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van Wyk L, Austin T, Barzilay B, Bravo MC, Breindahl M, Czernik C, Dempsey E, de Boode WP, de Vries W, Eriksen BH, Fauchére JC, Kooi EMW, Levy PT, McNamara PJ, Mitra S, Nestaas E, Rabe H, Rabi Y, Rogerson SR, Savoia M, Schena F, Seghal A, Schwarz CE, Thome U, van Laere D, Zaharie GC, Gupta S. A recommendation for the use of electrical biosensing technology in neonatology. Pediatr Res 2024:10.1038/s41390-024-03369-z. [PMID: 38977797 DOI: 10.1038/s41390-024-03369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024]
Abstract
Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.
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Affiliation(s)
- Lizelle van Wyk
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Topun Austin
- Neonatal Intensive Care Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Bernard Barzilay
- Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Maria Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz, Madrid, Spain
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christoph Czernik
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Willem de Vries
- Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jean-Claude Fauchére
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Elisabeth M W Kooi
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Philip T Levy
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, UK
| | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Clinic of Paediatrics and Adolescence, Akershus University Hospital, Lørenskog, Norway
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
| | - Marilena Savoia
- Neonatal Intensive Care Unit, S Maria Della Misericordia Hospital, Udine, Italy
| | | | - Arvind Seghal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Christop E Schwarz
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Thome
- Division of Neonatology, Department of Pediatrics, University of Leipzig Medical Centre, Leipzig, Germany
| | - David van Laere
- Neonatal Intensive Care Unit, Universitair Ziekenhuis, Antwerp, Belgium
| | - Gabriela C Zaharie
- Neonatology Department, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj -Napoca, Romania
| | - Samir Gupta
- Department of Engineering, Durham University, Durham, UK
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
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Rossiter A, Hilton JA, Fizza Haider S, Nasser SMT, Boyer N, Cooper C, Davis C, Marshall D, Skelding E, Pike J, Jarratt L, Wood L, Knight L, Holmes S, Cowman T, Shepley E, Dubravac N, Gray W, Munday C, Creagh-Brown B, Forni L. A service evaluation of measuring fluid responsiveness in acutely unwell hypotensive patients outside of critical care. Intensive Crit Care Nurs 2024:103694. [PMID: 38653631 DOI: 10.1016/j.iccn.2024.103694] [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: 10/03/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Early recognition and prompt, appropriate management may reduce mortality in patients with sepsis. The Surviving Sepsis Campaign's guidelines suggest the use of dynamic measurements to guide fluid resuscitation in sepsis; although these methods are rarely employed to monitor cardiac output in response to fluid administration outside intensive care units. This service evaluation investigated the introduction of a nurse led protocolised goal-directed fluid management using a non-invasive cardiac output monitor to the standard assessment of hypotensive ward patients. METHODS We introduced the use of a goal-directed fluid management protocol into our critical care outreach teams' standard clinical assessment. Forty-nine sequential patients before and thirty-nine after its introduction were included in the assessment. RESULTS Patients in the post-intervention cohort received less fluid in the 6 h following outreach assessment (750mls vs 1200mls). There were no differences in clinical background or rates of renal replacement therapy, but rates of invasive and non-invasive ventilation were reduced (0% vs 31%). Although the groups were similar, the post-intervention patients had lower recorded blood pressures. CONCLUSION IV fluid therapy in the patient with hypotension complicating sepsis can be challenging. Excessive IV fluid administration is commonplace and associated with harm, and the use of advanced non-invasive haemodynamic monitoring by trained nurses can provide objective evaluation of individualised response to treatment. Avoiding excessive IV fluid and earlier institution of appropriate vasopressor therapy may improve patient outcomes. IMPLICATIONS FOR CLINICAL PRACTICE Adoption of dynamic measures of cardiac output outside of critical care by trained critical care nurses is feasible and may translate into improved patient outcomes. In hospitals with a nurse-led critical care outreach service, consideration should be given to such an approach.
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Affiliation(s)
- Adam Rossiter
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.
| | - James Anthony Hilton
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Syed M T Nasser
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Naomi Boyer
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Cath Cooper
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Charlene Davis
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Emma Skelding
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Jennifer Pike
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Jarratt
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Wood
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Lucy Knight
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Sophie Holmes
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Tamsin Cowman
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Elaine Shepley
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Wendy Gray
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Caz Munday
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Ben Creagh-Brown
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Lui Forni
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Castro R, Born P, Muñoz F, Guzmán C, Kattan E, Hernandez G, Bakker J. Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery. J Pers Med 2024; 14:429. [PMID: 38673056 PMCID: PMC11051314 DOI: 10.3390/jpm14040429] [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: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
A positive fluid balance may evolve to fluid overload and associate with organ dysfunctions, weaning difficulties, and increased mortality in ICU patients. We explored whether individualized fluid management, assessing fluid responsiveness via a passive leg-raising maneuver (PLR) before a spontaneous breathing trial (SBT), is associated with less extubation failure in ventilated patients with a high fluid balance admitted to the ICU after liver transplantation (LT). We recruited 15 LT patients in 2023. Their postoperative fluid balance was +4476 {3697, 5722} mL. PLR maneuvers were conducted upon ICU admission (T1) and pre SBT (T2). Cardiac index (CI) changes were recorded before and after each SBT (T3). Seven patients were fluid-responsive at T1, and twelve were responsive at T2. No significant differences occurred in hemodynamic, respiratory, and perfusion parameters between the fluid-responsive and fluid-unresponsive patients at any time. Fluid-responsive patients at T1 and T2 increased their CI during SBT from 3.1 {2.8, 3.7} to 3.7 {3.4, 4.1} mL/min/m2 (p = 0.045). All fluid-responsive patients at T2 were extubated after the SBTs and consolidated extubation. Two out of three of the fluid-unresponsive patients experienced weaning difficulties. We concluded that fluid-responsive patients post LT may start weaning earlier and achieve successful extubation despite a high postoperative fluid balance. This highlights the profound impact of personalized assessments of cardiovascular state on critical surgical patients.
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Pablo Born
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Felipe Muñoz
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Hospital Clinico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330024, RM, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago Centro, Santiago 8330074, RM, Chile; (P.B.); (F.M.); (C.G.); (E.K.); (G.H.); (J.B.)
- Department of Intensive Care, Erasmus MC University Medical Center, P.O. Box 2040, 3000 Rotterdam, The Netherlands
- Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY 10019, USA
- NYU School of Medicine, Langone, New York, NY 10016, USA
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Douglas IS, Elwan MH, Najarro M, Romagnoli S. Dynamic monitoring tools for patients admitted to the emergency department with circulatory failure: narrative review with panel-based recommendations. Eur J Emerg Med 2024; 31:98-107. [PMID: 38364037 PMCID: PMC11232941 DOI: 10.1097/mej.0000000000001103] [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: 07/05/2023] [Accepted: 10/24/2023] [Indexed: 02/18/2024]
Abstract
Intravenous fluid therapy is commonly administered in the emergency department (ED). Despite the deleterious potential of over- and under-resuscitation, professional society guidelines continue to recommend administering a fixed volume of fluid in initial resuscitation. Predicting whether a specific patient will respond to fluid therapy remains one of the most important, but challenging questions that ED clinicians face in clinical practice. Surrogate parameters (i.e. blood pressure and heart rate), are widely used in usual care to estimate changes in stroke volume (SV). Due to their inadequacy in estimating SV, noninvasive techniques (e.g. bioreactance, echocardiography, noninvasive finger cuff technology), have been proposed as a more accurate and readily deployable method for assessing flow and preload responsiveness. Dynamic monitoring systems based on cardiac preload challenge and assessment of SV, by using noninvasive and continuous methods, provide more accurate, feasible, efficient, and reasonably accurate strategy for prediction of fluid responsiveness than static measurements. In this article, we aimed to analyze the different methods currently available for dynamic monitoring of preload responsiveness.
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Affiliation(s)
- Ivor S. Douglas
- Denver Health Medical Center, University of Colorado School of Medicine, Denver Colorado, USA
| | - Mohammed H. Elwan
- Emergency Department, Kettering General Hospital, Kettering, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt
| | - Marta Najarro
- Emergency Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Stefano Romagnoli
- Health Science Department, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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5
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Chung CR, Ko RE, Jang GY, Lee K, Suh GY, Kim Y, Woo EJ. Comparison of noninvasive cardiac output and stroke volume measurements using electrical impedance tomography with invasive methods in a swine model. Sci Rep 2024; 14:2962. [PMID: 38316842 PMCID: PMC10844629 DOI: 10.1038/s41598-024-53488-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
Pulmonary artery catheterization (PAC) has been used as a clinical standard for cardiac output (CO) measurements on humans. On animals, however, an ultrasonic flow sensor (UFS) placed around the ascending aorta or pulmonary artery can measure CO and stroke volume (SV) more accurately. The objective of this paper is to compare CO and SV measurements using a noninvasive electrical impedance tomography (EIT) device and three invasive devices using UFS, PAC-CCO (continuous CO) and arterial pressure-based CO (APCO). Thirty-two pigs were anesthetized and mechanically ventilated. A UFS was placed around the pulmonary artery through thoracotomy in 11 of them, while the EIT, PAC-CCO and APCO devices were used on all of them. Afterload and contractility were changed pharmacologically, while preload was changed through bleeding and injection of fluid or blood. Twenty-three pigs completed the experiment. Among 23, the UFS was used on 7 pigs around the pulmonary artery. The percentage error (PE) between COUFS and COEIT was 26.1%, and the 10-min concordance was 92.5%. Between SVUFS and SVEIT, the PE was 24.8%, and the 10-min concordance was 94.2%. On analyzing the data from all 23 pigs, the PE between time-delay-adjusted COPAC-CCO and COEIT was 34.6%, and the 10-min concordance was 81.1%. Our results suggest that the performance of the EIT device in measuring dynamic changes of CO and SV on mechanically-ventilated pigs under different cardiac preload, afterload and contractility conditions is at least comparable to that of the PAC-CCO device. Clinical studies are needed to evaluate the utility of the EIT device as a noninvasive hemodynamic monitoring tool.
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Affiliation(s)
- Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryoung Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geuk Young Jang
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea
| | - Kyounghun Lee
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yongmin Kim
- Department of Convergence IT Engineering, POSTECH, Pohang, Korea
| | - Eung Je Woo
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea.
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Teixeira JP, Zeidman A, Beaubien-Souligny W, Cerdá J, Connor MJ, Eggleston K, Juncos LA, da Silva JR, Wells C, Yessayan L, Barker AB, McConville W, Speer R, Wille KM, Neyra JA, Tolwani A. Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices. Blood Purif 2023; 52:857-879. [PMID: 37742622 DOI: 10.1159/000533573] [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: 03/22/2023] [Accepted: 06/29/2023] [Indexed: 09/26/2023]
Abstract
In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology and Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Zeidman
- Division of Nephrology, Department of Medicine, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jorge Cerdá
- Department of Medicine, Nephrology, Albany Medical College, Albany, New York, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Luis A Juncos
- Division of Nephrology, Department of Internal Medicine, Central Arkansas Veterans' Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Catherine Wells
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Wendy McConville
- School of Nursing, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Rajesh Speer
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
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Okwose NC, Fuller AS, Alyahya AI, Charman SJ, Eggett C, Luke P, MacGowan GA, Jakovljevic DG. Application of non-invasive bioreactance to assess hemodynamic function in patients with hypertrophic cardiomyopathy. Physiol Rep 2023; 11:e15729. [PMID: 37332077 DOI: 10.14814/phy2.15729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 06/20/2023] Open
Abstract
Non-invasive technologies have become popular for the clinical evaluation of cardiac function. The present study evaluated hemodynamic response to cardiopulmonary exercise stress testing using bioreactance technology in patients with hypertrophic cardiomyopathy. The study included 29 patients with HCM (age 55 ± 15 years; 28% female) and 12 age (55 ± 14 years), and gender matched (25% female) healthy controls. All participants underwent maximal graded cardiopulmonary exercise stress testing with simultaneous non-invasive hemodynamic bioreactance and gas exchange. At rest, patients with HCM demonstrated significantly lower cardiac output (4.1 ± 1.3 vs. 6.1 ± 1.2 L/min; p < 0.001), stroke volume (61.5 ± 20.8 vs. 89.5 ± 19.8 mL/beat; p < 0.001), and cardiac power output (0.97 ± 0.3 vs. 1.4 ± 0.3watt; p < 0.001), compared to controls. At peak exercise, the following hemodynamic and metabolic variables were lower in HCM patients that is, heart rate (118 ± 29 vs. 156 ± 20 beats/min; p < 0.001), cardiac output (15.5 ± 5.8 vs. 20.5 ± 4.7 L/min; p = 0.017), cardiac power output (4.3 ± 1.6 vs. 5.9 ± 1.8 watts; p = 0.017), mean arterial blood pressure (126 ± 11 vs. 134 ± 10 mmHg; p = 0.039), and oxygen consumption (18.3 ± 6.0 vs. 30.5 ± 8.3 mL/kg/min; p < 0.001), respectively. Peak arteriovenous oxygen difference and stroke volume were not significantly different between HCM patients and healthy controls (11.2 ± 6.4 vs. 11.9 ± 3.1 mL/100 mL, p = 0.37 and 131 ± 50.6 vs. 132 ± 41.9 mL/beat, p = 0.76). There was a moderate positive relationship between peak oxygen consumption and peak heart rate (r = 0.67, p < 0.001), and arteriovenous oxygen difference (r = 0.59, p = 0.001). Functional capacity is significantly reduced in patients with HCM primarily due to diminished central (cardiac) rather than peripheral factors. Application of non-invasive hemodynamic assessment may improve understanding of the pathophysiology and explain mechanisms of exercise intolerance in hypertrophic cardiomyopathy.
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Affiliation(s)
- Nduka Charles Okwose
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Research Centre for Health and Life Sciences, Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Amy S Fuller
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Alaa I Alyahya
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Eggett
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Luke
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Guy A MacGowan
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Research Centre for Health and Life Sciences, Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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Moschopoulos CD, Dimopoulou D, Dimopoulou A, Dimopoulou K, Protopapas K, Zavras N, Tsiodras S, Kotanidou A, Fragkou PC. New Insights into the Fluid Management in Patients with Septic Shock. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1047. [PMID: 37374251 PMCID: PMC10301281 DOI: 10.3390/medicina59061047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023]
Abstract
The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.
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Affiliation(s)
- Charalampos D. Moschopoulos
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Dimitra Dimopoulou
- Second Department of Pediatrics, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece;
| | - Anastasia Dimopoulou
- First Department of Pediatric Surgery, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece
| | | | - Konstantinos Protopapas
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Nikolaos Zavras
- Department of Pediatric Surgery, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Paraskevi C. Fragkou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
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Ha GB, Steinberg BA, Freedman R, Bayés-Genís A, Sanchez B. Safety evaluation of smart scales, smart watches, and smart rings with bioimpedance technology shows evidence of potential interference in cardiac implantable electronic devices. Heart Rhythm 2023; 20:561-571. [PMID: 36997272 DOI: 10.1016/j.hrthm.2022.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND Smart scales, smart watches, and smart rings with bioimpedance technology may create interference in patients with cardiac implantable electronic devices (CIEDs). OBJECTIVES The purpose of this study was to determine interference at CIEDs with simulations and benchtop testing, and to compare the results with maximum values defined in the ISO 14117 electromagnetic interference standard for these devices. METHODS The interference at pacing electrodes was determined by simulations on a male and a female computable model. A benchtop evaluation of representative CIEDs from 3 different manufacturers as specified in the ISO 14117 standard also was performed. RESULTS Simulations showed evidence of interference with voltage values exceeding threshold values defined in the ISO 14117 standard. The level of interference varied with the frequency and amplitude of the bioimpedance signal, and between male and female models. The level of interference generated with smart scale and smart rings simulations was lower than with smart watches. Across device manufacturers, generators demonstrated susceptibility to oversensing and pacing inhibition at different signal amplitudes and frequencies. CONCLUSIONS This study evaluated the safety of smart scales, smart watches, and smart rings with bioimpedance technology via simulation and testing. Our results indicate that these consumer electronic devices could interfere in patients with CIEDs. The present findings do not recommend the use of these devices in this population due to potential interference.
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Affiliation(s)
- Gia-Bao Ha
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, Utah
| | - Benjamin A Steinberg
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Roger Freedman
- Department of Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Antoni Bayés-Genís
- Department of Cardiology, Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Autonomous University of Barcelona, Barcelona, Spain
| | - Benjamin Sanchez
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, Utah.
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10
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Real-Time Measurements of Relative Tidal Volume and Stroke Volume Using Electrical Impedance Tomography with Spatial Filters: A Feasibility Study in a Swine Model Under Normal and Reduced Ventilation. Ann Biomed Eng 2023; 51:394-409. [PMID: 35960417 DOI: 10.1007/s10439-022-03040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 07/28/2022] [Indexed: 01/25/2023]
Abstract
Continuous monitoring of both hemodynamic and respiratory parameters would be beneficial to patients, e.g., those in intensive care unit. The objective of this exploratory animal study was to test the feasibility of simultaneous measurements of relative tidal volume (rTV) and relative stroke volume (rSV) using an electrical impedance tomography (EIT) device equipped with a new real-time source separation algorithm implemented as two spatial filters. Five pigs were anesthetized and mechanically ventilated. The supplied tidal volume from a mechanical ventilator was reduced to 70, 50 and 30% from the 100% normal volume to simulate hypoventilation. The respiratory volume signal and cardiac volume signal were generated by applying the spatial filters to the acquired EIT data, from which values of rTV and rSV were extracted. The measured rTV values were compared with the TV values from the mechanical ventilator using the four-quadrant concordance analysis method. For changes in TV, the concordance rate in each animal ranged from 81.8% to 100%, while it was 92.5% when the data from all five animals were pooled together. When the measured rTV values for each animal were scaled to the absolute TVEIT values in mL using the TVVent data from the mechanical ventilator, the smallest 95% limits of agreement (LoA) were - 6.04 and 7.44 mL for the 70% ventilation level, and the largest 95% LoA were - 18.1 and 19.4 mL for the 50% ventilation level. The percentage error between TVEIT and TVVent was 10.3%. Although similar statistical analyses on rSV data could not be performed due to limited intra-animal variability, changes in rSV values measured by the EIT device were comparable to those measured by an invasive hemodynamic monitor. In this animal study, we were able to demonstrate the feasibility of an EIT device for noninvasive and simultaneous measurements of rTV and rSV in real time. However, the performance of the real-time source separation method needs to be further validated on animals and human subjects, particularly over a wide range of SV values. Future clinical studies are needed to assess the potential usefulness of the new method in dynamic cardiopulmonary monitoring and explore other clinical applications.
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11
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Farshadmand J, Lowy Z, Hai O, Zeltser R, Makaryus AN. Utility of Cardiac Power Hemodynamic Measurements in the Evaluation and Risk Stratification of Cardiovascular Conditions. Healthcare (Basel) 2022; 10:2417. [PMID: 36553940 PMCID: PMC9777954 DOI: 10.3390/healthcare10122417] [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: 10/25/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Despite numerous advancements in prevention, diagnosis and treatment, cardiovascular disease has remained the leading cause of mortality globally for the past 20 years. Part of the explanation for this trend is persistent difficulty in determining the severity of cardiac conditions in order to allow for the deployment of prompt therapies. This review seeks to determine the prognostic importance of cardiac power (CP) measurements, including cardiac power output (CPO) and cardiac power index (CPI), in various cardiac pathologies. CP was evaluated across respective disease-state categories which include cardiogenic shock (CS), septic shock, transcatheter aortic valve replacement (TAVR), heart failure (HF), post-myocardial infarction (MI), critical cardiac illness (CCI) and an "other" category. Literature review was undertaken of articles discussing CP in various conditions and this review found utility and prognostic significance in the evaluation of TAVR patients with a significant correlation between one-year mortality and CPI; in HF patients showing CPI and CPO as valuable tools to assess cardiac function in the acute setting; and, additionally, CPO was found to be an essential tool in patients with CCI, as the literature showed that CPO was statistically correlated with mortality. Cardiac power and the derived measures obtained from this relatively easily obtained variable can allow for essential estimations of prognostic outcomes in cardiac patients.
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Affiliation(s)
- Jonathan Farshadmand
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 500 Hofstra Blvd., Hempstead, NY 11549, USA; (J.F.); (Z.L.); (R.Z.)
| | - Zachary Lowy
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 500 Hofstra Blvd., Hempstead, NY 11549, USA; (J.F.); (Z.L.); (R.Z.)
| | - Ofek Hai
- Department of Cardiology, Nassau University Medical Center, Hempstead, NY 11554, USA;
| | - Roman Zeltser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 500 Hofstra Blvd., Hempstead, NY 11549, USA; (J.F.); (Z.L.); (R.Z.)
- Department of Cardiology, Nassau University Medical Center, Hempstead, NY 11554, USA;
| | - Amgad N. Makaryus
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 500 Hofstra Blvd., Hempstead, NY 11549, USA; (J.F.); (Z.L.); (R.Z.)
- Department of Cardiology, Nassau University Medical Center, Hempstead, NY 11554, USA;
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12
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Bahouth MN, Negoita S, Tenberg A, Zink EK, Abshire MA, Davidson PM, Suarez JI, Szanton SL, Gottesman RF. Noninvasive cardiac output monitor to quantify hydration status in ischemic stroke patients: A feasibility study. J Neurol Sci 2022; 442:120413. [PMID: 36215798 DOI: 10.1016/j.jns.2022.120413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Individuals who are dehydrated, volume contracted or both at the time of hospitalization for acute ischemic stroke have worse clinical outcomes than do individuals with optimal volume status. Currently, there is no gold standard method for measuring hydration status, except indirect markers of a volume contracted state (VCS) including elevated blood urea nitrogen (BUN)/creatinine ratio. We sought to test the feasibility and acceptability of a non-invasive cardiac output monitor (NICOM) for the measurement of hydration status in a group of hospitalized ischemic stroke patients, and explore the relationship with a common indirect laboratory-based measure of VCS. METHODS We performed a prospective observational feasibility study of hospitalized acute ischemic stroke patients. We collected hemodynamic parameters using the NICOM device before and after fluid auto-bolus via passive leg raise and BUN/creatinine ratio. Successful acquisition of relevant hemodynamic data was the primary objective of this study. We explored agreement between the NICOM results and BUN/creatinine ratio using Cohen's kappa statistic. RESULTS Thirty patients hospitalized with acute ischemic stroke were enrolled. We found that 29/30 patients tolerated assessment with NICOM. Hemodynamic data were collected in all 30 patients. Data capture took an average of 10 min(SD ± 112 s). Agreement between NICOM and BUN/creatinine ratio was 70%; (expected agreement 51%; kappa 0.38). Agreement was stronger in the cohort without history of diabetes (81% agreement, kappa 0.61). CONCLUSIONS NICOM assessment was feasible in hospitalized stroke patients. The identification of an objective, real-time measure of hydration status would be clinically useful, and could allow precise, goal-directed care.
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Affiliation(s)
- M N Bahouth
- Department of Neurology, Johns Hopkins School of Medicine, United States of America.
| | - S Negoita
- Department of Neurology, Johns Hopkins School of Medicine, United States of America
| | - A Tenberg
- Johns Hopkins Hospital, United States of America
| | - E K Zink
- Johns Hopkins Hospital, United States of America
| | - M A Abshire
- Johns Hopkins School of Nursing, United States of America
| | - P M Davidson
- Johns Hopkins School of Nursing, United States of America
| | - J I Suarez
- Department of Neurology, Johns Hopkins School of Medicine, United States of America
| | - S L Szanton
- Johns Hopkins School of Nursing, United States of America
| | - R F Gottesman
- Department of Neurology, Johns Hopkins School of Medicine, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, United States of America
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13
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Reliability of bioreactance-derived hemodynamic monitoring during simulated sustained gravitational transitions induced by short-arm human centrifugation. Med Eng Phys 2022; 107:103868. [DOI: 10.1016/j.medengphy.2022.103868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/27/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022]
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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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15
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French WB, Scott M. Fluid and Hemodynamics. Anesthesiol Clin 2022; 40:59-71. [PMID: 35236583 DOI: 10.1016/j.anclin.2021.11.002] [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] [Indexed: 06/14/2023]
Abstract
Several components of an Enhanced Recovery After Surgery (ERAS) pathway act to improve and simplify perioperative fluid and hemodynamic therapy. Modern perioperative fluid management has shifted away from the liberal fluid therapy and toward more individualized approaches. Clinical evidence has also emphasized the importance of maintaining adequate mean arterial pressure and avoiding intraoperative hypotension. Goal-directed hemodynamic therapy (GDHT), or the use of cardiac output monitoring to guide fluid and vasopressor use, has been shown to reduce complications, but its role within ERAS pathways is likely best-suited to high-risk patients or those undergoing high-risk procedures. This article reviews the mechanisms by which ERAS pathways aid the provider in hemodynamic management, reviews trends, and evidence regarding fluid and hemodynamic therapy approaches, and provides guidance on the practical implementation of these concepts within ERAS pathways.
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Affiliation(s)
- W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1250 E Marshall Street, Richmond, VA 23219, USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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16
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Mehta Y, Kapoor PM, Maheswarappa HM, Saxena G. Noninvasive Bioreactance-Based Fluid Management Monitoring: A Review of Literature. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0041-1741491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractBody fluid balance is an independent predictor of mortality. For each liter of fluid over and above 5 L, risk-adjusted excess mortality is seen. Mortality increased by 2.3% for each 1 L of fluid and hospital costs increased by $999. Accordingly, most recent guidelines have endorsed dynamic modeling. Passive leg raising-induced increase of aortic blood flow ≥ 10% predicts fluid responsiveness with a sensitivity of 97% and a specificity of 94%. Thus, passive leg raising is often used as gold standard for validation of other procedures (though it's usefulness to assess respiratory variation in vena cava is not conclusive). STARLING, a device based on bioreactance, works on phase shift or time delay while bioimpedance works on the amplitude of the thoracic impedance. Unlike bioimpedance, bioreactance is not affected by the size of the patient, thoracic fluids, or position of sensors.STARLING is equipped with four sensor pads. Each pad contains two sensors, the outer sensor is a transmitting electrode and the inner sensor is a receiving electrode. The STARLING monitor induces a 75-KHz AC current. It then measures the time delay/phase shift.STARLING system, a bioreactance-based dynamic assessment system for fluid responsiveness, predicts it accurately, precisely, and noninvasively. It reduces invasive risks and is independently validated against pulmonary artery catheter. It is not affected by vasopressors or shock and has wide range of application.
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Affiliation(s)
- Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta the Medicity, Gurugram, Haryana, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Harish Mallapura Maheswarappa
- Division of Critical Care Medicine, Critical Care and Pain, Department of Anaesthesiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gaurav Saxena
- Medical Affairs Division, Baxter India Pvt Ltd, Gurugram, Haryana, India
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17
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Non-invasive continuous cardiac output monitoring in infants with hypoxic ischaemic encephalopathy. J Perinatol 2022; 42:1622-1629. [PMID: 36056257 PMCID: PMC9712087 DOI: 10.1038/s41372-022-01495-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To describe early, continuous, non-invasive measures of cardiac output (CO) and evolution over time in infants with hypoxic-ischaemic encephalopathy (HIE). STUDY DESIGN Prospective observational study of 44 infants with HIE (23 mild, 17 moderate, 4 severe) and 17 term controls. Infants with HIE had non-invasive CO monitoring (NICOM) continuously in the neonatal unit. Term controls had NICOM recorded at 6 and 24 h. A mixed-modelling approach was used to assess change in CO over time by group. RESULTS Infants with moderate HIE have significantly lower CO than the mild group at all timepoints (10.7 mls/kg/min lower, 95% CI:1.0,20.4, p = 0.03) which increases over time, driven by a gradual increase in stroke volume (SV). CO increased further during rewarming predominantly due to an increase in HR. CONCLUSION TH has a significant impact on HR but SV appears largely unaffected. NICOM may provide a non-invasive, continuous, low-cost alternative to monitoring CO in infants with HIE however further research is warranted.
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Figueiro-Filho EA, Robinson NTS, Carvalho J, Keunen J, Robinson M, Maxwell C. Hemodynamic Assessment of Pregnant People with and without Obesity by Noninvasive Bioreactance: A Pilot Study. AJP Rep 2022; 12:e69-e75. [PMID: 35141039 PMCID: PMC8816622 DOI: 10.1055/s-0041-1742270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to identify cardiovascular differences between pregnant people with and without obesity for trimester-specific changes in hemodynamic parameters using noninvasive cardiac output monitoring (NICOM). Study Design This study is a pilot prospective comparative cohort between pregnant people with and without obesity. Hemodynamic assessment was performed with NICOM (12-14, 21-23, and 34-36 weeks) during pregnancy. Results In first trimester, pregnant people with obesity had higher blood pressure, stroke volume (SV), total peripheral resistance index (TPRI), and cardiac output (CO). Pregnant people with obesity continued to have higher SV and cardiac index (second and third trimesters). During the first trimester, body mass index (BMI) positively correlated with SV, TPRI, and CO. Fat mass showed a strong correlation with TPRI. BMI positively correlated with CO during the second trimester and fat mass was positively associated with CO. During the third trimester, TPR negatively correlated with BMI and fat mass. Conclusion Fat mass gain in the period between the first and second trimesters in addition to the hemodynamic changes due to obesity and pregnancy contribute to some degree of left ventricular diastolic dysfunction which was manifested by lower SVs. Future work should investigate the possible causative role of obesity in the cardiovascular changes identified in people with obesity.
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Affiliation(s)
- Ernesto A Figueiro-Filho
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.,Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Na T S Robinson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, Queen Elizabeth Hospital, Barbados
| | - Jose Carvalho
- Department of Anaesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johannes Keunen
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Monique Robinson
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Chen Y, Fan T. Bioreactance-guided fluid therapy for excision of a giant brain tumor in an infant under general anesthesia: A case report and literature review. BRAIN SCIENCE ADVANCES 2021. [DOI: 10.26599/bsa.2021.9050007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pediatric patients are more likely to suffer from brain tumors. Surgical resection is often the optimal treatment. Perioperative management of pediatric brain tumor resection brings great challenges to anesthesiologists, especially for fluid therapy. In this case, the infant-patient was only 69-day-old, weighed 6 kg,but she was facing a gaint brain tumor (7.9 cm × 8.1 cm × 6.7 cm) excision. The infant was at great risks such as hemorrhagic shock, cerebral edema, pulmonary edema, congestive heart failure, coagulation dysfunction, etc. However, we tried to use the parameters obtained by bioreactance-based NICOM® device (Cheetah Medical) to guide the infant’s intraoperative fluid therapy, and successfully avoided these complications and achieved a good prognosis.
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Affiliation(s)
- Yao Chen
- Tsinghua University Yuquan Hospital, Beijing 100040, China
| | - Ting Fan
- Tsinghua University Yuquan Hospital, Beijing 100040, China
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20
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Lee K, Jang GY, Kim Y, Woo EJ. Multi-channel Trans-impedance Leadforming for Cardiopulmonary Monitoring: Algorithm Development and Feasibility Assessment using In Vivo Animal Data. IEEE Trans Biomed Eng 2021; 69:1964-1974. [PMID: 34855581 DOI: 10.1109/tbme.2021.3132012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objectives of this study were to (1) develop a multi-channel trans-impedance leadforming method for beat-to-beat stroke volume (SV) and breath-by-breath tidal volume (TV) measurements and (2) assess its feasibility on an existing in vivo animal dataset. METHODS A deterministic leadforming algorithm was developed to extract a cardiac volume signal (CVS) and a respiratory volume signal (RVS) from 208-channel trans-impedance data acquired every 20 ms by an electrical impedance tomography (EIT) device. SVEIT and TVEIT values were computed as a valley-to-peak value in the CVS and RVS, respectively. The method was applied to the existing dataset from five mechanically-ventilated pigs undergoing ten mini-fluid challenges. An invasive hemodynamic monitor was used in the arterial pressure-based cardiac output (APCO) mode to simultaneously measure SVAPCO values while a mechanical ventilator provided TVVent values. RESULTS The leadforming method could reliably extract the CVS and RVS from the 208-channel trans-impedance data measured with the EIT device, from which SV<sub>EIT</sub> and TV<sub>EIT</sub> were computed. The SV<sub>EIT</sub> and TV<sub>EIT</sub> values were comparable to those from the invasive hemodynamic monitor and mechanical ventilator. Using the data from 5 pigs and a simple calibration method to remove bias, the error in SV<sub>EIT<sub> and TV<sub>EIT<sub> was 9.5% and 5.4%, respectively. CONCLUSION We developed a new leadforming method for the EIT device to robustly extract both SV and TV values in a deterministic fashion. Future animal and clinical studies are needed to validate this leadforming method in various subject populations. SIGNIFICANCE The leadforming method could be an integral component for a new cardiopulmonary monitor in the future to simultaneously measure SV and TV noninvasively, which would be beneficial to patients.
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21
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Álvarez-Montoya D, Madrid-Muñoz C, Escobar-Robledo L, Gallo-Villegas J, Aristizábal-Ocampo D. A novel method for the noninvasive estimation of cardiac output with brachial oscillometric blood pressure measurements through an assessment of arterial compliance. Blood Press Monit 2021; 26:426-434. [PMID: 34128491 DOI: 10.1097/mbp.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To propose and validate a new method for estimating cardiac output based on the total arterial compliance (Ct) formula that does not need an arterial waveform and to apply it to brachial oscillometric blood pressure measurements (OBPMs). METHODS One hundred subjects with normal heart anatomy and function were included. Reference values for cardiac output were measured with echocardiography, and Ct was calculated with a two-element Windkessel model. Then, a statistical model of arterial compliance (Ce) was used to estimate cardiac output. Finally, the measured and estimated cardiac output values were compared for accuracy and reproducibility. RESULTS The model was derived from the data of 70 subjects and prospectively tested with the data from the remaining 30 individuals. The mean age of the whole group was 43.4 ± 12.8 years, with 46% women. The average blood pressure (BP) was 107.1/65.0 ± 15.0/9.6 mmHg and the average heart rate was 67.7 ± 11.4 beats/min. The average Ct was 1.39 ± 0.27 mL/mmHg and the average cardiac output was 5.5 ± 1.0 L/min. The mean difference in the cardiac output estimated by the proposed methodology vs. that measured by Doppler echocardiography was 0.022 L/min with an SD of 0.626 L/min. The intraclass correlation coefficient was 0.93, and the percentage error was 19%. CONCLUSION Cardiac output could be reliably and noninvasively obtained with brachial OBPMs through a novel method for estimating Ct without the need for an arterial waveform. The new method could identify hemodynamic factors that explain BP values in an ambulatory care setting.
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Affiliation(s)
- Diego Álvarez-Montoya
- Centro Clínico y de Investigación SICOR (Soluciones Integrales en Riesgo Cardiovascular)
| | - Camilo Madrid-Muñoz
- Centro Clínico y de Investigación SICOR (Soluciones Integrales en Riesgo Cardiovascular)
| | - Luis Escobar-Robledo
- Centro Clínico y de Investigación SICOR (Soluciones Integrales en Riesgo Cardiovascular)
| | - Jaime Gallo-Villegas
- Centro Clínico y de Investigación SICOR (Soluciones Integrales en Riesgo Cardiovascular)
- Facultad de Medicina, Universidad de Antioquia
| | - Dagnovar Aristizábal-Ocampo
- Centro Clínico y de Investigación SICOR (Soluciones Integrales en Riesgo Cardiovascular)
- Cellular and Molecular Biology Unit, Corporación para Investigaciones Biológicas, Medellín, Colombia
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22
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Gavelli F, Beurton A, Teboul JL, De Vita N, Azzolina D, Shi R, Pavot A, Monnet X. Bioreactance reliably detects preload responsiveness by the end-expiratory occlusion test when averaging and refresh times are shortened. Ann Intensive Care 2021; 11:133. [PMID: 34453633 PMCID: PMC8401368 DOI: 10.1186/s13613-021-00920-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background The end-expiratory occlusion (EEXPO) test detects preload responsiveness, but it is 15 s long and induces small changes in cardiac index (CI). It is doubtful whether the Starling bioreactance device, which averages CI over 24 s and refreshes the displayed value every 4 s (Starling-24.4), can detect the EEXPO-induced changes in CI (ΔCI). Our primary goal was to test whether this Starling device version detects preload responsiveness through EEXPO. We also tested whether shortening the averaging and refresh times to 8 s and one second, respectively, (Starling-8.1) improves the accuracy of the device in detecting preload responsiveness using EEXPO. Methods In 42 mechanically ventilated patients, during a 15-s EEXPO, we measured ∆CI through calibrated pulse contour analysis (CIpulse, PiCCO2 device) and using the Starling device. For the latter, we considered both CIStarling-24.4 from the commercial version and CIStarling-8.1 derived from the raw data. For relative ∆CIStarling-24.4 and ∆CIStarling-8.1 during EEXPO, we calculated the area under the receiver operating characteristic curve (AUROC) to detect preload responsiveness, defined as an increase in CIpulse ≥ 10% during passive leg raising (PLR). For both methods, the correlation coefficient vs. ∆CIpulse was calculated. Results Twenty-six patients were preload responders and sixteen non preload-responders. The AUROC for ∆CIStarling-24.4 was significantly lower compared to ∆CIStarling-8.1 (0.680 ± 0.086 vs. 0.899 ± 0.049, respectively; p = 0.027). A significant correlation was observed between ∆CIStarling-8.1 and ∆CIpulse (r = 0.42; p = 0.009), but not between ∆CIStarling-24.4 and ∆CIpulse. During PLR, both ∆CIStarling-24.4 and ∆CIStarling-8.1 reliably detected preload responsiveness. Conclusions Shortening the averaging and refresh times of the bioreactance signal to 8 s and one second, respectively, increases the reliability of the Starling device in detection of EEXPO-induced ∆CI. Trial registration: No. IDRCB:2018-A02825-50. Registered 13 December 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00920-7.
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Affiliation(s)
- Francesco Gavelli
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France. .,Emergency Medicine Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy.
| | - Alexandra Beurton
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Nello De Vita
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Danila Azzolina
- Research Support Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy
| | - Rui Shi
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Arthur Pavot
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, 78, Rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
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23
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Hopster K, Hurcombe SDA. Agreement of Bioreactance Cardiac Output Monitoring With Thermodilution in Healthy Standing Horses. Front Vet Sci 2021; 8:701339. [PMID: 34414227 PMCID: PMC8369349 DOI: 10.3389/fvets.2021.701339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
Bioreactance is the continuous analysis of transthoracic voltage variation in response to an applied high frequency transthoracic current and was recently introduced for non-invasive cardiac output measurement (NICOM). We evaluated NICOM compared to thermodilution (TD) in adult horses. Six healthy horses were used for this prospective, blinded, experimental study. Cardiac output (CO) measurements were performed simultaneously using TD and the bioreactance method. Different cardiac output scenarios were established using xylazine (0.5 mg/kg IV) and dobutamine (1.5–3 mcg/kg/min). Statistical analysis was performed by calculating the concordance rate, performing a regression analysis, Pearson correlation, and Bland Altman. The TD-based CO and NICOM values were highly correlated for low, normal and high CO values with an overall correlation coefficient. A 4-quadrant plot showed an 89% rate of concordance. The linear regression calculated a relationship between NICOM and TDCO of Y = 0.4874 · X + 0.5936. For the corrected Bland Altman agreement, the mean bias and lower/upper limits of agreement were −0.26 and −3.88 to 3.41 L/min, respectively. Compared to TD, bioreactance- based NICOM showed good accuracy at induced low, normal, and high CO states in normal horses. Future studies performed under more clinical conditions will show if this monitor can help to assess hemodynamic status and guide therapy in horses in ICU settings and under general anesthesia.
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Affiliation(s)
- Klaus Hopster
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Samuel D A Hurcombe
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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24
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Anand G, Yu Y, Lowe A, Kalra A. Bioimpedance analysis as a tool for hemodynamic monitoring: overview, methods and challenges. Physiol Meas 2021; 42. [PMID: 33607637 DOI: 10.1088/1361-6579/abe80e] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
Recent advances in hemodynamic monitoring have seen the advent of non-invasive methods which offer ease of application and improve patient comfort. Bioimpedance Analysis or BIA is one of the currently employed non-invasive techniques for hemodynamic monitoring. Impedance Cardiography (ICG), one of the implementations of BIA, is widely used as a non-invasive procedure for estimating hemodynamic parameters such as stroke volume (SV) and cardiac output (CO). Even though BIA is not a new diagnostic technique, it has failed to gain consensus as a reliable measure of hemodynamic parameters. Several devices have emerged for estimating CO using ICG which are based on evolving methodologies and techniques to calculate SV. However, the calculations are generally dependent on the electrode configurations (whole body, segmental or localised) as well as the accuracy of different techniques in tracking blood flow changes. Blood volume changes, concentration of red blood cells, pulsatile velocity profile and ambient temperature contribute to the overall conductivity of blood and hence its impedance response during flow. There is a growing interest in investigating limbs for localised BIA to estimate hemodynamic parameters such as pulse wave velocity. As such, this paper summarises the current state of hemodynamic monitoring through BIA in terms of different configurations and devices in the market. The conductivity of blood flow has been emphasized with contributions from both volume and velocity changes during flow. Recommendations for using BIA in hemodynamic monitoring have been mentioned highlighting the suitable range of frequencies (1 kHz-1 MHz) as well as safety considerations for a BIA setup. Finally, current challenges in using BIA such as geometry assumption and inaccuracies have been discussed while mentioning potential advantages of a multi-frequency analysis to cover all the major contributors to blood's impedance response during flow.
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Affiliation(s)
- Gautam Anand
- Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand
| | - Yang Yu
- Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand
| | - Andrew Lowe
- Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand
| | - Anubha Kalra
- Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand
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25
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Yeh PH, Chang YJ, Tsai SE. Observation of hemodynamic parameters using a non-invasive cardiac output monitor system to identify predictive indicators for post-spinal anesthesia hypotension in parturients undergoing cesarean section. Exp Ther Med 2020; 20:168. [PMID: 33093906 PMCID: PMC7571406 DOI: 10.3892/etm.2020.9298] [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: 03/19/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022] Open
Abstract
The administration of high-level spinal anesthesia for cesarean section may lead to significant hemodynamic changes. Bioreactance-based non-invasive cardiac output monitoring (NICOM™) provides an accurate monitoring system for parturients under spinal anesthesia. The present study hypothesized that baseline hemodynamic parameters obtained via the NICOM™ system could serve as predictive indicators for post-spinal anesthesia hypotension. Therefore, 80 full-term parturients with singleton pregnancies who underwent scheduled cesarean section were enrolled and allocated to either a supine position group or a 15˚ left tilt group. All parturients received standard pre-hydration with 750 ml of 0.9% saline. Baseline cardiac output index (CI), total peripheral resistance index (TPRI) and stroke volume (SV) were recorded using the NICOM™ system. Subsequently, spinal anesthesia with 2.4 ml of 0.5% hyperbaric bupivacaine, 10 µg of fentanyl and 0.2 mg of morphine was administered. Receiver operating characteristic (ROC) curves and multivariate logistic regression were used to analyze the data. A total of 40 parturients (51.9%) developed hypotension. The areas under the ROC curves were 0.666, 0.594 and 0.622 for the CI, TPRI and SV, respectively. The optimal cut-off value of the CI in predicting hypotension was 3.68 l/min/m2 (ROC, sensitivity=85.0%, specificity=48.6%). Furthermore, CI was considered as an independent factor for post-spinal anesthesia hypotension. In conclusion, the baseline CI obtained via the bioreactance-based NICOM™ system may serve as a predictor of post-spinal anesthesia hypotension in parturients regardless of patient position.
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Affiliation(s)
- Pin-Hung Yeh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua City 50006, Taiwan R.O.C
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Centre, Changhua Christian Hospital, Changhua City 50006, Taiwan R.O.C
| | - Sheng-En Tsai
- Department of Anesthesiology, Changhua Christian Hospital, Changhua City 50006, Taiwan R.O.C
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26
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Pandhita BAW, Okwose NC, Koshy A, Fernández ÓG, Cruz NB, Eggett C, Velicki L, Popovic D, MacGowan GA, Jakovljevic DG. Noninvasive Assessment of Cardiac Output in Advanced Heart Failure and Heart Transplant Candidates Using the Bioreactance Method. J Cardiothorac Vasc Anesth 2020; 35:1776-1781. [PMID: 33059979 DOI: 10.1053/j.jvca.2020.09.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/18/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of the present study was to assess the validity and trending ability of the bioreactance method in estimating cardiac output at rest and in response to stress in advanced heart failure patients and heart transplant candidates. DESIGN This was a prospective single-center study. SETTING This study was conducted at the heart transplant center at the Freeman Hospital, Newcastle upon Tyne, UK. PARTICIPANTS Eighteen patients with advanced chronic heart failure due to reduced left ventricular ejection fraction (19 ± 7%), and peak oxygen consumption 12.3 ± 3.9 mL/kg/min. INTERVENTIONS Participants underwent right heart catheterization using the Swan-Ganz catheter. MEASUREMENTS AND MAIN RESULTS Cardiac output was measured simultaneously using thermodilution and bioreactance at rest and during active straight leg raise test to volitional exertion. There was no significant difference in cardiac index values obtained by the thermodilution and bioreactance methods (2.26 ± 0.59 v 2.38 ± 0.50 L/min, p > 0.05) at rest and peak straight leg raise test (2.92 ± 0.77 v 3.01 ± 0.66 L/min, p > 0.05). In response to active leg raise test, thermodilution cardiac output increased by 22% and bioreactance by 21%. There was also a strong relationship between cardiac outputs from both methods at rest (r = 0.88, p < 0.01) and peak straight leg raise test (r = 0.92, p < 0.01). Cartesian plot analysis showed good trending ability of bioreactance compared with thermodilution (concordance rate = 93%) CONCLUSIONS: `Cardiac output measured by the bioreactance method is comparable to that from the thermodilution method. Bioreactance method may be used in clinical practice to assess hemodynamics and improve management of advanced heart failure patients undergoing heart transplant assessment.
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Affiliation(s)
- Bashar A W Pandhita
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Nduka C Okwose
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Aaron Koshy
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Óscar G Fernández
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Noelia B Cruz
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Christopher Eggett
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, and Department of Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Novi Sad, Serbia
| | - Dejana Popovic
- Division of Cardiology, University Clinical Centre Serbia, Faculty of Pharmacy University of Belgrade, Belgrade, Serbia
| | - Guy A MacGowan
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Djordje G Jakovljevic
- Cardiovascular Research, Clinical and Translational and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
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27
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Sengupta SP, Mungulmare K, Okwose NC, MacGowan GA, Jakovljevic DG. Comparison of cardiac output estimates by echocardiography and bioreactance at rest and peak dobutamine stress test in heart failure patients with preserved ejection fraction. Echocardiography 2020; 37:1603-1609. [PMID: 32949037 DOI: 10.1111/echo.14836] [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: 06/15/2020] [Revised: 07/25/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To assess the agreement between cardiac output estimated by two-dimensional echocardiography and bioreactance methods at rest and during dobutamine stress test in heart failure patients with preserved left ventricular ejection fraction (HFpEF). METHODS Hemodynamic measurements were assessed in 20 stable HFpEF patients (12 females; aged 61 ± 7 years) using echocardiography and bioreactance methods during rest and dobutamine stress test at increment dosages of 5, 10, 15, and 20 μg/kg/min until maximal dose was achieved or symptoms and sign occurred, that is, chest pain, abnormal blood pressure elevation, breathlessness, ischemic changes, or arrhythmia. RESULTS Resting cardiac output and cardiac index estimated by bioreactance and echocardiography were not significantly different. At peak dobutamine stress test, cardiac output and cardiac index estimated by echocardiography and bioreactance were significantly different (7.06 ± 1.43 vs 5.71 ± 1.59 L/min, P < .01; and 4.27 ± 0.67 vs 3.43 ± 0.87 L/m2 /min; P < .01) due to the significant differences in stroke volume. There was a strong positive relationship between cardiac outputs obtained by the two methods at peak dobutamine stress (r = .79, P < .01). The mean difference (lower and upper limits of agreement) between bioreactance and echocardiography cardiac outputs at rest and peak dobutamine stress was -0.45 (1.71 to -2.62) L/min and -1.35 (0.60 to -3.31) L/min, respectively. CONCLUSION Bioreactance and echocardiography methods provide different cardiac output values at rest and during stress thus cannot be used interchangeably. Ability to continuously monitor key hemodynamic variables such as cardiac output, stroke volume, and heart rate is the major advantage of bioreactance method.
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Affiliation(s)
- Shantanu P Sengupta
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India.,Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Kunda Mungulmare
- Cardiology, Sengupta Hospital and Research Institute, Ravinagar Nagpur, Maharashtra, India
| | - Nduka C Okwose
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Guy A MacGowan
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Faculty of Medical Sciences, Cardiovascular Research Translational and Clinical Research Institute, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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28
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Bioreactance-Based Noninvasive Fluid Responsiveness and Cardiac Output Monitoring: A Pilot Study in Patients with Aneurysmal Subarachnoid Hemorrhage and Literature Review. Crit Care Res Pract 2020; 2020:2748181. [PMID: 33014461 PMCID: PMC7512079 DOI: 10.1155/2020/2748181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/05/2020] [Accepted: 09/03/2020] [Indexed: 11/22/2022] Open
Abstract
Management of volume status, arterial blood pressure, and cardiac output are core elements in approaching the patients with aneurysmal subarachnoid hemorrhage (SAH). For the prevention and treatment of delayed cerebral ischemia (DCI), euvolemia is advocated and caution is made towards the avoidance of hypervolemia. Induced hypertension and cardiac output augmentation are the mainstays of medical management during active DCI, whereas the older triple-H paradigm has fallen out of favor due to lack of demonstrable physiological or clinical benefits and serious concern for adverse effects such as pulmonary edema and multiorgan system dysfunction. Furthermore, insight into clinical hemodynamics of patients with SAH becomes salient when one considers the frequently associated cardiac and pulmonary manifestations of the disease such as SAH-associated cardiomyopathy and neurogenic pulmonary edema. In terms of fluid and volume targets, less attention has been paid to dynamic markers of fluid responsiveness despite the well-established, in the general critical care literature, superiority of these as compared to traditionally used static markers such as central venous pressure (CVP). Based on this literature and sound pathophysiologic reasoning, reliance on static markers (such as CVP) is unjustified when one attempts to assess strategies augmenting stroke volume (SV), arterial blood pressure, and oxygen delivery. There are several options for continuous bedside cardiorespiratory monitoring and optimization of SAH patients. We, here, review a noninvasive monitoring technique based on thoracic bioreactance and focusing on continuous cardiac output and fluid responsiveness markers.
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29
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Rozental O, Thalappillil R, White RS, Tam CW. To Swan or Not to Swan: Indications, Alternatives, and Future Directions. J Cardiothorac Vasc Anesth 2020; 35:600-615. [PMID: 32859489 DOI: 10.1053/j.jvca.2020.07.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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Hankinson SJ, Williams CH, Ton VK, Gottlieb SS, Hong CC. Should we overcome the resistance to bioelectrical impedance in heart failure? Expert Rev Med Devices 2020; 17:785-794. [PMID: 32658589 DOI: 10.1080/17434440.2020.1791701] [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: 10/23/2022]
Abstract
INTRODUCTION Heart failure is associated with increased neurohormonal activation that results in changes in body composition including volume overload and the loss of skeletal muscle, body fat, and bone density. Bioelectrical impedance measures body composition based on the conduction of electrical current through body fluids. AREAS COVERED The PubMed and Scopus databases were reviewed up to the third week of June 2020. Cross-sectional studies, retrospective observational studies, prospective observational studies, and randomized controlled trials have examined numerous bioelectrical impedance monitoring strategies to guide the diagnosis, prognosis, and treatment of heart failure. These monitoring strategies include intrathoracic impedance, lung impedance, bioelectrical impedance vector analysis, leg bioelectrical impedance, and thoracic bioreactance. EXPERT COMMENTARY Based on the current evidence, more studies are needed to validate bioelectrical impedance in heart failure. Lung impedance appears to be useful for guiding heart failure treatment in patients with ST-elevation myocardial infarction and improving outcomes in outpatients with heart failure. Furthermore, bioelectrical impedance has potential as a noninvasive, quantitative heart failure variable for population-based research.
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Affiliation(s)
- Stephen J Hankinson
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Charles H Williams
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Van-Khue Ton
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine , Baltimore, MD, USA.,Harvard Medical School, Division of Cardiology, Massachusetts General Hospital , Boston, MA, USA
| | - Stephen S Gottlieb
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Charles C Hong
- Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
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Ling HZ, Jara PG, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. Effect of race on longitudinal central hemodynamics in pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:37-43. [PMID: 31692154 DOI: 10.1002/uog.21914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare central hemodynamics between white, black and Asian women in pregnancy. METHODS This was a prospective, longitudinal study of maternal central hemodynamics in white, black and Asian women with a singleton pregnancy, assessed using a bioreactance method at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. At each visit, cardiac output (CO), stroke volume (SV), heart rate (HR), peripheral vascular resistance (PVR) and mean arterial pressure were recorded. Multilevel linear mixed-effects analysis was performed to compare the repeated measures of the cardiac variables between white, black and Asian women, controlling for maternal characteristics, medical history and medication use. RESULTS The study population included 1165 white, 247 black and 116 Asian women. CO increased with gestational age to a peak at 32 weeks and then decreased; the highest CO was observed in white women and the lowest in Asian women. SV initially increased after the first visit but subsequently declined with gestational age in white women, decreased with gestational age in black women and remained static in Asian women. In all three study groups, HR increased with gestational age until 32 weeks and then remained constant; HR was highest in black women and lowest in white women. PVR showed a reversed pattern to that of CO; the highest values were in Asian women and the lowest in white women. The least favorable hemodynamic profile, which was observed in black and Asian women, was reflected in higher rates of a small-for-gestational-age infant. CONCLUSIONS There are race-specific differences in maternal cardiac adaptation to pregnancy. White women have the most favorable cardiac adaptation by increasing SV and HR, achieving the highest CO and lowest PVR. In contrast, black and Asian women have lower CO and higher PVR than do white women, with CO increasing through a rise in HR due to declining or static SV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Z Ling
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - P G Jara
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Bisquera
- School of Population Health & Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - L C Poon
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- The Chinese University of Hong Kong, Hong Kong, China
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College Hospital, London, UK
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Russell A, Rivers EP, Giri PC, Jaehne AK, Nguyen HB. A Physiologic Approach to Hemodynamic Monitoring and Optimizing Oxygen Delivery in Shock Resuscitation. J Clin Med 2020; 9:jcm9072052. [PMID: 32629778 PMCID: PMC7408843 DOI: 10.3390/jcm9072052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/18/2020] [Accepted: 06/27/2020] [Indexed: 12/14/2022] Open
Abstract
The approach to shock resuscitation focuses on all components of oxygen delivery, including preload, afterload, contractility, hemoglobin, and oxygen saturation. Resuscitation focused solely on preload and fluid responsiveness minimizes other key elements, resulting in suboptimal patient care. This review will provide a physiologic and practical approach for the optimization of oxygen delivery utilizing available hemodynamic monitoring technologies. Venous oxygen saturation (SvO2) and lactate will be discussed as indicators of shock states and endpoints of resuscitation within the framework of resolving oxygen deficit and oxygen debt.
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Affiliation(s)
- Amy Russell
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Emanuel P. Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (E.P.R.); (A.K.J.)
- Surgical Critical Care, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Paresh C. Giri
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Anja K. Jaehne
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (E.P.R.); (A.K.J.)
| | - H. Bryant Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
- Correspondence: ; Tel.: +1-909-558-4023
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Ling HZ, Gallardo-Arozena M, Company-Calabuig AM, Nicolaides KH, Kametas NA. Clinical validation of bioreactance for the measurement of cardiac output in pregnancy. Anaesthesia 2020; 75:1307-1313. [PMID: 32469423 DOI: 10.1111/anae.15110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 11/27/2022]
Abstract
Maternal cardiac dysfunction is associated with pre-eclampsia, fetal growth restriction and haemodynamic instability during obstetric anaesthesia. There is growing interest in the use of non-invasive cardiac output monitoring to guide antihypertensive and fluid therapies in obstetrics. The aim of this study was to validate thoracic bioreactance using the NICOM® instrument against transthoracic echocardiography in pregnant women, and to assess the effects of maternal characteristics on the absolute difference of stroke volume, cardiac output and heart rate. We performed a prospective study involving women with singleton pregnancies in each trimester. We recruited 56 women who were between 11 and 14 weeks gestation, 57 between 20 and 23 weeks, and 53 between 35 and 37 weeks. Cardiac output was assessed repeatedly and simultaneously over 5 min in the left lateral position with NICOM and echocardiography. The performance of NICOM was assessed by calculating bias, 95% limits of agreement and mean percentage difference relative to echocardiography. Multivariate regression analysis evaluated the effect of maternal characteristics on the absolute difference between echocardiography and NICOM. The mean percentage difference of cardiac output measurements between the two methods was ±17%, with mean bias of -0.13 l.min-1 and limits of agreement of -1.1 to 0.84; stroke volume measurements had a mean percentage difference of ±15%, with a mean bias of -0.8 ml (-10.9 to 12.6); and heart rate measurements had a mean percentage difference of ±6%, with a mean bias of -2.4 beats.min-1 (-6.9 to 2.0). Similar results were found when the analyses were confined to each individual trimester. The absolute difference between NICOM and echocardiography was not affected by maternal age, weight, height, race, systolic or diastolic blood pressure. In conclusion, NICOM demonstrated good agreement with echocardiography, and can be used in pregnancy for the measurement of cardiac function.
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Affiliation(s)
- H Z Ling
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - M Gallardo-Arozena
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - A M Company-Calabuig
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - K H Nicolaides
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - N A Kametas
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
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Mitrev L, van Helmond N, Kaddissi G, Awad A, Patel K, Aji J, Ogbara J, Rafeq Z, Nagubandi V, Orr D, Gaughan J, Rosenbloom M. A Pilot Study Comparing Aortic Valve Area Estimates Derived from Fick Cardiac Output with Estimates Based on Cheetah-NICOM Cardiac Output. Sci Rep 2020; 10:7852. [PMID: 32398730 PMCID: PMC7217935 DOI: 10.1038/s41598-020-64753-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/06/2020] [Indexed: 11/30/2022] Open
Abstract
Cardiac output during cardiac catheterization is often estimated using the modified Fick method (COFick). In this proof-of-concept, prospective non-randomized study carried out in a single academic healthcare centre, we examined whether replacing COFick in the Gorlin formula with Cheetah-NICOM monitor cardiac output (COCheetah) could produce an accurate and precise estimate of aortic valve area in patients with severe aortic stenosis. In twenty-six subjects, COFick and COCheetah were obtained concurrently. A spot and 3-minute running average of COCheetah was used. Bland and Altman analysis was used to derive bias, 95% limits of agreement (LOA) and confidence intervals (CI). The mean difference (bias) between AVACheetah (average) and AVAFick was 0.11 cm2 and the 95% LOA were ±0.42 cm2. The 95% CI of the bias was 0.02–0.2 cm2. The bias and 95% LOA of AVACheetah (spot value) were 0.14 ± 0.42cm2, with a 95% CI of 0.06–0.23 cm2. No proportional bias was present. AVACheetah thus appears to be a reasonably accurate measure of AVA in patients with severe aortic stenosis compared to AVAFick measured using a modified Fick CO. However, the limits of agreement were not narrow enough to consider AVACheetah and AVAFick interchangeable.
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Affiliation(s)
- Ludmil Mitrev
- Department of Anaesthesiology/Division of Cardiac Anaesthesia, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA.
| | - Noud van Helmond
- Department of Anaesthesiology/Division of Cardiac Anaesthesia, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Georges Kaddissi
- Department of Cardiology, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Ahmed Awad
- Department of Anaesthesiology/Division of Cardiac Anaesthesia, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Kinjal Patel
- Department of Anaesthesiology/Division of Cardiac Anaesthesia, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Janah Aji
- Department of Cardiology, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Jeffrey Ogbara
- Department of Cardiology, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Zahi Rafeq
- Department of Cardiology, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Vineeth Nagubandi
- Department of Anaesthesiology/Division of Cardiac Anaesthesia, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Debbie Orr
- Department of Cardiology, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - John Gaughan
- Department of Medicine, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Michael Rosenbloom
- Chief, Department of Cardiothoracic Surgery, Cooper University Hospital, One Cooper Plaza, Camden, NJ, 08103, USA
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Douglas IS, Alapat PM, Corl KA, Exline MC, Forni LG, Holder AL, Kaufman DA, Khan A, Levy MM, Martin GS, Sahatjian JA, Seeley E, Self WH, Weingarten JA, Williams M, Hansell DM. Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial. Chest 2020; 158:1431-1445. [PMID: 32353418 PMCID: PMC9490557 DOI: 10.1016/j.chest.2020.04.025] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/16/2020] [Accepted: 04/02/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. RESEARCH QUESTION Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? STUDY DESIGN AND METHODS We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. RESULTS In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals. INTERPRETATION Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care. CLINICAL TRIAL REGISTRATION NCT02837731.
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Affiliation(s)
- Ivor S Douglas
- Pulmonary Science and Critical Care Medicine, Denver Health Medical Center and University of Colorado, Anschutz Medical Campus, Denver, CO.
| | - Philip M Alapat
- Pulmonary, Critical Care and Sleep Medicine, Ben Taub Hospital, Houston, TX
| | - Keith A Corl
- Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI
| | - Matthew C Exline
- Pulmonary, Critical Care and Sleep Medicine, Ohio State University Hospital, Columbus, OH
| | - Lui G Forni
- Intensive Care Medicine and Nephrology, University of Surrey & Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Andre L Holder
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | - David A Kaufman
- NYU School of Medicine, New York, NY; Pulmonary and Critical Care Medicine, Bridgeport Hospital, Bridgeport, CT
| | - Akram Khan
- Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - Mitchell M Levy
- Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI
| | - Gregory S Martin
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | | | - Eric Seeley
- Pulmonary, Critical Care Medicine and Allergy, University of California San Francisco, San Francisco, CA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN
| | - Jeremy A Weingarten
- Pulmonary, Critical Care and Sleep Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Mark Williams
- Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Douglas M Hansell
- Cheetah Medical, Wilmington, DE; Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Ling HZ, Jara PG, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. Maternal cardiac function in women at high risk for pre-eclampsia treated with 150 mg aspirin or placebo: an observational study. BJOG 2020; 127:1018-1025. [PMID: 32133780 DOI: 10.1111/1471-0528.16193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare maternal haemodynamics in women at low and high risk for preterm pre-eclampsia (PE), and between those at high risk who are randomised to aspirin or placebo. DESIGN Prospective, longitudinal observational study. SETTING Maternity units in six UK hospitals. POPULATION Women participating in the Aspirin for Prevention of Preterm Pre-eclampsia (ASPRE) trial. The population comprised three groups of women: low risk for preterm PE (n = 1362), high risk for preterm PE treated with aspirin (n = 208) and high risk for preterm PE on placebo (n = 220). METHODS Women had four visits during pregnancy: 11-14, 19-24, 30-34, and 35-37 weeks' gestation. Blood pressure was measured with a device validated for pregnancy, and PE and maternal haemodynamics were assessed with a bioreactance monitor at each visit. A multilevel linear mixed-effects analysis was performed to examine longitudinal changes of maternal haemodynamic variables, controlling for demographic characteristics, past medical history and medication use. MAIN OUTCOME MEASURES Longitudinal changes of cardiac output (CO), mean arterial pressure (MAP), and peripheral vascular resistance (PVR). RESULTS The low-risk group demonstrated the expected changes with an increase in CO and reduction in MAP and PVR, with a quadratic change across gestation. In contrast, the high-risk groups had a declining CO, and higher MAP and PVR during pregnancy. The administration of aspirin did not appear to affect maternal haemodynamics. CONCLUSIONS Women screened as high risk for preterm PE have a pathological cardiac adaptation to pregnancy and the prophylactic use of aspirin (150 mg oral daily from the first trimester) in this group may not alter this haemodynamic profile. TWEETABLE ABSTRACT In women at high risk of pre-eclampsia, prophylactic use of aspirin may not alter the impaired maternal cardiac adaptation.
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Affiliation(s)
- H Z Ling
- Fetal Medicine Research Institute, King's College London, London, UK
| | - P G Jara
- Fetal Medicine Research Institute, King's College London, London, UK
| | - A Bisquera
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - L C Poon
- Fetal Medicine Research Institute, King's College London, London, UK.,Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College London, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College London, London, UK
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Abstract
PURPOSE OF REVIEW Bedside cardiac output (CO) measurement is an important part of routine hemodynamic monitoring in the differential diagnosis of circulatory shock and fluid management. Different choices of CO measurement devices are available. The purpose of this review is to review the importance of CO [or stroke volume (SV)] measurement and to discuss the various methods (devices) used in determination of CO. RECENT FINDINGS CO measurement devices can be classified into two types: those use simple physical principles with minimal assumptions, and those predicting CO via mathematical modelling with a number of assumptions. Both have pros and cons, with the former being more accurate but with limited continuous monitoring capability whereas the latter less accurate but usually equipped with continuous monitoring functionality. With frequent updates in mathematical models, research data constantly become outdated in this area. Recent data suggest devices based on mathematical modelling have limited accuracies and poor precisions. SUMMARY Measurement of CO or SV is important in critically ill patients. Most devices have accuracy and reliability issues. The choice of device should depend on the purpose of measurement. For diagnostic purposes, devices based on simple physical principles, especially thermodilution and transthoracic echocardiography are more reliable due to accuracy.
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Deep neuromuscular blockade during spinal surgery reduces intra-operative blood loss. Eur J Anaesthesiol 2020; 37:187-195. [DOI: 10.1097/eja.0000000000001135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cho WJ, Cho SY, Lee AR. Systemic hemodynamic effects of norepinephrine versus phenylephrine in intermittent bolus doses during spinal anesthesia for cesarean delivery. Anesth Pain Med (Seoul) 2020; 15:53-60. [PMID: 33329790 PMCID: PMC7713867 DOI: 10.17085/apm.2020.15.1.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022] Open
Abstract
Background Norepinephrine, a potent α-adrenergic agonist with β-adrenergic effects, has recently emerged as a potential alternative to phenylephrine that does not lower cardiac output (CO) and heart rate (HR) during cesarean deliveries. We examined the systemic hemodynamic effects of both agents in this setting, using intermittent bolus doses to treat spinal anesthesia-induced hypotension. Methods A total of 56 parturients consenting to spinal anesthesia for elective cesarean delivery were randomly assigned to phenylephrine (100 μg/ml) or norepinephrine (5 μg/ml) intermittent bolus dosing. The primary study outcome was maternal normalized CO, examining and other hemodynamic variables, maternal side effects, and fetal outcomes secondarily. Results In terms of systolic blood pressure and HR, there were significant within-group differences over time (P < 0.001 and P < 0.001, respectively). Normalized CO and stroke volume (SV) also showed significant differences between groups (P < 0.001 and P = 0.002, respectively). In the phenylephrine group, normalized CO and SV declined (relative to baseline values) by as much as 13% and 9%, respectively; whereas in the norepinephrine group, normalized CO did not differ significantly from baseline, and SV increased up to 5% (relative to baseline). Normalized total peripheral resistance likewise displayed significant within-group differences over time (P < 0.001). Conclusions During elective cesarean delivery, intermittent bolus doses of norepinephrine proved effective for treating spinal anesthesia-induced hypotension, while maintaining CO and SV. No maternal complications or fetal effects were evident.
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Affiliation(s)
- Woo Jin Cho
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Seung Yeon Cho
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Ae-Ryoung Lee
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
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O'Neill R, Dempsey EM, Garvey AA, Schwarz CE. Non-invasive Cardiac Output Monitoring in Neonates. Front Pediatr 2020; 8:614585. [PMID: 33585366 PMCID: PMC7880199 DOI: 10.3389/fped.2020.614585] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Circulatory monitoring is currently limited to heart rate and blood pressure assessment in the majority of neonatal units globally. Non-invasive cardiac output monitoring (NiCO) in term and preterm neonates is increasing, where it has the potential to enhance our understanding and management of overall circulatory status. In this narrative review, we summarized 33 studies including almost 2,000 term and preterm neonates. The majority of studies evaluated interchangeability with echocardiography. Studies were performed in various clinical settings including the delivery room, patent ductus arteriosus assessment, patient positioning, red blood cell transfusion, and therapeutic hypothermia for hypoxic ischemic encephalopathy. This review presents an overview of NiCO in neonatal care, focusing on technical and practical aspects as well as current available evidence. We discuss potential goals for future research.
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Affiliation(s)
- Roisin O'Neill
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Aisling A Garvey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Christoph E Schwarz
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital, Tübingen, Germany
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Rali AS, Buechler T, Van Gotten B, Waters A, Shah Z, Haglund N, Sauer A. Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock: The NICOM Study. J Card Fail 2019; 26:160-165. [PMID: 31751786 DOI: 10.1016/j.cardfail.2019.11.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/13/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The bioreactance technique is a relatively new, totally noninvasive technique that is used to measure cardiac output (CO) and is easy to use. The Non-Invasive Cardiac Output Monitor (NICOM) is 1 such system. Although approved by the Food and Drug Administration for measurement of stroke volume, there is a paucity of literature validating this technology in decompensated heart failure and cardiogenic shock. METHODS AND RESULTS Fifty patients admitted to our cardiac intensive care unit for cardiogenic shock and Swan-Ganz catheter-guided therapy were prospectively enrolled in the study after informed consent. Simultaneous measurements of CO were obtained using NICOM, indirect Fick and bolus thermodilution. The intraclass correlation coefficient (ICC) was used to assess the precision of NICOM for CO using the 3 repeated measurements of CO over the pooled data. The agreement of the NICOM device in the defined clinical population, compared to indirect Fick and thermodilution, was evaluated by comparing the Pearson correlation coefficient, the Bland-Altman plot and the Lin concordance correlation coefficient. The ICC for cardiac output measured by NICOM showed excellent repeatability (ICC = 0.93, 95% CI = 0.92-0.94, n = 262) in the pooled data. The Pearson correlation coefficient for cardiac output measured by NICOM was poor when compared to indirect Fick (n = 263, r = 0.132, P = 0.033) and TD (n = 258, r = 0.275, P < 0.001). CONCLUSIONS NICOM technology is not a reliable method of measuring CO in patients with decompensated heart failure and cardiogenic shock.
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Affiliation(s)
- Aniket S Rali
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Tyler Buechler
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Bridget Van Gotten
- Department of Nursing, The University of Kansas Health System, Kansas City, Kansas
| | - Andrew Waters
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Zubair Shah
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Nicholas Haglund
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas
| | - Andrew Sauer
- Department of Cardiovascular Medicine, The University of Kansas Health System, Kansas City, Kansas.
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Pestel G, Fukui K, Higashi M, Schmidtmann I, Werner C. [Meta-analyses on measurement precision of non-invasive hemodynamic monitoring technologies in adults]. Anaesthesist 2019; 67:409-425. [PMID: 29789877 DOI: 10.1007/s00101-018-0452-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An ideal non-invasive monitoring system should provide accurate and reproducible measurements of clinically relevant variables that enables clinicians to guide therapy accordingly. The monitor should be rapid, easy to use, readily available at the bedside, operator-independent, cost-effective and should have a minimal risk and side effect profile for patients. An example is the introduction of pulse oximetry, which has become established for non-invasive monitoring of oxygenation worldwide. A corresponding non-invasive monitoring of hemodynamics and perfusion could optimize the anesthesiological treatment to the needs in individual cases. In recent years several non-invasive technologies to monitor hemodynamics in the perioperative setting have been introduced: suprasternal Doppler ultrasound, modified windkessel function, pulse wave transit time, radial artery tonometry, thoracic bioimpedance, endotracheal bioimpedance, bioreactance, and partial CO2 rebreathing have been tested for monitoring cardiac output or stroke volume. The photoelectric finger blood volume clamp technique and respiratory variation of the plethysmography curve have been assessed for monitoring fluid responsiveness. In this manuscript meta-analyses of non-invasive monitoring technologies were performed when non-invasive monitoring technology and reference technology were comparable. The primary evaluation criterion for all studies screened was a Bland-Altman analysis. Experimental and pediatric studies were excluded, as were all studies without a non-invasive monitoring technique or studies without evaluation of cardiac output/stroke volume or fluid responsiveness. Most studies found an acceptable bias with wide limits of agreement. Thus, most non-invasive hemodynamic monitoring technologies cannot be considered to be equivalent to the respective reference method. Studies testing the impact of non-invasive hemodynamic monitoring technologies as a trend evaluation on outcome, as well as studies evaluating alternatives to the finger for capturing the raw signals for hemodynamic assessment, and, finally, studies evaluating technologies based on a flow time measurement are current topics of clinical research.
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Affiliation(s)
- G Pestel
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - K Fukui
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - M Higashi
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - I Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsmedizin Mainz, Mainz, Deutschland
| | - C Werner
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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Ultrasound Assessment of the Change in Carotid Corrected Flow Time in Fluid Responsiveness in Undifferentiated Shock. Crit Care Med 2019; 46:e1040-e1046. [PMID: 30134304 DOI: 10.1097/ccm.0000000000003356] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN Prospective, noninterventional study. SETTING ICU at a large academic center. PATIENTS Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1 ± 18.7 ms versus -4.0 ± 8 ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7 ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.
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Ling HZ, Guy GP, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. The effect of parity on longitudinal maternal hemodynamics. Am J Obstet Gynecol 2019; 221:249.e1-249.e14. [PMID: 30951684 DOI: 10.1016/j.ajog.2019.03.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/24/2019] [Accepted: 03/27/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results. OBJECTIVE The objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age. STUDY DESIGN This was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11+0 to 13+6, 19+0 to 24+0, 30+0 to 34+0, and 35+0 to 37+0 weeks' gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy. RESULTS In groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1. CONCLUSION There are parity-specific differences in maternal cardiac adaptation in pregnancy.
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Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-153. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
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Barroso MTC, Hoppe MW, Boehme P, Krahn T, Kiefer C, Kramer F, Mondritzki T, Pirez P, Dinh W. Test-Retest Reliability of Non-Invasive Cardiac Output Measurement during Exercise in Healthy Volunteers in Daily Clinical Routine. Arq Bras Cardiol 2019; 113:231-239. [PMID: 31291418 PMCID: PMC6777898 DOI: 10.5935/abc.20190116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/14/2018] [Indexed: 12/28/2022] Open
Abstract
Background Thoracic bioreactance (TB), a noninvasive method for the measurement of
cardiac output (CO), shows good test-retest reliability in healthy adults
examined under research and resting conditions. Objective In this study, we evaluate the test-retest reliability of CO and cardiac
power (CPO) output assessment during exercise assessed by TB in healthy
adults under routine clinical conditions. Methods 25 test persons performed a symptom-limited graded cycling test in an
outpatient office on two different days separated by one week.
Cardiorespiratory (power output, VO2peak) and hemodynamic
parameters (heart rate, stroke volume, CO, mean arterial pressure, CPO) were
measured at rest and continuously under exercise using a spiroergometric
system and bioreactance cardiograph (NICOM, Cheetah Medical). Results After 8 participants were excluded due to measurement errors (outliers),
there was no systematic bias in all parameters under all conditions (effect
size: 0.2-0.6). We found that all noninvasively measured CO showed
acceptable test-retest-reliability (intraclass correlation coefficient:
0.59-0.98; typical error: 0.3-1.8). Moreover, peak CPO showed better
reliability (intraclass correlation coefficient: 0.80-0.85; effect size:
0.9-1.1) then the TB CO, thanks only to the superior reliability of MAP
(intraclass correlation coefficient: 0.59-0.98; effect size: 0.3-1.8). Conclusion Our findings preclude the clinical use of TB in healthy subject population
when outliers are not identified.
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Affiliation(s)
- Michael Thomas Coll Barroso
- Helios Clinics Wuppertal - Department of Cardiology, University Hospital Witten/Herdecke, Wuppertal - Germany
| | - Matthias Wilhelm Hoppe
- University Wuppertal - Department of Movement and Training Science, Wuppertal - Germany.,Department of Orthopedic, Trauma, Hand and Neuro Surgery, Klinikum Osnabrück GmbH, Osnabrück - Germany
| | - Philip Boehme
- Helios Clinics Wuppertal - Department of Cardiology, University Hospital Witten/Herdecke, Wuppertal - Germany.,Bayer AG - Open Innovation & Digital Technologies, Wuppertal - Germany
| | - Thomas Krahn
- Bayer AG - Research & Development, Pharmaceuticals, Biomarker Research, Wuppertal - Germany
| | - Christian Kiefer
- Helios Clinics Wuppertal - Department of Cardiology, University Hospital Witten/Herdecke, Wuppertal - Germany
| | - Frank Kramer
- Bayer AG - Translational Science, Clinical Sciences Experimental, Wuppertal - Germany
| | - Thomas Mondritzki
- Helios Clinics Wuppertal - Department of Cardiology, University Hospital Witten/Herdecke, Wuppertal - Germany.,Bayer AG - Research & Development, Pharmaceutical, Preclinical Research, Wuppertal - Germany
| | - Phillipe Pirez
- Bayer AG - Translational Science, Clinical Sciences Experimental, Wuppertal - Germany
| | - Wilfried Dinh
- Helios Clinics Wuppertal - Department of Cardiology, University Hospital Witten/Herdecke, Wuppertal - Germany.,Bayer AG - Translational Science, Clinical Sciences Experimental, Wuppertal - Germany
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Ling HZ, Guy GP, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:51-57. [PMID: 30246326 DOI: 10.1002/uog.20125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A. METHODS This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5th and 95th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics. RESULTS The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35th , 30th or 25th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher. CONCLUSION Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Z Ling
- Fetal Medicine Research Institute, King's College London, London, UK
| | - G P Guy
- Fetal Medicine Research Institute, King's College London, London, UK
| | - A Bisquera
- School of Population Health & Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - L C Poon
- Fetal Medicine Research Institute, King's College London, London, UK
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College London, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College London, London, UK
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McHugh A, El-Khuffash A, Bussmann N, Doherty A, Franklin O, Breathnach F. Hyperoxygenation in pregnancy exerts a more profound effect on cardiovascular hemodynamics than is observed in the nonpregnant state. Am J Obstet Gynecol 2019; 220:397.e1-397.e8. [PMID: 30849354 DOI: 10.1016/j.ajog.2019.02.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Supplemental oxygen is administered to pregnant women in many different clinical scenarios in obstetric practice. Despite the accepted uses for maternal hyperoxygenation, the impact of hyperoxia on maternal hemodynamic indices has not been evaluated. As a result, there is a paucity of data in the literature in relation to the physiological changes to the maternal circulation in response to supplemental oxygen. OBJECTIVE The hemodynamic effects of oxygen therapy are under-recognized and the impact of hyperoxygenation on maternal hemodynamics is currently unknown. Using noninvasive cardiac output monitoring which employs transthoracic bioreactance, we examined the effect of brief hyperoxygenation on cardiac index, systemic vascular resistance, blood pressure, stroke volume, and heart rate in pregnant mothers during the third trimester, compared with those effects observed in a nonpregnant population subjected to the same period of hyperoxygenation. STUDY DESIGN Hemodynamic monitoring was performed in a continuous manner over a 30-minute period using noninvasive cardiac output monitoring. Hyperoxygenation (O2 100% v/v inhalational gas) was carried out at a rate of 12 L/min via a partial non-rebreather mask for 10-minutes. Cardiac index, systemic vascular resistance, stroke volume, heart rate, and blood pressure were recorded before hyperoxygenation, at completion of hyperoxygenation, and 10 minutes after the cessation of hyperoxygenation. Two-way analysis of variance with repeated measures was used to assess the change in hemodynamic indices over time and the differences between the 2 groups. RESULTS Forty-six pregnant and 20 nonpregnant women with a median age of 33 years (interquartile range, 26-38 years) and 32 years (interquartile range, 28-37 years) were recruited prospectively, respectively (P=.82). The median gestational age was 35 weeks (33-37 weeks). In the pregnant group, there was a fall in cardiac index during the hyperoxygenation exposure period (P=.009) coupled with a rise in systemic vascular resistance with no recovery at 10 minutes after cessation of hyperoxygenation (P=.02). Heart rate decreased after hyperoxygenation exposure and returned to baseline by 10 minutes after cessation of therapy. There was a decrease in stroke volume over the exposure period, with no change in systolic or diastolic blood pressure. In the nonpregnant group, there was no significant change in the cardiac index, systemic vascular resistance, stroke volume, heart rate, or systolic or diastolic blood pressure during the course of exposure to hyperoxygenation. CONCLUSION Hyperoxygenation during the third trimester is associated with a fall in maternal cardiac index and a rise in systemic vascular resistance without recovery to baseline levels at 10 minutes after cessation of hyperoxygenation. The hemodynamic changes that were observed in this study in response to hyperoxygenation therapy during pregnancy could counteract any intended increase in oxygen delivery. The observed maternal effects of hyperoxygenation call for a reevaluation of the role of hyperoxygenation treatment in the nonhypoxemic pregnant patient.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland.
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Anne Doherty
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
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Parovic M, Okwose NC, Bailey K, Velicki L, Fras Z, Seferovic PM, MacGowan GA, Jakovljevic DG. NT-proBNP is a weak indicator of cardiac function and haemodynamic response to exercise in chronic heart failure. ESC Heart Fail 2019; 6:449-454. [PMID: 30788904 PMCID: PMC6437429 DOI: 10.1002/ehf2.12424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/13/2019] [Accepted: 02/03/2019] [Indexed: 11/11/2022] Open
Abstract
AIMS N-terminal prohormone of brain natriuretic peptide (NT-proBNP) plays an important role in diagnosis and management of heart failure. The aim of the present study was to assess haemodynamic response to exercise and to evaluate the relationship between NT-proBNP, cardiac function, and exercise tolerance in chronic heart failure. METHODS AND RESULTS A single-centre, cross-sectional pilot study recruited 17 patients with chronic heart failure with reduced left ventricular ejection fraction (age 67 ± 7 years) and 20 healthy volunteers (age 65 ± 12 years). The NT-proBNP was measured in the heart failure group. All participants completed maximal graded cardiopulmonary exercise stress testing coupled with gas exchange (using metabolic analyser for determination of exercise tolerance, i.e. peak O2 consumption) and continuous haemodynamic measurements (i.e. cardiac output and cardiac power output) using non-invasive bioreactance technology. Heart failure patients demonstrated significantly lower peak exercise cardiac function and exercise tolerance than healthy controls, i.e. cardiac power output (5.0 ± 2.0 vs. 3.2 ± 1.2 W, P < 0.01), cardiac output (18.2 ± 6.3 vs. 13.5 ± 4.0 L/min, P < 0.01), heart rate (148 ± 23.7 vs. 111 ± 20.9 beats/min, P < 0.01), and oxygen consumption (24.3 ± 9.5 vs. 16.8 ± 3.8 mL/kg/min, P < 0.01). There was no significant relationship between NT-proBNP and cardiac function at rest, i.e. cardiac power output (r = -0.28, P = 0.28), cardiac output (r = -0.18, P = 0.50), and oxygen consumption (r = -0.18, P = 0.50), or peak exercise, i.e. cardiac power output (r = 0.18, P = 0.49), cardiac output (r = 0.13, P = 0.63), and oxygen consumption (r = -0.05, P = 0.84). CONCLUSIONS Lack of a significant and strong relationship between the NT-proBNP and measures of cardiac function and exercise tolerance may suggest that natriuretic peptides should be considered with caution in interpretation of the severity of cardiac dysfunction and functional capacity in chronic heart failure.
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Affiliation(s)
- Milos Parovic
- Cardiovascular Research Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Institute of Genetic Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Nduka C Okwose
- Cardiovascular Research Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Institute of Genetic Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Kristian Bailey
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Department of Cardiovascular Surgery, Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
| | - Zlatko Fras
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.,Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Petar M Seferovic
- Cardiology Department, Medical School, University of Belgrade, Belgrade, Serbia.,Clinical Centre Serbia, Belgrade, Serbia.,Serbian Academy of Science and Arts, Belgrade, Serbia
| | - Guy A MacGowan
- Cardiovascular Research Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Institute of Genetic Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Djordje G Jakovljevic
- Cardiovascular Research Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Institute of Genetic Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,RCUK Centre for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
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Manohar N, Ramesh VJ, Radhakrishnan M, Chakraborti D. Haemodynamic changes during prone positioning in anaesthetised chronic cervical myelopathy patients. Indian J Anaesth 2019; 63:212-217. [PMID: 30988536 PMCID: PMC6423938 DOI: 10.4103/ija.ija_810_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background and Aims: Anaesthetised patients, when positioned prone, experience hypotension and reduction in cardiac output. Associated autonomic dysfunction in cervical myelopathy patients predisposes them to haemodynamic changes. The combined effect of prone positioning and autonomic dysfunction in anaesthetised patients remains unknown. Methods: Thirty adult chronic cervical myelopathy patients, aged 18-65 years with Nurick grade ≥2 were recruited in this prospective observational study. Heart rate, mean blood pressure, cardiac output, stroke volume, total peripheral resistance and stroke volume variation were measured using NICOM® monitor. Data were collected in supine before anaesthetic induction (baseline), 2 minutes after induction, 2 minutes after intubation, before and after prone positioning and every 5 minutes thereafter until skin incision. Repeated measures analysis of variance (ANOVA) was used to analyse the haemodynamic parameters across the time points. Bivariate Spearman's correlation was used to find factors associated with blood pressure changes. A P value <0.05 was kept significant. Results: Cardiac output during the entire study period remained stable (P = 0.186). Sixty percent of the patients experienced hypotension. At 15 and 20 minutes after prone positioning, mean blood pressure decreased (P = 0.001), stroke volume increased (P = 0.001), and heart rate and total peripheral resistance decreased (P < 0.001, P = 0.001, respectively). These changes were significant when compared to pre-prone position values. Number of levels of spinal cord compression positively correlated with the incidence of hypotension. Conclusion: Cervical myelopathy patients experienced hypotension with preserved cardiac output in prone position due to a reduction in total peripheral resistance. Hypotension correlated with the number of levels of spinal cord compression.
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Affiliation(s)
- Nitin Manohar
- Department of Neuroanesthesia, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Venkatapura J Ramesh
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Muthuchellappan Radhakrishnan
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhritiman Chakraborti
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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