respiratory distress syndrome. Front Physiol 2023; 14:1230654. [PMID: 37614757 PMCID: PMC10443730 DOI: 10.3389/fphys.2023.1230654] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
While both cardiac output (Qcirculatory) and right atrial pressure (PRA) are important measures in the intensive care unit (ICU), they are outputs of the system and not determinants. That is to say, in a model of the circulation wherein venous return and cardiac function find equilibrium at an 'operating point' (OP, defined by the PRA on the x-axis and Qcirculatory on the y-axis) both the PRA and Qcirculatory are, necessarily, dependent variables. A simplified geometrical approximation of Guyton's model is put forth to illustrate that the independent variables of the system are: 1) the mean systemic filling pressure (PMSF), 2) the pressure within the pericardium (PPC), 3) cardiac function and 4) the resistance to venous return. Classifying independent and dependent variables is clinically-important for therapeutic control of the circulation. Recent investigations in patients with acute respiratory distress syndrome (ARDS) have illuminated how PMSF, cardiac function and the resistance to venous return change when placing a patient in prone. Moreover, the location of the OP at baseline and the intimate physiological link between the heart and the lungs also mediate how the PRA and Qcirculatory respond to prone position. Whereas turning a patient from supine to prone is the focus of this discussion, the principles described within the framework apply equally-well to other more common ICU interventions including, but not limited to, ventilator management, initiating vasoactive medications and providing intravenous fluids.
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Affiliation(s)
- Jon-Emile S. Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, Toronto, ON, Canada
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Moller PW, Berger DC. Commentary: Feasibility to estimate mean systemic filling pressure with inspiratory holds at the bedside. Front Physiol 2023; 14:1135769. [PMID: 36950297 PMCID: PMC10025291 DOI: 10.3389/fphys.2023.1135769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/21/2023] [Indexed: 03/08/2023] Open
Affiliation(s)
- Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Per Werner Moller,
| | - David Christian Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Persichini R, Lai C, Teboul JL, Adda I, Guérin L, Monnet X. Venous return and mean systemic filling pressure: physiology and clinical applications. Crit Care 2022; 26:150. [PMID: 35610620 PMCID: PMC9128096 DOI: 10.1186/s13054-022-04024-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/17/2022] [Indexed: 01/15/2023] Open
Abstract
Venous return is the flow of blood from the systemic venous network towards the right heart. At steady state, venous return equals cardiac output, as the venous and arterial systems operate in series. However, unlike the arterial one, the venous network is a capacitive system with a high compliance. It includes a part of unstressed blood, which is a reservoir that can be recruited via sympathetic endogenous or exogenous stimulation. Guyton’s model describes the three determinants of venous return: the mean systemic filling pressure, the right atrial pressure and the resistance to venous return. Recently, new methods have been developed to explore such determinants at the bedside. In this narrative review, after a reminder about Guyton’s model and current methods used to investigate it, we emphasize how Guyton’s physiology helps understand the effects on cardiac output of common treatments used in critically ill patients.
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Affiliation(s)
- Romain Persichini
- Service de Réanimation et Soins Continus, Centre Hospitalier de Saintonge, 11 Boulevard Ambroise Paré, 17108, Saintes cedex, France.
| | - Christopher Lai
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Imane Adda
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Laurent Guérin
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
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Berger D, Wigger O, de Marchi S, Grübler MR, Bloch A, Kurmann R, Stalder O, Bachmann KF, Bloechlinger S. The effects of positive end-expiratory pressure on cardiac function: a comparative echocardiography-conductance catheter study. Clin Res Cardiol 2022; 111:705-719. [PMID: 35381904 PMCID: PMC9151717 DOI: 10.1007/s00392-022-02014-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/21/2022] [Indexed: 01/09/2023]
Abstract
Background Echocardiographic parameters of diastolic function depend on cardiac loading conditions, which are altered by positive pressure ventilation. The direct effects of positive end-expiratory pressure (PEEP) on cardiac diastolic function are unknown. Methods Twenty-five patients without apparent diastolic dysfunction undergoing coronary angiography were ventilated noninvasively at PEEPs of 0, 5, and 10 cmH2O (in randomized order). Echocardiographic diastolic assessment and pressure–volume-loop analysis from conductance catheters were compared. The time constant for pressure decay (τ) was modeled with exponential decay. End-diastolic and end-systolic pressure volume relationships (EDPVRs and ESPVRs, respectively) from temporary caval occlusion were analyzed with generalized linear mixed-effects and linear mixed models. Transmural pressures were calculated using esophageal balloons. Results τ values for intracavitary cardiac pressure increased with the PEEP (n = 25; no PEEP, 44 ± 5 ms; 5 cmH2O PEEP, 46 ± 6 ms; 10 cmH2O PEEP, 45 ± 6 ms; p < 0.001). This increase disappeared when corrected for transmural pressure and diastole length. The transmural EDPVR was unaffected by PEEP. The ESPVR increased slightly with PEEP. Echocardiographic mitral inflow parameters and tissue Doppler values decreased with PEEP [peak E wave (n = 25): no PEEP, 0.76 ± 0.13 m/s; 5 cmH2O PEEP, 0.74 ± 0.14 m/s; 10 cmH2O PEEP, 0.68 ± 0.13 m/s; p = 0.016; peak A wave (n = 24): no PEEP, 0.74 ± 0.12 m/s; 5 cmH2O PEEP, 0.7 ± 0.11 m/s; 10 cmH2O PEEP, 0.67 ± 0.15 m/s; p = 0.014; E’ septal (n = 24): no PEEP, 0.085 ± 0.016 m/s; 5 cmH2O PEEP, 0.08 ± 0.013 m/s; 10 cmH2O PEEP, 0.075 ± 0.012 m/s; p = 0.002]. Conclusions PEEP does not affect active diastolic relaxation or passive ventricular filling properties. Dynamic echocardiographic filling parameters may reflect changing loading conditions rather than intrinsic diastolic function. PEEP may have slight positive inotropic effects. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02267291, registered 17. October 2014. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-022-02014-1.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Olivier Wigger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Stefano de Marchi
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin R Grübler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Zentrum Für Intensivmedizin, Kantonsspital Luzern, Luzern, Switzerland
| | - Reto Kurmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Luzern, Luzern, Switzerland
| | | | - Kaspar Felix Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Zentrum Für Intensivmedizin, Kantonsspital Luzern, Luzern, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital,, University of Bern, Bern, Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Klinik Für Kardiologie, Kantonsspital Winterthur, Winterthur, Switzerland
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Megri M, Fridenmaker E, Disselkamp M. Where Are We Heading With Fluid Responsiveness and Septic Shock? Cureus 2022; 14:e23795. [PMID: 35518529 PMCID: PMC9065654 DOI: 10.7759/cureus.23795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 11/05/2022] Open
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Cai T, Li C, Xu B, Wang L, Du Z, Hao X, Guo D, Xing Z, Jiang C, Xin M, Wang P, Fan Q, Wang H, Hou X. Drainage From Superior Vena Cava Improves Upper Body Oxygenation in Patients on Femoral Veno-Arterial Extracorporeal Membrane Oxygenation. Front Cardiovasc Med 2022; 8:807663. [PMID: 35242819 PMCID: PMC8886363 DOI: 10.3389/fcvm.2021.807663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/27/2021] [Indexed: 01/20/2023] Open
Abstract
Objective To investigate the feasibility of drainage from the superior vena cava (SVC) to improve upper body oxygenation in patients with cardiogenic shock undergoing femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). Methods Seventeen adult patients receiving peripheral femoral VA ECMO for circulatory support were enrolled. The femoral drainage cannula was shifted three times (from the inferior vena cava (IVC) level to the SVC level and then the IVC level again), all under ultrasound guidance, at an interval of 15 minutes. The blood gas levels of the right radial artery (RA) and SVC and cerebral oxygen saturation (ScO2) were measured and compared. Results Fifteen patients (88.2%) were successfully weaned from ECMO, and 12 patients (70.6%) survived to discharge. The oxygen saturation (SO2) and oxygen partial pressure (PO2) of the RA (97.0 ± 3.5% to 98.3 ± 1.5%, P < 0.05, SO2; 127.4 ± 58.2 mmHg to 153.1 ± 67.8 mmHg, P < 0.05, PO2) and SVC (69.5 ± 9.0% to 75.7 ± 8.5%, P < 0.05, SO2; 38.5 ± 5.6 mmHg to 43.6 ± 6.4 mmHg, P < 0.05, PO2) were increased; ScO2 was also increased on both sides (left: 50.6 ± 8.6% to 55.0 ± 9.0%, P < 0.05; right: 48.7 ± 9.2% to 52.3 ± 9.8%, P < 0.05) when the femoral drainage cannula was shifted from the IVC level to the SVC level. When the femoral drainage cannula was shifted from SVC level to the IVC level again, the SO2 and PO2 of RA (98.3 ± 1.5% to 96.9 ± 3.2%, P <0.05, SO2; 153.1 ± 67.8 mmHg to 125.8 ± 63.3 mmHg, P <0.05, PO2) and SVC (75.7 ± 38.5% to 70.4 ± 7.6%, P <0.05, SO2; 43.6 ± 6.4 mmHg to 38.9 ± 4.5 mmHg, P <0.05, PO2) were decreased; ScO2 was also reduced on both sides (left: 55.0 ± 9.0% to 50.7 ± 8.2%, P < 0.05; right: 52.3 ± 9.8% to 48.7 ± 9.3%, P <0.05). Conclusion Drainage from the SVC by shifting the cannula upward could improve upper body oxygenation in patients with cardiogenic shock undergoing femoral VA ECMO. This cannulation strategy provides an alternative solution for differential hypoxia.
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Affiliation(s)
- Tong Cai
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bo Xu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dong Guo
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhichen Xing
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chunjing Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng Xin
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Pengcheng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiushi Fan
- School of Public Health, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Werner-Moller P, Heinisch PP, Hana A, Bachmann KF, Sondergaard S, Jakob SM, Takala J, Berger D. Experimental validation of a mean systemic pressure analog against zero-flow measurements in porcine VA-ECMO. J Appl Physiol (1985) 2022; 132:726-736. [PMID: 35085032 DOI: 10.1152/japplphysiol.00804.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
The mean systemic pressure analog (Pmsa), calculated from running hemodynamic data, estimates mean systemic filling pressure (MSFP). This post hoc study used data from a porcine veno-arterial extracorporeal membrane oxygenation (ECMO) model [n = 9; Sus scrofa domesticus; ES breed (Schweizer Edelschwein)] with eight experimental conditions; Euvolemia [a volume state where ECMO flow produced normal mixed venous saturation (SVO2) without vascular collapse]; three levels of increasing norepinephrine infusion (Vasoconstriction 1-3); status after stopping norepinephrine (Post Vasoconstriction); and three steps of volume expansion (10 mL/kg crystalloid bolus) (Volume Expansion 1-3). In each condition, Pmsa and a "reduced-pump-speed-Pmsa" (Pmsared) were calculated from baseline and briefly reduced pump speeds, respectively. We calculated agreement for absolute values (per condition) and changes (between consecutive conditions) of Pmsa and Pmsared, against MSFP at zero ECMO flow. Euvolemia venous return driving pressure was 5.1 ± 2.0 mmHg. Bland-Altman analysis for Pmsa vs. MSFP (all conditions; 72 data pairs) showed bias (confidence interval) 0.5 (0.1-0.9) mmHg; limits of agreement (LoA) -2.7 to 3.8 mmHg. Bias for ΔPmsa vs. ΔMSFP (63 data pairs): 0.2 (-0.2 to 0.6) mmHg, LoA -3.2 to 3.6 mmHg. Bias for Pmsared vs. MSFP (72 data pairs): 0.0 (-0.3 to -0.3) mmHg; LoA -2.3 to 2.4 mmHg. Bias for ΔPmsared vs. ΔMSFP (63 data pairs) was 0.2 (-0.1 to 0.4) mmHg; LoA -1.8 to 2.1 mmHg. In conclusion, during veno-arterial ECMO, under clinically relevant levels of vasoconstriction and volume expansion, Pmsa accurately estimated absolute and changing values of MSFP, with low between-method precision. The within-method precision of Pmsa was excellent, with a least significant change of 0.15 mmHg.NEW & NOTEWORTHY This is the first study ever to validate the mean systemic pressure analog (Pmsa) against the reference mean systemic filling pressure (MSFP) determined at full arterio-venous pressure equilibrium. Using a porcine ECMO model with clinically relevant levels of vasoconstriction and volume expansion, we showed that Pmsa accurately estimated absolute and changing values of MSFP, with a poor between-method precision. The within-method precision of Pmsa was excellent.
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Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesia, Surgery and Intensive Care, SV Hospital Group, Alingsas, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Laurentius Hospital, Roermond, The Netherlands
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Intensive Care Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Soren Sondergaard
- Department of Intensive Care and Neurointensive Stepdown Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Pitton MB, Weinmann A, Kloeckner R, Mittler J, Ruckes C, Düber C, Otto G. Transjugular Portosystemic Stent Shunt: Impact of Right Atrial Pressure on Portal Venous Hemodynamics Within the First Week. Cardiovasc Intervent Radiol 2021; 45:102-111. [PMID: 34853873 PMCID: PMC8716358 DOI: 10.1007/s00270-021-03003-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/30/2021] [Indexed: 12/15/2022]
Abstract
Purpose Porto-systemic pressure gradient is used to prognosticate rebleeding and resolution of ascites after TIPS. This study investigates the reliability of portal pressure characteristics as quantified immediately after TIPS placement and at short-term control. Patients and Methods Portal venous pressure (PVP) and right atrial pressure (RAP) were prospectively obtained before and after TIPS as well as ≥ 48 h after TIPS procedure. Porto-systemic pressure gradients (PSG) and pressure changes were calculated. A multivariate regression analysis was performed to predict portal hemodynamics at short-term control. Results The study included 124 consecutive patients. Indications for TIPS were refractory ascites, variceal bleeding or combinations of both. Pre- and post-interventional PSG yielded 16.4 ± 5.3 mmHg and 5.9 ± 2.7 mmHg, respectively. At that time, 105/124 patients (84.7%) met the target (PSG ≤ 8 mmHg). After 4 days (median), PSG was 8.5 ± 3.5 mmHg and only 66 patients (53%) met that target. In patients exceeding the target PSG at follow-up, PVP was significantly higher and RAP was lower resulting in the increased PSG. The highly variable changes of RAP were the main contributor to different pressure gradients. In the multivariate regression analysis, PVP and RAP immediately after TIPS were predictors for PSG at short-term control with moderately predictive capacity (AUC = 0.75). Conclusion Besides the reduction of portal vein pressure, the highly variable right atrial pressure was the main contributor to different pressure gradients. Thus, immediate post-TIPS measurements do not reliably predict portal hemodynamics during follow-up. These findings need to be further investigated with respect to the corresponding clinical course of the patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-03003-z.
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Affiliation(s)
- Michael Bernhard Pitton
- Department of Diagnostic and Interventional Radiology, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstr.1, 55131, Mainz, Germany.
| | - Arndt Weinmann
- Department of Internal Medicine, University Medical Center, Langenbeckstr.1, 55131, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstr.1, 55131, Mainz, Germany
| | - Jens Mittler
- Department of General and Visceral Surgery and Transplantation Surgery, University Medical Center, Langenbeckstr.1, 55131, Mainz, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center, 55131, Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center, Johannes Gutenberg University Mainz, Langenbeckstr.1, 55131, Mainz, Germany
| | - Gerd Otto
- Emeritus of the Division of Transplantation Surgery, University Medical Center, Langenbeckstr.1, 55131, Mainz, Germany
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Stiles TW, Morfin Rodriguez AE, Mohiuddin HS, Lee H, Dalal FA, Fuertes WW, Adams TH, Stewart RH, Quick CM. Algebraic formulas characterizing an alternative to Guyton's graphical analysis relevant for heart failure. Am J Physiol Regul Integr Comp Physiol 2021; 320:R851-R870. [PMID: 33596744 DOI: 10.1152/ajpregu.00260.2019] [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]
Abstract
Although Guyton's graphical analysis of cardiac output-venous return has become a ubiquitous tool for explaining how circulatory equilibrium emerges from heart-vascular interactions, this classical model relies on a formula for venous return that contains unphysiological assumptions. Furthermore, Guyton's graphical analysis does not predict pulmonary venous pressure, which is a critical variable for evaluating heart failure patients' risk of pulmonary edema. Therefore, the purpose of the present work was to use a minimal closed-loop mathematical model to develop an alternative to Guyton's analysis. Limitations inherent in Guyton's model were addressed by 1) partitioning the cardiovascular system differently to isolate left ventricular function and lump all blood volumes together, 2) linearizing end-diastolic pressure-volume relationships to obtain algebraic solutions, and 3) treating arterial pressures as constants. This approach yielded three advances. First, variables related to morbidities associated with left ventricular failure were predicted. Second, an algebraic formula predicting left ventricular function was derived in terms of ventricular properties. Third, an algebraic formula predicting flow through the portion of the system isolated from the left ventricle was derived in terms of mechanical properties without neglecting redistribution of blood between systemic and pulmonary circulations. Although complexities were neglected, approximations necessary to obtain algebraic formulas resulted in minimal error, and predicted variables were consistent with reported values.
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Affiliation(s)
- Thomas W Stiles
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | | | - Hanifa S Mohiuddin
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Hyunjin Lee
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Fazal A Dalal
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Wesley W Fuertes
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Thaddeus H Adams
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Randolph H Stewart
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
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15
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He H, Yuan S, Long Y, Liu D, Zhou X, Ince C. Effect of norepinephrine challenge on cardiovascular determinants assessed using a mathematical model in septic shock: a physiological study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:561. [PMID: 33987259 PMCID: PMC8105783 DOI: 10.21037/atm-20-6686] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/12/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The present study investigated the cardiovascular determinants of cardiac output (CO), mean systemic filling pressure analogue (Pmsa) derived by Geoffrey Parkin, efficiency of heart (Eh) and related parameters to a norepinephrine (NE) challenge [an increase of 10 mmHg mean arterial pressure (MAP) by NE] in septic shock patients using of a mathematical model. METHODS Twenty-seven septic shock patients with pulse index continuous cardiac output (PiCCO) monitoring were enrolled. These patients required NE to maintain an individualized MAP for organ perfusion after early fluid resuscitation based on their clinical condition. NE was decreased to obtain a decrease of 10 mmHg from base MAP (MAP-10mmHg), and the NE doses were adjusted to return MAP to baseline (MAPbase) and produce an increase of 10 mmHg from MAPbase (MAP+10mmHg). Two NE challenge episodes were analyzed for each patient: from MAP-10mmHg to MAPbase and from MAPbase to MAP+10mmHg. The Pmsa, pressure gradient for venous return (PGvr), and Eh (PGvr relative to Pmsa) were estimated using a mathematical model for the three MAP levels (MAP-10mmHg, MAPbase and MAP+10mmHg). RESULTS A total of 54 episodes of NE challenges were obtained in 27 patients. Significant and consistent increases were observed in the central venous pressure (CVP), Pmsa, and PGvr in response during the NE titration. ΔCO negatively and significantly correlated with ΔCVP (r=-0.722, P<0.0001), ΔPmsa (r=-0.549, P<0.0001), ΔResistance of venous return (Rvr) (r=-0.597, P<0.0001), and ΔResistance of systemic vascular beds (Rsys) (r=-0.597, P<0.0001). Episodes of decreasing CO/Eh were associated with a higher ΔCVP than the CO/Eh-increasing episodes. The area under the curve (AUC) of ΔCVP to predict decreased CO by the incremental NE was 0.86, and the AUC of ΔCVP to predict decreased Eh was 0.94. A cutoff of ΔCVP >1.5 mmHg for detecting decreased CO resulted in a sensitivity of 75% and a specificity of 94.1%. A cutoff of ΔCVP >1.5 mmHg for detecting decreased Eh resulted in a sensitivity of 64.3% and a specificity of 100%. CONCLUSIONS There were a highly divergent response in Eh and CO to afterload challenge episodes of an NE-induced 10mmHg increase in MAP. An increase in CVP may be an early alarm to identify the reduction in CO/Eh during an NE-induced increase of MAP.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Hospital, Rotterdam, The Netherlands
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16
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Valenti E, Moller PW, Takala J, Berger D. Collapsibility of caval vessels and right ventricular afterload: decoupling of stroke volume variation from preload during mechanical ventilation. J Appl Physiol (1985) 2021; 130:1562-1572. [PMID: 33734829 DOI: 10.1152/japplphysiol.01039.2020] [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
Collapsibility of caval vessels and stroke volume and pulse pressure variations (SVV, PPV) are used as indicators of volume responsiveness. Their behavior under increasing airway pressures and changing right ventricular afterload is incompletely understood. If the phenomena of SVV and PPV augmentation are manifestations of decreasing preload, they should be accompanied by decreasing transmural right atrial pressures. Eight healthy pigs equipped with ultrasonic flow probes on the pulmonary artery were exposed to positive end-expiratory pressure of 5 and 10 cmH2O and three volume states (Euvolemia, defined as SVV < 10%, Bleeding, and Retransfusion). SVV and PPV were calculated for the right and PPV for the left side of the circulation at increasing inspiratory airway pressures (15, 20, and 25 cmH2O). Right ventricular afterload was assessed by surrogate flow profile parameters. Transmural pressures in the right atrium and the inferior and superior caval vessels (IVC and SVC) were determined. Increasing airway pressure led to increases in ultrasonic surrogate parameters of right ventricular afterload, increasing transmural pressures in the right atrium and SVC, and a drop in transmural IVC pressure. SVV and PPV increased with increasing airway pressure, despite the increase in right atrial transmural pressure. Right ventricular stroke volume variation correlated with indicators of right ventricular afterload. This behavior was observed in both PEEP levels and all volume states. Stroke volume variation may reflect changes in right ventricular afterload rather than changes in preload.NEW & NOTEWORTHY Stroke volume variation and pulse pressure variation are used as indicators of preload or volume responsiveness of the heart. Our study shows that these variations are influenced by changes in right ventricular afterload and may therefore reflect right ventricular failure rather than pure volume responsiveness. A zone of collapse detaches the superior vena cava and its diameter variation from the right atrium.
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Affiliation(s)
- Elisa Valenti
- Department of Intensive Care Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland.,Intensive Care Unit and Department of Intensive Care, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Per W Moller
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, SV Hospital Group, Alingsas, Sweden
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
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17
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Schulz L, Geri G, Vieillard‐Baron A, Vignon P, Parkin G, Aneman A. Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study. Acta Anaesthesiol Scand 2021; 65:320-328. [PMID: 33169357 DOI: 10.1111/aas.13735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa ) and derived variables to explain the response to a fluid bolus. METHODS The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa , the volume efficiency (Evol ), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. RESULTS Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P = .03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P = .04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 = .48, P < .001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r = .55, P < .001). CONCLUSION The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.
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Affiliation(s)
- Luis Schulz
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
| | - Guillaume Geri
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Antoine Vieillard‐Baron
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Philippe Vignon
- Medical‐surgical Intensive Care Unit Limoges University Hospital Limoges France
- INSERM CIC 1435 Limoges University Hospital Limoges France
- Faculty of Medicine University of Limoges Limoges France
| | - Geoffrey Parkin
- Intensive Care Unit Monash Medical Centre Clayton Vic. Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney NSW Australia
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18
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Bachmann KF, Zwicker L, Nettelbeck K, Casoni D, Heinisch PP, Jenni H, Haenggi M, Berger D. Assessment of Right Heart Function during Extracorporeal Therapy by Modified Thermodilution in a Porcine Model. Anesthesiology 2020; 133:879-891. [PMID: 32657798 DOI: 10.1097/aln.0000000000003443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation therapy is a growing treatment modality for acute cardiorespiratory failure. Cardiac output monitoring during veno-arterial extracorporeal membrane oxygenation therapy remains challenging. This study aims to validate a new thermodilution technique during veno-arterial extracorporeal membrane oxygenation therapy using a pig model. METHODS Sixteen healthy pigs were centrally cannulated for veno-arterial extracorporeal membrane oxygenation, and precision flow probes for blood flow assessment were placed on the pulmonary artery. After chest closure, cold boluses of 0.9% saline solution were injected into the extracorporeal membrane oxygenation circuit, right atrium, and right ventricle at different extracorporeal membrane oxygenation flows (4, 3, 2, 1 l/min). Rapid response thermistors in the extracorporeal membrane oxygenation circuit and pulmonary artery recorded the temperature change. After calculating catheter constants, the distributions of injection volumes passing each circuit were assessed and enabled calculation of pulmonary blood flow. Analysis of the exponential temperature decay allowed assessment of right ventricular function. RESULTS Calculated blood flow correlated well with measured blood flow (r2 = 0.74, P < 0.001). Bias was -6 ml/min [95% CI ± 48 ml/min] with clinically acceptable limits of agreement (668 ml/min [95% CI ± 166 ml/min]). Percentage error varied with extracorporeal membrane oxygenation blood flow reductions, yielding an overall percentage error of 32.1% and a percentage error of 24.3% at low extracorporeal membrane oxygenation blood flows. Right ventricular ejection fraction was 17 [14 to 20.0]%. Extracorporeal membrane oxygenation flow reductions increased end-diastolic and end-systolic volumes with reductions in pulmonary vascular resistance. Central venous pressure and right ventricular ejection fractions remained unchanged. End-diastolic and end-systolic volumes correlated highly (r2 = 0.98, P < 0.001). CONCLUSIONS Adapted thermodilution allows reliable assessment of cardiac output and right ventricular behavior. During veno-arterial extracorporeal membrane oxygenation weaning, the right ventricle dilates even with stable function, possibly because of increased venous return. EDITOR’S PERSPECTIVE
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19
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van Loon LM, van der Hoeven H, Veltink PH, Lemson J. The inspiration hold maneuver is a reliable method to assess mean systemic filling pressure but its clinical value remains unclear. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1390. [PMID: 33313135 PMCID: PMC7723632 DOI: 10.21037/atm-20-3540] [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] [Indexed: 11/22/2022]
Abstract
Background The upstream pressure for venous return (VR) is considered to be a combined conceptual blood pressure of the systemic vessels: the mean systemic filling pressure (MSFP). The relevance of estimating the MSFP during dynamic changes of the circulation at the bedside is controversial. Herein, we studied the effect of high ventilatory pressures on the relationship between VR and central venous pressure (CVP). Methods In 9 healthy pigs under anaesthesia and mechanically ventilated, MSFP was estimated from extrapolated VR versus CVP relationships during inspiratory hold maneuvers (IHMs) with different levels of ventilatory pressure (Pvent). MSFP was measure 3 times per animal during euvolemia and hypovolemia. Hypovolemia was induced by bleeding with 10 mL/kg. The estimated MSFP values were compared to the blood pressure recording after induced ventricle fibrillation (i.e., mean circulatory filling pressure). Results Our results revealed a strong linear correlation between VR and CVP [R2 of 0.92 (range, 0.67–0.99)], during IHMs with different levels of Pvent. Volume status significantly alters the resulting MSFP, 20±1 and 16±2 mmHg for euvolemia and hypovolemia respectively. This estimation of the MSFP was strongly correlated—but not interchangeable—to the blood pressure recording after induced ventricle fibrillation (R2=0.8 and P=0.045). Conclusions In conclusion, we showed a strong linear correlation between VR and CVP—when applying IHMs with high levels of Pvent—however the clinical applicability of this method to guide volume therapy in its current form is improbable.
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Affiliation(s)
- Lex M van Loon
- Cardiovascular and Respiratory Physiology Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - Peter H Veltink
- Biomedical Signals and Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, The Netherlands
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20
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Berger D, Hobi J, Möller PW, Haenggi M, Takala J, Jakob SM. Right ventricular stroke volume assessed by pulmonary artery pulse contour analysis. Intensive Care Med Exp 2020; 8:58. [PMID: 33026562 PMCID: PMC7539259 DOI: 10.1186/s40635-020-00347-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background Stroke volume measurement should provide estimates of acute treatment responses. The current pulse contour method estimates left ventricle stroke volume. Heart-lung interactions change right ventricular stroke volume acutely. We investigated the accuracy, precision, and trending abilities of four calibrated stroke volume estimates based on pulmonary artery pulse contour analysis. Results Stroke volume was measured in 9 pigs with a pulmonary artery ultrasound flow probe at 5 and 10 cmH2O of PEEP and three volume states (baseline, bleeding, and retransfusion) and compared against stroke volume estimates of four calibrated pulmonary pulse contour algorithms based on pulse pressure or pressure integration. Bland-Altman comparison with correction for multiple measurements and trend analysis were performed. Heart rate and stroke volumes were 104 ± 24 bpm and 30 ± 12 mL, respectively. The stroke volume estimates had a minimal bias: − 0.11 mL (95% CI − 0.55 to 0.33) to 0.32 mL (95% CI − 0.06 to 0.70). The limits of agreement were − 8.0 to 7.8 mL for calibrated pulse pressure to − 10.4 to 11.5 mL for time corrected pressure integration, resulting in a percentage error of 36 to 37%. The calibrated pulse pressure method performed best. Changes in stroke volume were trended very well (concordance rates 73–100%, r2 0.26 to 0.987, for pulse pressure methods and 71–100%, r2 0.236 to 0.977, for integration methods). Conclusions Pulmonary artery pulse contour methods reliably detect acute changes in stroke volume with good accuracy and moderate precision and accurately trend short-term changes in cardiac output over time.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Jan Hobi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Per W Möller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.,Department of Anaesthesiology, Alingsas Hospital, Alingsås, Sweden
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
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21
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Liu S, do Amaral Campos PPZ, Casoni D, Berger D, Kohler A, Bloch A, Bervini D, Setzer F, Cameron DR, Z'Graggen W, Hana A, Langer R, Corrêa TD, Beldi G, Takala J, Jakob SM. Defense mechanisms to increasing back pressure for hepatic oxygen transport and venous return in porcine fecal peritonitis. Am J Physiol Gastrointest Liver Physiol 2020; 319:G289-G302. [PMID: 32658622 DOI: 10.1152/ajpgi.00216.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
High central venous pressure (CVP) acutely decreases venous return. How this affects hepatic oxygen transport in sepsis remains unclear. The aim of this study was to evaluate the effects of repeated increases in CVP via standard nursing procedures (NPs) on hepato-splanchnic and renal oxygen transport in a prolonged porcine sepsis model. Twenty anesthetized and mechanically ventilated pigs with regional hemodynamics monitored were randomized to fecal peritonitis or controls (n = 10 pigs/group). Resuscitation was started after 8 h of observation and continued for 3 days. NPs were performed at baseline and 8 h, 32 h, 56 h, and 72 h after resuscitation started. NPs increased CVP by 4-7 mmHg in both groups. In controls, this was associated with less decrease in hepatic arterial (Qha; 62 ± 70 mL/min) than portal venous flow (Qpv; 364 ± 151 mL/min). Portal venous oxygen content and hepatic O2 delivery (Do2) and consumption (V̇o2) decreased by 11 ± 6 mL/dL and 0.9 ± 0.3 and 0.4 ± 0.3 mL·min-1·kg-1, respectively. In septic animals, hepatic Do2 decreased more in response to increasing CVP (1.5 ± 0.9 mL·min-1·kg-1), which was attributable to a larger fall in both Qha (88 ± 66 ml/min) and portal O2 content (14 ± 10 mL/dL, all P < 0.05). This resulted in numerically lower hepatic V̇o2 since O2 extraction did not increase significantly. In control conditions, a smaller decrease in Qha compared with Qpv helped to limit the reduction in hepatic V̇o2 in response to acute CVP increase. In sepsis, the contribution of Qha to maintain hepatic Do2 was reduced, which jeopardized hepatic V̇o2 further. Renal arterial flow was similarly affected by CVP increase as Qha.NEW & NOTEWORTHY Sepsis impairs intrinsic mechanisms to attenuate effects of increasing back pressure on hepatic oxygen transport.
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Affiliation(s)
- Shengchen Liu
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | | | - Daniela Casoni
- Experimental Surgery Facility, Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Setzer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David R Cameron
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rupert Langer
- Institue of Pathology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thiago D Corrêa
- Department of Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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22
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Bouchez S, De Somer F. The evolving role of the modern perfusionist: insights from transesophageal echocardiography. Perfusion 2020; 36:222-232. [PMID: 32729372 DOI: 10.1177/0267659120944094] [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: 11/16/2022]
Abstract
Transesophageal echocardiography is a relatively non-invasive, mobile, safe imaging technique that is ideal for providing real-time information on cardiac anatomy and function during heart surgery. The technology has evolved from two-dimensional to real-time three-dimensional imaging during cardiac procedures, which has significantly benefited preoperative planning, intraoperative guidance, evaluation, and postoperative follow-up. Transesophageal echocardiography may serve the clinical perfusionist by providing imaging guidance for identifying potential problems before cardiopulmonary bypass, guiding the proper placement of cannulas, monitoring cardiac performance on cardiopulmonary bypass, and providing useful feedback during weaning from cardiopulmonary bypass. Although the perfusionist should be able to understand all echocardiographic images and measurements in depth, perfusion-related echocardiographic information can or should be used to optimize the clinical practice of the modern perfusionist. Vice versa, whenever the perfusionist suspects a problem, the surgical team including the sonographer should verify this "clinical treat" by echocardiography whenever possible.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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23
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Werner-Moller P, Berger D, Takala J. Letter to the Editor: Venous return and the physical connection between distribution of segmental pressures and volumes. Am J Physiol Heart Circ Physiol 2020; 318:H203-H204. [PMID: 31910359 DOI: 10.1152/ajpheart.00698.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Anaesthesiology, Alingsas Hospital, Alingsas, Sweden
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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24
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Brengelmann GL. Reply to "Letter to the Editor: Venous return and the physical connection between distribution of segmental pressures and volumes". Am J Physiol Heart Circ Physiol 2020; 318:H205-H206. [PMID: 31910360 DOI: 10.1152/ajpheart.00730.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- George L Brengelmann
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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25
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Brengelmann GL. Venous return and the physical connection between distribution of segmental pressures and volumes. Am J Physiol Heart Circ Physiol 2019; 317:H939-H953. [PMID: 31518160 DOI: 10.1152/ajpheart.00381.2019] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
More than sixty years ago, Guyton and coworkers related their observations of venous return to a mathematical model. Showing steady-state flow (F) as proportional to the difference between mean systemic pressure (Pms) and right atrial pressure (Pra), the model fit their data. The parameter defined by the ratio (Pms - Pra)/F, first called an "impedance," came to be called the "resistance to venous return." The interpretation that Pra opposes Pms and that, to increase output, the heart must act to reduce back pressure at the right atrium was widely accepted. Today, the perceived importance of Pms is evident in the efforts to find reliable ways to estimate it in patients. This article reviews concepts about venous return, criticizing some as inconsistent with elementary physical principles. After review of basic background topics-the steady-state vascular compliance; stressed versus unstressed volume-simulations from a multicompartment model based on data and definitions from Rothe's classical review of the venous system are presented. They illustrate the obligatory connection between flow-dependent compartment pressures and the distribution of volume among vascular compartments. An appendix shows that the pressure profile can be expressed either as decrements relative to arterial pressure or as increments relative to Pra (the option taken in the original model). Conclusion: The (Pms - Pra)/F formulation was never about Pms physically driving venous return; it was about how intravascular volume distributes among compliant compartments in accordance with their flow-dependent distending pressures, arbitrarily expressed relative to Pra rather than arterial pressure.
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Affiliation(s)
- George L Brengelmann
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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26
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Moller PW, Berger D. Reply to “What if what you are looking for is not there?” and “Towards a functional definition of euvolemia”. J Appl Physiol (1985) 2019; 127:276. [DOI: 10.1152/japplphysiol.00229.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Per W. Moller
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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27
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28
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Berger D, Moller PW, Takala J. Reply to "Is the Guytonian framework justified in explaining heart lung interactions?" and "Venous return, mean systemic pressure and getting the right answer for the wrong reason". ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:186. [PMID: 31169266 PMCID: PMC6526252 DOI: 10.21037/atm.2019.04.50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 08/25/2023]
Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per W. Moller
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Östra, Gothenburg, Sweden
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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29
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Werner-Moller P, Sondergaard S, Jakob SM, Takala J, Berger D. Effect of volume status on the estimation of mean systemic filling pressure. J Appl Physiol (1985) 2019; 126:1503-1513. [PMID: 30817243 DOI: 10.1152/japplphysiol.00897.2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Various methods for indirect assessment of mean systemic filling pressure (MSFP) produce controversial results compared with MSFP at zero blood flow. We recently reported that the difference between MSFP at zero flow measured by right atrial balloon occlusion (MSFPRAO) and MSFP estimated using inspiratory holds depends on the volume status. We now compare three indirect estimates of MSFP with MSFPRAO in euvolemia, bleeding, and hypervolemia in a model of anesthetized pigs (n = 9) with intact circulation. MSFP was estimated using instantaneous beat-to-beat venous return during tidal ventilation (MSFPinst_VR), right atrial pressure-flow data pairs at flow nadir during inspiratory holds (MSFPnadir_hold), and a dynamic model analog adapted to pigs (MSFPa). MSFPRAO was underestimated by MSFPnadir_hold and MSFPa in all volume states. Volume status modified the difference between MSFPRAO and all indirect methods (method × volume state interaction, P ≤ 0.020). All methods tracked changes in MSFPRAO concordantly, with the lowest bias seen for MSFPa [bias (confidence interval): -0.4 (-0.7 to -0.0) mmHg]. We conclude that indirect estimates of MSFP are unreliable in this experimental setup. NEW & NOTEWORTHY For indirect estimations of MSFP using inspiratory hold maneuvers, instantaneous beat-to-beat venous return, or a dynamic model analog, the accuracy was affected by the underlying volume state. All methods investigated tracked changes in MSFPRAO concordantly.
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Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland.,Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital Ostra, Gothenburg , Sweden
| | - Soren Sondergaard
- Centre of Elective Surgery, Silkeborg Regional Hospital , Silkeborg , Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
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30
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Marques NR, De Riese J, Yelverton BC, McQuitty C, Jupiter D, Willmann K, Salter M, Kinsky M, Johnston WE. Diastolic Function and Peripheral Venous Pressure as Indices for Fluid Responsiveness in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2019; 33:2208-2215. [PMID: 30738752 DOI: 10.1053/j.jvca.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus. DESIGN Prospective observational study. SETTING Two-center, university hospital study. PARTICIPANTS The study comprised 29 patients undergoing elective coronary revascularization. INTERVENTION Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders. MEASUREMENTS AND MAIN RESULTS Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058). CONCLUSION Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness.
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31
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Mahmood SS, Pinsky MR. Heart-lung interactions during mechanical ventilation: the basics. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:349. [PMID: 30370276 DOI: 10.21037/atm.2018.04.29] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The hemodynamic effects of mechanical ventilation can be grouped into three clinically relevant concepts. First, since spontaneous ventilation is exercise. In patients increased work of breathing, initiation of mechanical ventilatory support may improve O2 delivery because the work of breathing is reduced. Second, changes in lung volume alter autonomic tone, pulmonary vascular resistance, and at high lung volumes compress the heart in the cardiac fossa similarly to cardiac tamponade. As lung volume increases so does the pressure difference between airway and pleural pressure. When this pressure difference exceeds pulmonary artery pressure, pulmonary vessels collapse as they pass form the pulmonary arteries into the alveolar space increasing pulmonary vascular resistance. Hyperinflation increases pulmonary vascular resistance impeding right ventricular ejection. Anything that over distends lung units will increase their vascular resistance, and if occurring globally throughout the lung, increase pulmonary vascular resistance. Decreases in end-expiratory lung volume cause alveolar collapse increases pulmonary vasomotor tone by the process of hypoxic pulmonary vasoconstriction. Recruitment maneuvers that restore alveolar oxygenation without over distention will reduce pulmonary artery pressure. Third, positive-pressure ventilation increases intrathoracic pressure. Since diaphragmatic descent increases intra-abdominal pressure, the decrease in the pressure gradient for venous return is less than would otherwise occur if the only change were an increase in right atrial pressure. However, in hypovolemic states, it can induce profound decreases in venous return. Increases in intrathoracic pressure decreases left ventricular afterload and will augment left ventricular ejection. In patients with hypervolemic heart failure, this afterload reducing effect can result in improved left ventricular ejection, increased cardiac output and reduced myocardial O2 demand. This brief review will focus primarily on mechanical ventilation and intrathoracic pressure as they affect right and left ventricular function and cardiac output.
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Affiliation(s)
- Syed S Mahmood
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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32
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Berger D, Takala J. Determinants of systemic venous return and the impact of positive pressure ventilation. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:350. [PMID: 30370277 PMCID: PMC6186556 DOI: 10.21037/atm.2018.05.27] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/14/2018] [Indexed: 12/29/2022]
Abstract
Venous return, i.e., the blood flowing back to the heart, is driven by the pressure difference between mean systemic filling pressure and right atrial pressure (RAP). Besides cardiac function, it is the major determinant of cardiac output. Mean systemic filling pressure is a function of the vascular volume. The concept of venous return has a central role for heart lung interactions and the explanation of shock states. Mechanical ventilation during anaesthesia and critical illness may severely affect venous return by different mechanisms. In the first part of the following article, we will discuss the development of the concept of venous return, its specific components mean systemic and mean circulatory filling pressure (MCFP), RAP and resistance to venous return (RVR). We show how these pressures relate to the volume state of the circulation. Various interpretations and critiques are elucidated. In the second part, we focus on the impact of positive pressure ventilation on venous return and its components, including latest results from latest research.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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33
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Lindsey ML, Gray GA, Wood SK, Curran-Everett D. Statistical considerations in reporting cardiovascular research. Am J Physiol Heart Circ Physiol 2018; 315:H303-H313. [PMID: 30028200 PMCID: PMC6139626 DOI: 10.1152/ajpheart.00309.2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The problem of inadequate statistical reporting is long standing and widespread in the biomedical literature, including in cardiovascular physiology. Although guidelines for reporting statistics have been available in clinical medicine for some time, there are currently no guidelines specific to cardiovascular physiology. To assess the need for guidelines, we determined the type and frequency of statistical tests and procedures currently used in the American Journal of Physiology-Heart and Circulatory Physiology. A PubMed search for articles published in the American Journal of Physiology-Heart and Circulatory Physiology between January 1, 2017, and October 6, 2017, provided a final sample of 146 articles evaluated for methods used and 38 articles for indepth analysis. The t-test and ANOVA accounted for 71% (212 of 300 articles) of the statistical tests performed. Of six categories of post hoc tests, Bonferroni and Tukey tests were used in 63% (62 of 98 articles). There was an overall lack in details provided by authors publishing in the American Journal of Physiology-Heart and Circulatory Physiology, and we compiled a list of recommended minimum reporting guidelines to aid authors in preparing manuscripts. Following these guidelines could substantially improve the quality of statistical reports and enhance data rigor and reproducibility.
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Affiliation(s)
- Merry L Lindsey
- Mississippi Center for Heart Research, Department of Physiology and Biophysics, University of Mississippi Medical Center , Jackson, Mississippi.,Research Service, G. V. (Sonny) Montgomery Veterans Affairs Medical Center , Jackson, Mississippi
| | - Gillian A Gray
- British Heart Foundation/University Centre for Cardiovascular Science, Edinburgh Medical School, University of Edinburgh , Edinburgh , United Kingdom
| | - Susan K Wood
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina School of Medicine , Columbia, South Carolina
| | - Douglas Curran-Everett
- Division of Biostatistics and Bioinformatics, National Jewish Health , Denver, Colorado.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver , Denver, Colorado
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34
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Kamiya A, Hayama Y, Shimizu S, Kawada T. State-space representation of the extended Guyton's model. Am J Physiol Heart Circ Physiol 2017. [PMID: 28626078 DOI: 10.1152/ajpheart.00315.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Atsunori Kamiya
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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