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Zhang H, Lian H, Zhang Q, Zhao H, Wang X. Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients? Ann Intensive Care 2024; 14:114. [PMID: 39031301 PMCID: PMC11264666 DOI: 10.1186/s13613-024-01352-9] [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: 05/11/2024] [Accepted: 07/09/2024] [Indexed: 07/22/2024] Open
Abstract
OBJECTIVE To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation. METHODS This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D). RESULTS A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%). CONCLUSIONS CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.
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Affiliation(s)
- Hongmin Zhang
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Qing Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
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Kenny JÉS, Prager R, Rola P, Haycock K, Gibbs SO, Johnston DH, Horner C, Eibl JK, Lau VC, Kemp BO. Simultaneous Venous-Arterial Doppler Ultrasound During Early Fluid Resuscitation to Characterize a Novel Doppler Starling Curve: A Prospective Observational Pilot Study. J Intensive Care Med 2024; 39:628-635. [PMID: 38190576 PMCID: PMC11188059 DOI: 10.1177/08850666231224396] [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: 01/10/2024]
Abstract
Background: The likelihood of a patient being preload responsive-a state where the cardiac output or stroke volume (SV) increases significantly in response to preload-depends on both cardiac filling and function. This relationship is described by the canonical Frank-Starling curve. Research Question: We hypothesize that a novel method for phenotyping hypoperfused patients (ie, the "Doppler Starling curve") using synchronously measured jugular venous Doppler as a marker of central venous pressure (CVP) and corrected flow time of the carotid artery (ccFT) as a surrogate for SV will refine the pretest probability of preload responsiveness/unresponsiveness. Study Design and Methods: We retrospectively analyzed a prospectively collected convenience sample of hypoperfused adult emergency department (ED) patients. Doppler measurements were obtained before and during a preload challenge using a wireless, wearable Doppler ultrasound system. Based on internal jugular and carotid artery Doppler surrogates of CVP and SV, respectively, we placed hemodynamic assessments into quadrants (Qx) prior to preload augmentation: low CVP with normal SV (Q1), high CVP and normal SV (Q2), low CVP and low SV (Q3) and high CVP and low SV (Q4). The proportion of preload responsive and unresponsive assessments in each quadrant was calculated based on the maximal change in ccFT (ccFTΔ) during either a passive leg raise or rapid fluid challenge. Results: We analyzed 41 patients (68 hemodynamic assessments) between February and April 2021. The prevalence of each phenotype was: 15 (22%) in Q1, 8 (12%) in Q2, 39 (57%) in Q3, and 6 (9%) in Q4. Preload unresponsiveness rates were: Q1, 20%; Q2, 50%; Q3, 33%, and Q4, 67%. Interpretation: Even fluid naïve ED patients with sonographic estimates of low CVP have high rates of fluid unresponsiveness, making dynamic testing valuable to prevent ineffective IVF administration.
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Affiliation(s)
- Jon-Émile S. Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, Sudbury, ON, Canada
| | - Ross Prager
- Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Philippe Rola
- Division of Intensive Care, Santa Cabrini Hospital, Montreal, QC, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | | | | | | | - Joseph K. Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, Sudbury, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Vivian C. Lau
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Benjamin O. Kemp
- Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, IL, USA
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Mahrose R, Kasem AA. Pulse Pressure Variation-Based Intraoperative Fluid Management Versus Traditional Fluid Management for Colon Cancer Patients Undergoing Open Mass Resection and Anastomosis: A Randomized Controlled Trial. Anesth Pain Med 2023; 13:e135659. [PMID: 38024002 PMCID: PMC10676660 DOI: 10.5812/aapm-135659] [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: 02/21/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background Bowel edema leads to decreased perfusion and oxygenation of the intestine at the anastomotic site after colonic mass resection with failure of healing and leakage. Additionally, dehydration causes bowel hypoperfusion and difficulty healing with more complications. Fluid therapy guided by dynamic monitoring of fluid response can help avoid bowel dehydration and edema with fewer complications. Objectives The main goal of this study was to compare the effects of intraoperative fluid therapy based on pulse pressure variation (PPV) to traditional fluid therapy to maintain adequate hydration without intraoperative instability of hemodynamics and postoperative complications. Methods This randomized controlled study was conducted on 90 adult patients (age range: 18-70 years) undergoing elective open colonic mass resection and anastomosis at Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. There were two groups of patients, namely group A (n = 45; conventional fluid management [CFM] group) and group B (n = 45; goal-guided fluid management [GGFM] group based on PPV), using randomly generated data from a computer. Intraoperative fluids and vasopressors were given using GGFM or routine care. The key tool for directing hemodynamic management in the GGFM algorithm was the fluid protocol and PPV. As a result, the outcomes were measured to include the volume of intraoperative fluid, water fraction, and postoperative complications. Results In this study, 90 patients underwent analysis. Both groups' demographics were similar (P > 0.05). Baseline characteristics and surgical procedures did not differ significantly between the two groups (P > 0.05). Both the amount of urine output and the intraoperative administration of crystalloids were statistically significantly higher in group A (P < 0.05). The two groups' heart rate, mean arterial pressure and intraoperative usage of colloids and ephedrine were not statistically different (P > 0.05). Water fraction, bowel recovery, anastomotic leak, and length of hospital stay were significantly higher in the CFM group (P < 0.05). Conclusions For patients with the American Society of Anesthesiologists physical status I - II undergoing elective open resection of colonic mass and anastomosis, PPV-based GGFM, a less invasive tool for intraoperative fluid management, might be a better option than CFM.
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Affiliation(s)
- Ramy Mahrose
- Anesthesia, Intensive Care and Pain Management, Ain Shams University, Cairo, Egypt
| | - Amr A. Kasem
- Anesthesia, Intensive Care and Pain Management, Ain Shams University, Cairo, Egypt
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Kenny JÉS, Gibbs SO, Eibl JK, Eibl AM, Yang Z, Johnston D, Munding CE, Elfarnawany M, Lau VC, Kemp BO, Nalla B, Atoui R. Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve. Ultrasound J 2023; 15:32. [PMID: 37505318 PMCID: PMC10382420 DOI: 10.1186/s13089-023-00330-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023] Open
Abstract
Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.
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Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada.
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada.
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Andrew M Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | - Zhen Yang
- Flosonics Medical, 325 W. Front Street, Toronto, ON, Canada
| | | | | | | | - Vivian C Lau
- OSF Saint Francis Medical Center, Peoria, IL, USA
| | | | - Bhanu Nalla
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
| | - Rony Atoui
- Health Sciences North Research Institute, Sudbury, ON, Canada
- NOSM University, Sudbury, ON, Canada
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Kenny JES, Prager R, Rola P, McCulloch G, Eibl JK, Haycock K. The effect of gravity-induced preload change on the venous excess ultrasound (VExUS) score and internal jugular vein Doppler in healthy volunteers. Intensive Care Med Exp 2023; 11:19. [PMID: 37055637 PMCID: PMC10102271 DOI: 10.1186/s40635-023-00504-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/20/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The venous excess ultrasound (VExUS) score is a multi-organ Doppler approach to assess venous congestion. Despite growing use of VExUS in research and clinical practice, other veins can be visualized to assess for venous hypertension, which may overcome acquisition barriers of the VExUS exam. In this pilot, observational study, we used a wearable Doppler ultrasound to assess the relationship between jugular venous Doppler and the VExUS score under different preload conditions. We hypothesized that jugular Doppler morphology would accurately distinguish preload conditions, that it would most closely relate to the hepatic venous Doppler morphology in the fully supine position and that the VExUS score would be influenced by preload condition. RESULTS We recruited 15 healthy volunteers with no cardiovascular history. Preload change was achieved using a tilt-table with three positions: supine, fully upright, and 30-degree head-down tilt. In each position, a VExUS score was performed; furthermore, inferior vena collapsibility and sphericity index were calculated. At the same time, jugular venous Doppler was captured by a novel, wireless, wearable ultrasound system. A continuous jugular venous Doppler morphology was 96% accurate for detecting the low preload condition. The jugular venous Doppler morphology was highly correlated with the hepatic vein, but only in the supine position. Gravitational position did not significantly affect the sphericity index or the VExUS score. CONCLUSIONS The jugular vein Doppler morphology was able to accurately distinguish low from high preload conditions in healthy volunteers. Comparisons between VExUS Doppler morphologies and other veins should occur in the supine position when gravitational pressure gradients are minimized; finally, different preload conditions in healthy subjects did not affect the VExUS score.
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Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada.
- Flosonics Medical, Toronto, ON, Canada.
| | - Ross Prager
- Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, QC, Canada
| | | | - Joseph K Eibl
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada
- Flosonics Medical, Toronto, ON, Canada
- Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, USA
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [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: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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Chen H, Gong SR, Shang XL, Li J, Yu RG. The magnitude, but not the duration of elevated central venous pressure is associated with mortality in sepsis patients: An analysis of the MIMIC-IV database. PLoS One 2023; 18:e0281549. [PMID: 36753503 PMCID: PMC9907836 DOI: 10.1371/journal.pone.0281549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND It is unclear whether the magnitude and duration of elevated central venous pressure (ECVP) greater than ten mmHg has the same impact on mortality in sepsis patients. METHODS Critically ill patients with sepsis were identified from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The duration and the magnitude of ECVP were calculated. Normalized ECVP load was defined as the ECVP load (the sum of ECVP value times its duration) divided by the total duration of ECVP. The primary endpoint was 28-day mortality. Kaplan-Meier survival analysis was used to compare survival between patients with high or low normalized ECVP load. RESULTS A total of 1071 sepsis patients were included. Higher normalized ECVP load was associated with higher mortality rate; in contrast, the duration of ECVP was not associated with mortality. A linear relationship between normalized ECVP load and mortality was identified. Patients with higher normalized ECVP load had less urine output and more positive fluid balance. CONCLUSION The magnitude, but not the duration of ECVP, is associated with mortality in sepsis patients. ECVP should be considered as a valuable and easily accessible safety parameter during fluid resuscitation.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Shu-Rong Gong
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Jun Li
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Department of Critical Care Medicine, Fujian Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, Fujian, China,* E-mail: ,
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Central venous pressure estimation with force-coupled ultrasound of the internal jugular vein. Sci Rep 2023; 13:1500. [PMID: 36707658 PMCID: PMC9883282 DOI: 10.1038/s41598-022-22867-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/20/2022] [Indexed: 01/29/2023] Open
Abstract
We estimate central venous pressure (CVP) with force-coupled ultrasound imaging of the internal jugular vein (IJV). We acquire ultrasound images while measuring force applied over the IJV by the ultrasound probe imaging surface. We record collapse force, the force required to completely occlude the vein, in 27 healthy subjects. We find supine collapse force and jugular venous pulsation height (JVP), the clinical noninvasive standard, have a linear correlation coefficient of r2 = 0.89 and an average absolute difference of 0.23 mmHg when estimating CVP. We perturb our estimate negatively by tilting 16 degrees above supine and observe decreases in collapse force for every subject which are predictable from our CVP estimates. We perturb venous pressure positively to values experienced in decompensated heart failure by having subjects perform the Valsalva maneuver while the IJV is being collapsed and observe an increase in collapse force for every subject. Finally, we derive a CVP waveform with an inverse three-dimensional finite element optimization that uses supine collapse force and segmented force-coupled ultrasound data at approximately constant force.
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Bayraktar M, Kaçmaz M. Correlation of internal jugular vein, common carotid artery, femoral artery and femoral vein diameters with central venous pressure. Medicine (Baltimore) 2022; 101:e31207. [PMID: 36316929 PMCID: PMC9622599 DOI: 10.1097/md.0000000000031207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This study aimed to detect the correlation of central venous pressure (CVP) with the internal jugular vein (IJV), common carotid artery (CCA), femoral vein (FV), and femoral artery (FA) diameters measured with ultrasound (USG) in patients under mechanical ventilation to evaluate whether they are suitable to be used as an alternative low-cost and noninvasive method for the detection of CVP. METHODS A total of 40 patients aged from 18 to 90 who had been receiving therapy in the intensive care unit (ICU) were included in the study. Central venous catheter was placed into the patients through right IJV or subclavian vein in their first 24-hour of hospitalization and the right atrium pressure (RAP) was measured from the catheter, the tip of which was confirmed to reach right atrium. In the same session, CCA, IJV, FA, and FV diameters were measured with USG and their correlations with CVP were calculated. In addition, correlations of the measured venous and artery diameters between each other were detected as well. RESULTS There was a significantly high correlation between CVP and CCA diameter (R = 0.603, P < .000). There was a significantly low correlation between CVP and IJV diameter (R = 0.352, P = .026), a significantly low correlation between FA and FV diameters (R = 0.317, P = .047), a significantly low correlation between FA and CCA diameters (R = 0.330, P = .038), and a significantly low correlation between IJV and CCA diameters (R = 0.364, P = .020). CONCLUSION CVP and CCA diameters exhibited a high correlation. For detection of CVP, the ultrasonographic CCA diameter measurement can be used as an alternative noninvasive method which is easy to use and minimally affected by measurement errors of individuals and which has low learning curve compared with the other measurement methods.
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Affiliation(s)
- Muhammet Bayraktar
- Department of Public Health, Ömer Halisdemir University Faculty of Medicine, Nigde, Türkiye
- *Correspondence: Muhammet Bayraktar, Ömer Halisdemir University Faculty of Medicine, Nigde 51170, Türkiye (e-mail: )
| | - Mustafa Kaçmaz
- Department of Anesthesiology, Ömer Halisdemir University Faculty of Medicine, Nigde, Türkiye
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Assessing Fluid Intolerance with Doppler Ultrasonography: A Physiological Framework. Med Sci (Basel) 2022; 10:medsci10010012. [PMID: 35225945 PMCID: PMC8883898 DOI: 10.3390/medsci10010012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/11/2022] Open
Abstract
Ultrasonography is becoming the favored hemodynamic monitoring utensil of emergentologists, anesthesiologists and intensivists. While the roles of ultrasound grow and evolve, many clinical applications of ultrasound stem from qualitative, image-based protocols, especially for diagnosing and managing circulatory failure. Often, these algorithms imply or suggest treatment. For example, intravenous fluids are opted for or against based upon ultrasonographic signs of preload and estimation of the left ventricular ejection fraction. Though appealing, image-based algorithms skirt some foundational tenets of cardiac physiology; namely, (1) the relationship between cardiac filling and stroke volume varies considerably in the critically ill, (2) the correlation between cardiac filling and total vascular volume is poor and (3) the ejection fraction is not purely an appraisal of cardiac function but rather a measure of coupling between the ventricle and the arterial load. Therefore, management decisions could be enhanced by quantitative approaches, enabled by Doppler ultrasonography. Both fluid ‘responsiveness’ and ‘tolerance’ are evaluated by Doppler ultrasound, but the physiological relationship between these constructs is nebulous. Accordingly, it is argued that the link between them is founded upon the Frank–Starling–Sarnoff relationship and that this framework helps direct future ultrasound protocols, explains seemingly discordant findings and steers new routes of enquiry.
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Kenny JÉS, Barjaktarevic I, Mackenzie DC, Rola P, Haycock K, Eibl AM, Eibl JK. Inferring the Frank-Starling Curve From Simultaneous Venous and Arterial Doppler: Measurements From a Wireless, Wearable Ultrasound Patch. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:676995. [PMID: 35047930 PMCID: PMC8757733 DOI: 10.3389/fmedt.2021.676995] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022] Open
Abstract
The Frank–Starling relationship is a fundamental concept in cardiovascular physiology, relating change in cardiac filling to its output. Historically, this relationship has been measured by physiologists and clinicians using invasive monitoring tools, relating right atrial pressure (Pra) to stroke volume (SV) because the Pra-SV slope has therapeutic implications. For example, a critically ill patient with a flattened Pra-SV slope may have low Pra yet fail to increase SV following additional cardiac filling (e.g., intravenous fluids). Provocative maneuvers such as the passive leg raise (PLR) have been proposed to identify these “fluid non-responders”; however, simultaneously measuring cardiac filling and output via non-invasive methods like ultrasound is cumbersome during a PLR. In this Hypothesis and Theory submission, we suggest that a wearable Doppler ultrasound can infer the Pra-SV relationship by simultaneously capturing jugular venous and carotid arterial Doppler in real time. We propose that this method would confirm that low cardiac filling may associate with poor response to additional volume. Additionally, simultaneous assessment of venous filling and arterial output could help interpret and compare provocative maneuvers like the PLR because change in cardiac filling can be confirmed. If our hypothesis is confirmed with future investigation, wearable monitors capable of monitoring both variables of the Frank–Starling relation could be helpful in the ICU and other less acute patient settings.
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Affiliation(s)
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, United States
| | - David C Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine.,Tufts University School of Medicine, Boston, MA, United States
| | - Philippe Rola
- Division of Intensive Care, Santa Cabrini Hospital, Montreal, QC, Canada
| | - Korbin Haycock
- Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA, United States
| | - Andrew M Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Joseph K Eibl
- Health Sciences North Research Institute, Sudbury, ON, Canada.,Northern Ontario School of Medicine, Sudbury, ON, Canada
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12
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Huang A, Liao L, Pan L, Pinhu L. Association Between the Central Venous Pressure and All-Cause Mortality in Critically Ill Patients with Acute Kidney Injury. Int J Gen Med 2021; 14:8019-8027. [PMID: 34785944 PMCID: PMC8590983 DOI: 10.2147/ijgm.s331686] [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: 09/06/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Elevated central venous pressure (CVP) plays an important role in the occurrence of acute kidney injury (AKI) and it is also independently associated with the prognosis of critically ill patients. However, the effect of CVP on critically ill AKI patients remains unclear. In this study, we analyzed the relationship between CVP and all-cause mortality of critically ill patients with AKI. Patients and Methods The clinical data of patients in intensive care unit (ICU) were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database and retrospectively analyzed. The all-cause mortality for up to 90 days was the main observed outcome. We used the minimum CVP value obtained during the first 72 hours after ICU admission for our analysis and patients were grouped according to this parameter. Patients were also analyzed after being further divided according to stages 1, 2 and 3 of AKI. Multiple Cox regression and Kaplan–Meier analyses were used to explore the association between CVP measurements and death of ICU patients with AKI. Results A total of 1986 ICU patients with AKI were studied. A total of 527 (26.5%) patients died by day 90. The high CVP group (patients with ≥10 mmHg) had the lowest 90-day survival rate (P =0.001 by log rank test) when according to Kaplan–Meier analysis. By using Cox regression analysis, high CVP was found to be linked to an increase in mortality (CVP ≥10 mmHg versus ≤5 mmHg, HR, 1.336, 95% CI, 1.064 to 1.677, P trend=0.014). Furthermore, when using in a multivariate Cox regression analysis with CVP as a continuous variable, the higher CVP levels were still an independent risk factor for 90-day all-cause mortality (per 1 mmHg increase, HR, 1.031, 95% CI, 1.013–1.049, P=0.001). In subgroup analysis, a similar trend was observed in patients with AKI stages 2 and 3. Conclusion The minimum CVP level during the first 72h after ICU admission was positively associated with mortality in critically ill patients with AKI and this more marked in cases with severe AKI.
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Affiliation(s)
- Aifang Huang
- Renal Division, Department of Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, 530021, People's Republic of China
| | - Lin Liao
- Department of Clinical Laboratory, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, 530021, People's Republic of China
| | - Ling Pan
- Renal Division, Department of Medicine, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, 530021, People's Republic of China
| | - Liao Pinhu
- Department of Emergency, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, 530021, People's Republic of China
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Rosalia L, Ozturk C, Van Story D, Horvath MA, Roche ET. Object‐Oriented Lumped‐Parameter Modeling of the Cardiovascular System for Physiological and Pathophysiological Conditions. ADVANCED THEORY AND SIMULATIONS 2021. [DOI: 10.1002/adts.202000216] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Luca Rosalia
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA 02139 USA
- Harvard‐MIT Program in Health Sciences and Technology Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Caglar Ozturk
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - David Van Story
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Markus A. Horvath
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA 02139 USA
- Harvard‐MIT Program in Health Sciences and Technology Massachusetts Institute of Technology Cambridge MA 02139 USA
| | - Ellen T. Roche
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA 02139 USA
- Harvard‐MIT Program in Health Sciences and Technology Massachusetts Institute of Technology Cambridge MA 02139 USA
- Department of Mechanical Engineering Massachusetts Institute of Technology Cambridge MA 02139 USA
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14
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Mareev VY, Garganeeva AA, Ageev FT, Arutunov GP, Begrambekova YL, Belenkov YN, Vasyuk YA, Galyavich AS, Gilarevsky SR, Glezer MG, Drapkina OM, Duplyakov DV, Kobalava ZD, Koziolova NA, Kuzheleva EA, Mareev YV, Ovchinnikov AG, Orlova YA, Perepech NB, Sitnikova MY, Skvortsov AA, Skibitskiy VV, Chesnikova AI. [The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]. ACTA ACUST UNITED AC 2021; 60:13-47. [PMID: 33522467 DOI: 10.18087/cardio.2020.12.n1427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - A A Garganeeva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - F T Ageev
- Scientific Medical Research Center of Cardiology, Russia
| | - G P Arutunov
- Russian National Research Medical University named after Pirogov, Moscow
| | - Yu L Begrambekova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - Yu N Belenkov
- Sechenov Moscow State Medical University, Moscow, Russia
| | - Yu A Vasyuk
- Moscow State Medical and Dental University named after Evdokimov, Moscow, Russia
| | | | - S R Gilarevsky
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - M G Glezer
- Sechenov Moscow State Medical University, Moscow, Russia
| | - O M Drapkina
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia
| | - D V Duplyakov
- Samara Regional Clinical Cardiological Dispensary, Russia
| | - Zh D Kobalava
- Russian State University of Peoples' Friendship, Moscow, Russia
| | - N A Koziolova
- Federal State Budgetary Institution of Healthcare of Higher Education "Perm State Medical University named after Academician E.A. Wagner ", Russia
| | - E A Kuzheleva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics, Glasgow, Great Britain
| | | | - Ya A Orlova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | | | - M Yu Sitnikova
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A A Skvortsov
- Scientific Medical Research Center of Cardiology, Russia
| | - V V Skibitskiy
- Kuban State Medical University" of the Ministry of Health of the Russian Federation, Russia
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Central Venous Pressure Estimation by Ultrasound Measurement of Inferior Vena Cava and Aorta Diameters in Pediatric Critical Patients: An Observational Study. Pediatr Crit Care Med 2021; 22:e1-e9. [PMID: 33009360 DOI: 10.1097/pcc.0000000000002526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the ability to predict central venous pressure by ultrasound measured inferior vena cava and aortic diameters in a PICU population and to assess interoperator concordance. DESIGN Noninterventional observational study. SETTING PICU of a tertiary-care academic center. PATIENTS Eighty-eight pediatric patients (0-16 yr old) with a central venous catheter in place were studied. Sixty-nine percent of the patients received positive-pressure ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An experienced and a nonexperienced operator used ultrasound to measure the maximal diameter of inferior vena cava and minimal diameter of the inferior vena cava and the maximum diameter of the abdominal aorta from the subxiphoid window. The inferior vena cava collapsibility index and the ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta were then derived. The central venous pressure was measured using a central venous catheter and recorded. Twenty-three patients had low central venous pressure values (≤ 4 mm Hg), 35 patients a value in the range of 5-9 mm Hg, and 30 patients high values (≥ 10 mm Hg). Both inferior vena cava collapsibility index and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta were predictive of high (≥ 10 mm Hg) or low (≤ 4 mm Hg) central venous pressure. The test accuracy showed the best results in predicting low central venous pressure with an inferior vena cava collapsibility index greater than or equal to 35% and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta less than or equal to 0.8, and in predicting high central venous pressure with an inferior vena cava collapsibility index less than or equal to 20% and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta greater than or equal to 1.3. Inferior vena cava collapsibility index returned generally higher accuracy values than ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta. Lin's coefficient of concordance between the operators was 0.78 for inferior vena cava collapsibility index and 0.86 for ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta. CONCLUSIONS Inferior vena cava collapsibility index and ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta correlate well with central venous pressure measurements in this PICU population, and specific inferior vena cava collapsibility index or ratio of maximal diameter of inferior vena cava/maximum diameter of the abdominal aorta thresholds appear to be able to differentiate children with high or low central venous pressure. However, the actual clinical application of these statistically significant results remains limited, especially by the intrinsic flaws of the procedure.
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Singh Y, Villaescusa JU, da Cruz EM, Tibby SM, Bottari G, Saxena R, Guillén M, Herce JL, Di Nardo M, Cecchetti C, Brierley J, de Boode W, Lemson J. Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:620. [PMID: 33092621 PMCID: PMC7579971 DOI: 10.1186/s13054-020-03326-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. METHODS Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. RESULTS Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. CONCLUSIONS These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Javier Urbano Villaescusa
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Eduardo M da Cruz
- Department of Pediatrics, Children's Hospital Colorado, Section of Cardiac Intensive Care, The Heart Institute, Pittsburgh, USA
| | - Shane M Tibby
- Department of Pediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Gabriella Bottari
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Rohit Saxena
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Marga Guillén
- Department of Pediatric Intensive Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jesus Lopez Herce
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Matteo Di Nardo
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Joe Brierley
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Li DK, Mao JY, Long Y, Liu DW, Wang XT. Pulmonary hypertension with adult respiratory distress syndrome: prevalence, clinical impact, and association with central venous pressure. Pulm Circ 2020; 10:2045894020933087. [PMID: 32699608 PMCID: PMC7357056 DOI: 10.1177/2045894020933087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/15/2020] [Indexed: 02/06/2023] Open
Abstract
Pulmonary hypertension (PH) occurs in patients with acute respiratory distress syndrome (ARDS); the most severe form comprises acute cor pulmonale (ACP). Here, we investigated the prevalence of PH in patients with ARDS to evaluate its correlation with ACP risk, ARDS severity and central venous pressure (CVP). We conducted a secondary analysis using data from the MIMIC-III open-source clinical database. The prevalence of PH associated with new-onset ARDS during the first 72 h after intensive care unit admission was investigated; moreover, the association between ACP risk score and PH was validated. We also evaluated the association between elevated CVP (mean CVP > 10 mmHg) and PH and other clinical outcomes. Among 2434 patients who met the ARDS Berlin criteria and underwent echocardiography or pulmonary artery catheterization evaluation, a total of 583 (24.0%) patients were diagnosed with moderate or severe PH, of which 418 had low and 165 had high ACP risk. After adjustment for disease/ARDS severity, ACP risk score, and other demographic variables, elevated CVP was independently associated with the occurrence of PH (odds ratio, 2.239 (1.674, 2.993), p < 0.005). Among patients with PH, higher mean CVP was associated with prolonged hospital stay (13.4 vs. 15.2 days, p = 0.041) and duration of ventilation (116.5 vs. 150.5 h, p = 0.023). Incidence of PH was 24.0% in patients with new-onset ARDS in this retrospective study. Elevated CVP is relevant with higher incidence of PH and worse clinical outcome; these highlighted the importance of hemodynamic monitoring in the management of ARDS.
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Affiliation(s)
- Dong-Kai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Jia-Yu Mao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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18
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Tansey EA, Montgomery LEA, Quinn JG, Roe SM, Johnson CD. Understanding basic vein physiology and venous blood pressure through simple physical assessments. ADVANCES IN PHYSIOLOGY EDUCATION 2019; 43:423-429. [PMID: 31408386 DOI: 10.1152/advan.00182.2018] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
An understanding of the complexity of the cardiovascular system is incomplete without a knowledge of the venous system. It is important for students to understand that, in a closed system, like the circulatory system, changes to the venous side of the circulation have a knock-on effect on heart function and the arterial system and vice versa. Veins are capacitance vessels feeding blood to the right side of the heart. Changes in venous compliance have large effects on the volume of blood entering the heart and hence cardiac output by the Frank-Starling Law. In healthy steady-state conditions, venous return has to equal cardiac output, i.e., the heart cannot pump more blood than is delivered to it. A sound understanding of the venous system is essential in understanding how changes in cardiac output occur with changes in right atrial pressure or central venous pressure, and the effect these changes have on arterial blood pressure regulation. The aim of this paper is to detail simple hands-on physiological assessments that can be easily undertaken in the practical laboratory setting and that illustrate some key functions of veins. Specifically, we illustrate that venous valves prevent the backflow of blood, that venous blood pressure increases from the heart to the feet, that the skeletal muscle pump facilitates venous return, and we investigate the physiological and clinical significance of central venous pressure and how it may be assessed.
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Affiliation(s)
- Etain A Tansey
- Centre for Biomedical Sciences Education, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Northern Ireland, United Kingdom
| | - Laura E A Montgomery
- Centre for Biomedical Sciences Education, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Northern Ireland, United Kingdom
| | - Joe G Quinn
- Centre for Biomedical Sciences Education, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Northern Ireland, United Kingdom
| | - Sean M Roe
- Centre for Biomedical Sciences Education, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Northern Ireland, United Kingdom
| | - Christopher D Johnson
- Centre for Biomedical Sciences Education, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Northern Ireland, United Kingdom
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20
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Moinadini S, Tajoddini S, Hedayat AA. Prediction of the central venous pressure in trauma patients on the basis of non-invasive parameters using artificial neural network. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919855881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Generally, in traumatic patients, uncontrolled bleeding leads to shock and ultimately death. So, any early detection of shock can reduce the likelihood of a patient’s death. At present, the precise method for estimating the body’s need for fluids is to measure central venous pressure (CVP). However, this method is invasive and time consuming. Objective: This study aimed to predict the central venous pressure value and range of trauma patients through non-invasive parameters such as caval index, lactate clearance, base excess and shock index. Methods: A prospective observational study was performed in 100 trauma patients. Written informed consent was obtained from patient(s) or relatives for their anonymized information to be published in any article. Results: It indicated that parameters such as caval index (at a proposed cutoff point of 35%), lactate clearance (at a cutoff point of 6%) and base excess (at a proposed cutoff point of 6 mmol/L) are approximately of the same level of accuracy for estimating the central venous pressure range, while parameter shock index (at a cutoff point of 1.25) is of the least level of accuracy to predict the central venous pressure range. Results also showed that among all proposed predictive models for estimating the central venous pressure value, which were on the basis of either non-linear regression or artificial neural network, the most accurate model was the one on the basis of the artificial neural network. Among parameters lactate clearance, base excess and shock index used to form the artificial neural network-based model, parameters base excess and lactate clearance were of the highest and lowest level of importance, respectively. Conclusion: Among all proposed models and non-invasive parameters to predict the central venous pressure range, CVPLC model (at a cutoff point of 9), which is a non-linear regression model and is in terms of parameter lactate clearance, was the most accurate model.
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Affiliation(s)
- Shiva Moinadini
- Department of Emergency Medicine, Aliebn Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Shahrad Tajoddini
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Amir Ahmad Hedayat
- Department of Civil Engineering, Islamic Azad University Kerman Branch, Kerman, Iran
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Parenti N, Scalese M, Palazzi C, Agrusta F, Cahill J, Agnelli G. Role of Internal Jugular Vein Ultrasound Measurements in the Assessment of Central Venous Pressure in Spontaneously Breathing Patients: A Systematic Review. J Acute Med 2019; 9:39-48. [PMID: 32995230 PMCID: PMC7440374 DOI: 10.6705/j.jacme.201906_9(2).0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/28/2018] [Accepted: 07/04/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Few studies have tested the role of the internal jugular vein (IJV) ultrasonographic (US) diameters in the assessment of central venous pressure (CVP) in spontaneously breathing patients. No review or meta-analysis is currently available on the role of IJV assessment in this setting. The aim of this systematic review is to check the reliability and accuracy of IJV US diameters in predicting CVP and to evaluate its correlation with CVP in spontaneously breathing patients. METHODS This systematic review was based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We included studies on the accuracy and reliability of the IJV ultrasound measures and studies exploring its correlation with CVP in adult spontaneously breathing patients. The studies' report quality was assessed by Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 scales. RESULTS A total of five studies was eligible for final analysis. The studies on IJV ultrasound measures showed a good quality in reporting. The anterior-posterior diameter maximum of IJV (AP-IJV Dmax) showed the best correlation with the CVP with a good inter-rater reliability and validity in predicting CVP. All measures showed good inter-rater reliability and validity in predicting CVP, but only the AP-IJV Dmax showed good correlation with CVP. CONCLUSIONS The AP-IJV Dmax could be a potential surrogate of CVP because of its good reliability and validity in predicting CVP value and its fair-moderate correlation with CVP. Anyway, further research should confi rm these conclusions.
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Affiliation(s)
- Nicola Parenti
- University of Modena e Reggio EmiliaLargo del Pozzo, 71Modena41125Italy
| | - Marco Scalese
- Institute of Clinical Physiology-Italian National Research Council (IFC-CNR)PisaItaly
| | - Carmela Palazzi
- University of Modena e Reggio EmiliaLargo del Pozzo, 71Modena41125Italy
| | - Federica Agrusta
- University of Modena e Reggio EmiliaLargo del Pozzo, 71Modena41125Italy
| | - Jane Cahill
- University of LeedsSchool of HealthcareLeedsUK
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Premkumar M, Rangegowda D, Kajal K, Khumuckham JS. Noninvasive estimation of intravascular volume status in cirrhosis by dynamic size and collapsibility indices of the inferior vena cava using bedside echocardiography. JGH OPEN 2019; 3:322-328. [PMID: 31406926 PMCID: PMC6684769 DOI: 10.1002/jgh3.12166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/26/2019] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
Background and Aim Echocardiographic assessment of the inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) is a noninvasive estimate of intravascular volume status (IVS) but requires validation for cirrhosis. We evaluated IVC dynamics in cirrhosis and correlated it with conventional tools such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and right atrial pressure (RAP). Methods A total of 673 consecutive cirrhotic patients were screened by echocardiography, and 125 patients underwent right heart catheterization with recording of hepatic venous pressure gradient (HVPG), RAP, pulmonary artery (PA) pressure, and PCWP. CVP data were available for 80 (64%) patients, and finally, 76 patients (84% male, 50% ethanol related, mean age 52.1 years, 57.8% with ascites) with complete data were enrolled. Results The mean CVP measured was 12.8 ± 4.8 mmHg, and IVCCI was 29.5 ± 10.9%. The IVCD ranged from 0.97 to 2.26 cm and from 0.76 to 1.84 cm during expiration and inspiration, respectively, with a mean of 1.8 ± 0.9 cm. The mean IVCD correlated with RAP (r = 0.633, P = 0.043) but not with HVPG (r = 0.344, P = 0.755), PCWP (r = 0.562, P = 0.072), or PA pressure (r = 0.563, P = 0.588). A negative linear correlation was observed between the CVP and the IVCCI (r = −0.827, P = 0.023) in all patients and substratified for those with (r = −0.748, P = 0.039) and without ascites (r = −0.761, P = 0.047). A positive correlation was observed between CVP and IVCDmax (r = 0.671, P = 0.037) and IVCDmin (r = 0.612, P = 0.040). Conclusions IVCD and collapsibility index provides noninvasive IVS assessment, independent of HVPG or ascites, with the potential for calculating fluid requirements in cirrhosis.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Devaraja Rangegowda
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Kamal Kajal
- Department of Anesthesia and Critical Care Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Jelen S Khumuckham
- Department of Cardiology Institute of Liver and Biliary Sciences New Delhi India
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Chen X, Wang X, Honore PM, Spapen HD, Liu D. Renal failure in critically ill patients, beware of applying (central venous) pressure on the kidney. Ann Intensive Care 2018; 8:91. [PMID: 30238174 PMCID: PMC6146958 DOI: 10.1186/s13613-018-0439-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022] Open
Abstract
The central venous pressure (CVP) is traditionally used as a surrogate of intravascular volume. CVP measurements therefore are often applied at the bedside to guide fluid administration in postoperative and critically ill patients. Pursuing high CVP levels has recently been challenged. A high CVP might impede venous return to the heart and disturb microcirculatory blood flow which may cause tissue congestion and organ failure. By imposing an increased "afterload" on the kidney, an elevated CVP will particularly harm kidney hemodynamics and promote acute kidney injury (AKI) even in the absence of volume overload. Maintaining the lowest possible CVP should become routine to prevent and treat AKI, especially when associated with septic shock, cardiac surgery, mechanical ventilation, and intra-abdominal hypertension.
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Affiliation(s)
- Xiukai Chen
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, 200 Lothrop Street, BST E1240, Pittsburgh, PA 15261 USA
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
| | - Patrick M. Honore
- Department of Intensive Care, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Van Gehuchtenplein, 1020 Brussels, Belgium
| | - Herbert D. Spapen
- Department of Intensive Care, University Hospital, Vrije Universiteit Brussel (VUB), 101, Laarbeeklaan, Jette 1090 Brussels, Belgium
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
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Yang Y, Ma J, Zhao L. High central venous pressure is associated with acute kidney injury and mortality in patients underwent cardiopulmonary bypass surgery. J Crit Care 2018; 48:211-215. [PMID: 30243200 DOI: 10.1016/j.jcrc.2018.08.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/15/2018] [Accepted: 08/24/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE We sought to investigate the relationship between high CVP, AKI, and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass. MATERIALS All patients aged 18 years or older who underwent cardiac surgery with CPB were prospectively reviewed. Patients were excluded when renal artery were involved before and during surgery. Patients were dichotomized into high CVP group(>10 mmHg) and low CVP group(<10 mmHg). All patients were followed by telephone. RESULTS A total of 1941 patients were included in observed study. In high CVP group, three hundred forty-seven patients (43.32%) developed AKI, while eighty-six (7.543%) in low CVP group(P <0.0001). Furthermore, in every KDIGO stage, patients of AKI in high CVP group were more than those in low CVP group(P <0.0001). The incidence of AKI increased as CVP increased, especially when CVP was higher than 10cmH2O. In a median follow-up time of 9.2 months, Crude mortality is 8.365% in the high CVP group compared to 1.929% in the low CVP group (p<0.0001). In multivariate analysis, CVP remained the independent predictor of survival. CONCLUSIONS High CVP is associated with AKI , and it is independently related to all-cause mortality in patients underwent cardiovascular surgery with cardiopulmonary bypass.
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Affiliation(s)
- Yanli Yang
- Center of Anesethology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, ChaoYang District, Beijing 100029, China.
| | - Jun Ma
- Center of Anesethology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, ChaoYang District, Beijing 100029, China
| | - Liyun Zhao
- Center of Anesethology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Rd, ChaoYang District, Beijing 100029, China
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Babaie S, Behzad A, Mohammadpour M, Reisi M. A Comparison between the Bedside Sonographic Measurements of the Inferior Vena Cava Indices and the Central Venous Pressure While Assessing the Decreased Intravascular Volume in Children. Adv Biomed Res 2018; 7:97. [PMID: 30050885 PMCID: PMC6036785 DOI: 10.4103/abr.abr_213_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hemodynamic monitoring is an essential part in the treatment of critically ill patients. Establishment of intravascular volume and creation of a normal systemic perfusion are the most important part to reduce the risk of organ failure and mortality. This study aimed to determine the correlation between the inferior vena cava (IVC) sonographic indices and the central venous pressure (CVP) to provide a useful guide for noninvasive intravascular volume status assessment in children. Materials and Methods: Target sample of children who were admitted to the pediatric critical care unit and required CVP monitoring were enrolled in this study. The collapsibility index (CI) and IVC/aorta (AO) ratio, from bedside ultrasonography measurement of the IVC, were calculated. Results: Of the 70 participants, 22 patients (31.4%) revealed a CVP of 8 mm/Hg or less and 48 patients (68.6%) revealed a CVP >8 mm/Hg. Fifty-six patients (80%) had an IVC-CI of 0.5 or greater and 17 patients (24.3%) had an IVC/AO of 0.8 or less. IVC-CI index is 45.5% sensitive and 91.7% specific with positive predictive value of 71.4 and negative predictive value of 78.6 to predict CVP <8, and the IVC/AO index is 50.8% sensitive and 87.5% specific with a positive predictive value of 64.7 and a negative predictive value of 79.2 to predict CVP <8. Conclusion: Based on the present finding, the IVC sonographic indices provide a useful guide for noninvasive intravascular volume status assessment in children.
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Affiliation(s)
- Sharareh Babaie
- Department of Pediatrics, Faculty of Medicine, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azita Behzad
- Department of Pediatric Intensive Care Unit, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Department of Pediatric Intensive Care Unit, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Reisi
- Department of Pediatrics, Faculty of Medicine, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Noncommunicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Cesur S, Çardaközü T, Kuş A, Türkyılmaz N, Yavuz Ö. Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery. J Clin Monit Comput 2018; 33:249-257. [PMID: 29948666 PMCID: PMC6420438 DOI: 10.1007/s10877-018-0163-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.
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Affiliation(s)
- Sevim Cesur
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey.
| | - Tülay Çardaközü
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Alparslan Kuş
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Neşe Türkyılmaz
- Department of Anesthesiology and Reanimation, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
| | - Ömer Yavuz
- Department of General Surgery, Kocaeli University of Medical Faculty, Izmit, Kocaeli, Turkey
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Choi SJ, Ha EJ, Jhang WK, Park SJ. Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients. BMC Pediatr 2018; 18:58. [PMID: 29439683 PMCID: PMC5811958 DOI: 10.1186/s12887-018-1059-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 02/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Central venous pressure (CVP) is an important factor affecting capillary blood flow, and it is associated with poor outcomes in adult septic shock patients. However, whether a similar association exists in pediatric patients remains unclear. METHODS We retrospectively analyzed data from patients admitted to our pediatric intensive care unit (PICU) between February 2009 and July 2015. Patients were divided into two groups-survivors and nonsurvivors-according to 28-day mortality. The associations between (a) mortality and CVP at 6, 24, 48, and 72 h after initiating treatment for established septic shock was analyzed and (b) initial serum lactic acid levels and 6-h CVP. RESULTS Two hundred twenty-six patients were included in this study, and the mortality rate was 29.6% (67 deaths, nonsurvivor group). Initial serum lactic acid levels, Pediatric Risk of Mortality (PRISM) III score, and Vasoactive-Inotropic Score (VIS) within 24 h after PICU admission were significantly higher in the nonsurvivors than in survivors (1.3 [0.9, 2.4] vs. 3.9 [1.6, 8.0] mmol/l, 11.0 [7.0, 15.0] vs. 17.0 [10.0, 21.5], 12.0 [7.0, 25.0] vs. 22.5 [8.0, 55.0], respectively with p-values < 0.001, < 0.001, and 0.009, respectively). In addition, compared to survivors, a greater percentage of nonsurvivors required mechanical ventilation (92.5% vs. 51.6%, p < 0.001) and showed a greater extent of fluid overload at 48 h after admission (3.9% vs. 1.9%, p = 0.006), along with higher 6-h CVP (10.0 [7.0, 16.0] vs. 8.0 [5.0, 11.0] mmHg, p < 0.001). Patient survival according to levels of CVP (CVP < 8 mmHg, CVP 8-12 mmHg, or CVP > 12 mmHg) showed that the CVP > 12-mmHg group had significantly greater mortality rates (50.0%, p = 0.002) than the other groups (21.3% and 27.5%). Furthermore, multivariate analysis identified significant associations of CVP > 12 mmHg, serum lactic acid levels, and the need for mechanical ventilation with mortality (OR: 2.74, 1.30, and 12.51, respectively; 95% CI: 1.11-6.72, 1.12-1.50, and 4.12-37.96, respectively). CONCLUSIONS Elevated CVP is an independent risk factor for mortality in pediatric septic shock patients.
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Affiliation(s)
- Seung Jun Choi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Eun-Ju Ha
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Won Kyoung Jhang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Seong Jong Park
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Republic of Korea.
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Li DK, Wang XT, Liu DW. Association between elevated central venous pressure and outcomes in critically ill patients. Ann Intensive Care 2017; 7:83. [PMID: 28795349 PMCID: PMC5549673 DOI: 10.1186/s13613-017-0306-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 07/29/2017] [Indexed: 01/09/2023] Open
Abstract
Background Some prior studies have shown that elevated mean central venous pressure in certain patient populations and disease processes may lead to poor prognosis. However, these studies failed to generalize the concept of elevated central venous pressure (ECVP) load to all patients in critical care settings because of the limited cases and exclusive cohorts. The aim of the study was to investigate the association between elevated central venous pressure and outcomes in critical care. Methods We performed a retrospective analysis on a single-center public database (MIMIC) of more than 9000 patients and more than 500,000 records of central venous pressure measurement. We evaluated the association between mean central venous pressure level and 28-day mortality after intensive care unit admission. The secondary outcomes were duration of mechanical ventilation, vasoactive drug use, laboratory results related to organ dysfunction and length of intensive care unit hospitalization. Accordingly, we proposed the concept of ECVP10 (the time sum of CVP above 10 mmHg) and investigated its association with outcome. Results There were 1645 deaths at 28 days after admission. Compared with the lowest quartile of mean central venous pressure [mean (SD) 7.4 (1.9) mmHg], the highest quartile [17.4 (4.1) mmHg] was associated with a 33.6% (95% CI 1.117–1.599) higher adjusted risk of death. Poor secondary outcomes were also associated with higher quartiles of elevated mean central venous pressure. After stratification by mean central venous pressure, elevated duration of central venous pressure above 10 mmHg was significantly higher in the non-survival group than in the survival group. Conclusions Elevated central venous pressure level correlated with poor outcomes and prolonged treatment in critical care settings. Level and duration of elevated central venous pressure should be both evaluated to establish its cause and apply appropriate treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0306-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dong-Kai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Drevet CM, Opprecht N, Nadji A, Mirek S, Aho S, Ricolfi F, Girard C, Bouhemad B. Impact of restrictive fluid protocol on hypoxemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2017; 42:152-156. [PMID: 28735155 DOI: 10.1016/j.jcrc.2017.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/19/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In patients with aneurysmal subarachnoid hemorrhage (aSAH), acute cardiac dysfunction and triple-H-therapy, can lead to hypoxemia. Our aim was to assess impact of a protocoled fluid restrictive approach on hypoxemia in these patients. METHODS We included prospectively ICU patients with aSAH admitted within 24h after the bleed. The study was divided into 2 phases. The first phase, from January to December 2012, was designated as control group (group C). The second phase, from February 2014 to January 2015, was designated as study group (group S). Between these periods, a protocoled fluid intake approach was implemented to maintain as low as possible the cumulative fluid balances. RESULTS Effective fluid restriction was obtained: at day 3 cumulative fluid balances were respectively for group C and group S, 1559±2402ml and 759±1855ml (p=0.04); and 2211±4918ml vs 529±2806ml (p=0.04) at day 7. We observed reduction in proportion of hypoxemic patient in group S compared to group C, at day 3 (22% vs 40%, p=0.047) and at day 7 (28% vs 57%, p=0.007). CONCLUSIONS Fluid restrictive management of patients with aSAH decreases number of hypoxemic patients at day 3 and day 7.
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Affiliation(s)
- Claire-Marie Drevet
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Nicolas Opprecht
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Abdelouaïd Nadji
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Sebastien Mirek
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Serge Aho
- Service d'Epidémiologie et d'Hygiène Hospitalières, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Frederic Ricolfi
- Service d'imagerie diagnostique et thérapeutique Neuroradiologie et Urgences CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Claude Girard
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France
| | - Bélaïd Bouhemad
- Service d'Anesthésie Réanimation, CHU de Dijon, Dijon, France, BP 77908, 21709 Dijon Cedex, France.
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Mukherjee V, Brosnahan SB, Bakker J. How to Use Fluid Responsiveness in Sepsis. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2017. [DOI: 10.1007/978-3-319-51908-1_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Magder S. Right Atrial Pressure in the Critically Ill: How to Measure, What Is the Value, What Are the Limitations? Chest 2016; 151:908-916. [PMID: 27815151 DOI: 10.1016/j.chest.2016.10.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/17/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022] Open
Abstract
Right atrial pressure (Pra) is determined by the interaction of the function of the heart as a pump, which is called cardiac function, and the factors that determine the return of blood to the heart, which is called return function. Thus, monitoring Pra or its surrogate, central venous pressure (CVP), can give important insights into mechanisms behind changes in hemodynamic status, responses to interventions, and the likelihood of diagnoses. Examination of the components of the Pra tracing, especially during the ventilator cycle, can also give information about right-sided cardiac diastolic function, the status of the tricuspid valve, volume responsiveness, and the cardiac rhythm. Importantly, the pressure difference from the large venous reservoir to the heart is small, and thus great care must be taken with technical factors that affect the measurement.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, QC, Canada.
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Yamada H, Tsukamoto T, Narumiya H, Oda K, Higaki S, Iizuka R, Yanagita M, Deguchi M. Initial central venous pressure could be a prognostic marker for hemodynamic improvement of polymyxin B direct hemoperfusion: a retrospective cohort study. J Intensive Care 2016; 4:64. [PMID: 27777780 PMCID: PMC5057477 DOI: 10.1186/s40560-016-0186-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/15/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Direct hemoperfusion with polymyxin B-immobilized fiber column (PMX-DHP) could improve the hemodynamic status of septic shock patients. As PMX-DHP is an invasive and costly procedure, it is desirable to estimate the therapeutic effect before performing the therapy. However, it is still unclear when this therapy should be started and what type of sepsis it should be employed for. In this study, we retrospectively examined the clinical effect of patients treated with PMX-DHP by using central venous pressure (CVP). METHODS Seventy patients who received PMX-DHP for septic shock during the study period were recruited and divided into a low CVP group (n = 33, CVP < 12 mmHg) and a high CVP group (n = 37, CVP≧12 mmHg). The primary endpoint was vasopressor dependency index at 24 hours after starting PMX-DHP, and the secondary endpoint was the 28-day survival rate. Additionally, we performed a multivariate linear regression analysis on the difference in the vasopressor dependency index. RESULTS The vasopressor dependency index significantly improved at 24 h in the low CVP group (0.33 to 0.16 mmHg-1; p < 0.01) but not in the high CVP group (0.43 to 0.34 mmHg-1; p = 0.41), and there was a significant difference between the two groups in the index at 24 h (p = 0.02). The 28-day survival rate was higher in the low CVP group (79 vs. 43 %; p < 0.01). Multivariate linear regression analysis showed that CVP (p = 0.04) was independently associated with the difference in the vasopressor dependency index. CONCLUSIONS Our study indicates that the clinical effect of PMX-DHP for septic shock patients with higher CVP (≧12 mmHg) might be limited and that the initial CVP when performing PMX-DHP could function as an independent prognostic marker for the hemodynamic improvement.
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Affiliation(s)
- Hiroyuki Yamada
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan ; Department of Metabolism, Nephrology and Rheumatology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
| | - Tatsuo Tsukamoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan
| | - Hiromichi Narumiya
- Department of Metabolism, Nephrology and Rheumatology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan ; Department of Emergency, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
| | - Kazumasa Oda
- Department of Emergency, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
| | - Satoshi Higaki
- Department of Emergency, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
| | - Ryoji Iizuka
- Department of Emergency, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan
| | - Masako Deguchi
- Department of Metabolism, Nephrology and Rheumatology, Japanese Red Cross Kyoto Daini Hospital, 355-5 Haruobi, Kamigyo-ku, Kyoto, 602-8026 Japan
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Avellan S, Uhr I, McKelvey D, Sondergaard S. Identifying the position of the right atrium to align pressure transducer for CVP : Spirit level or 3D electromagnetic positioning? J Clin Monit Comput 2016; 31:943-949. [PMID: 27510178 DOI: 10.1007/s10877-016-9918-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 08/02/2016] [Indexed: 01/20/2023]
Abstract
The central venous pressure, CVP, is an important variable in the management of selected perioperative and intensive care cases and in clinical decision support systems, CDSS. In current routine, when measuring CVP the health care provider may use anatomical landmarks and a spirit level, SL, to adjust the pressure transducer to the level of the tricuspid valve, i.e. the phlebostatic axis. The aim of the study was to assess the agreement in the postoperative setting between the SL method and electromagnetic 3D positioning (EM). CVP was measured with patients in positions dictated by nursing routines. The staff members measured CVP using SL to position the transducer at the perceived phlebostatic level. This position was compared to coordinates based on an electromagnetic field with external sensors at anatomical landmarks and an internal sensor in the CV catheter for 3D determination of the phlebostatic axis. An electronic survey took bearing on the accepted error in measurement among colleagues at the department. There was a clinically relevant difference between the CVP measured by the staff members and the CVP based on the 3D EM positioning. The limits of agreement extended in excess of ±8 mmHg and half of the measurements had deviations outside an accepted error range of ±2.5 mmHg. There was a large variation in CVP measurements when assessing the agreement with the current method. This may indicate the need for improvement in accuracy, e.g. using the electromagnetic field positioning system, in association with routine monitoring and clinical decision support systems.
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Affiliation(s)
- S Avellan
- Medical School, University of Gothenburg, 405 40, Gothenburg, Sweden
| | - I Uhr
- Medical School, University of Gothenburg, 405 40, Gothenburg, Sweden
| | - D McKelvey
- Chalmers University of Technology, Chalmersplatsen 4, 412 96, Gothenburg, Sweden
| | - Soren Sondergaard
- Centre of Elective Surgery, Silkeborg Regional Hospital, 8600, Silkeborg, Denmark.
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Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 2016; 42:324-332. [DOI: 10.1007/s00134-015-4168-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022]
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35
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Magder S. Value of CVP: an epidemiological or physiological question? Intensive Care Med 2016; 42:458-459. [PMID: 26818385 DOI: 10.1007/s00134-015-4208-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Affiliation(s)
- S Magder
- Department of Critical Care, McGill University Heath Centre (Glen Site Campus), 1001 Decarie Blvd, room D03.6358, Montreal, QC, H4A 3J1, Canada.
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Hilbert T, Ellerkmann RK, Klaschik S, Putensen C, Thudium M. The Use of Internal Jugular Vein Ultrasonography to Anticipate Low or High Central Venous Pressure During Mechanical Ventilation. J Emerg Med 2016; 50:581-7. [PMID: 26806319 DOI: 10.1016/j.jemermed.2015.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/17/2015] [Accepted: 11/18/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Critically low or high central venous pressure (CVP) values, together with systemic hypotension, can indicate hypovolemia or acute heart failure. However, measuring CVP requires the insertion of a central venous catheter, a time-consuming procedure that can be associated with severe complications. OBJECTIVE We sought to evaluate the use of ultrasonography of the internal jugular vein (IJV) to estimate low or high CVP values in patients who were on ventilation. METHODS Ultrasonography of IJV dimensions and the collection of hemodynamic data was performed in 47 patients, and the ratio between IJV diameter in the 30° and 0° position was calculated (ratio(30/0)). The predictive value of ratio(30/0) for estimating low and high CVP levels was analyzed using receiver operating characteristic curves. RESULTS The median IJV diameter ratio(30/0) was 0.49. CVP ranged from 1 to 13 mm Hg (median 7 mm Hg). Seventeen patients had a CVP ≤ 5 mm Hg or lower (defined as "low"), and in 11 patients, values of ≥ 10 mm Hg were measured (defined as "high"). The corresponding IJV diameter ratios increased significantly from 0.34 (in the low CVP group) to 0.9 (in the high CVP group). Receiver operating characteristic analysis revealed a good predictive value of the ratio(30/0) for the prediction of low or high CVP values, respectively. A ratio(30/0) of < 0.45 optimally indicated a low CVP, while > 0.65 was the cutoff value to detect a CVP ≥ 10 mm Hg. CONCLUSION The estimation of low or high CVP values by IJV ultrasonography in different patient positions can be a helpful instrument for the rapid hemodynamic assessment of the critically ill patient.
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Affiliation(s)
- Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Richard K Ellerkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sven Klaschik
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Marcus Thudium
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Abstract
Although invasive hemodynamic monitoring requires considerable skill, studies have shown a striking lack of knowledge of the measurements obtained with the pulmonary artery catheter (PAC). This article reviews monitoring using a PAC. Issues addressed include basic physiology that determines cardiac output and blood pressure; methodology in the measurement of data obtained from a PAC; use of the PAC in making a diagnosis and for patient management, with emphasis on a responsive approach to management; and uses of the PAC that are not indications by themselves for placing the catheter, but can provide useful information when a PAC is in place.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Centre, 687 Pine Avenue West, Montreal, Quebec H3A 1A1, Canada.
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Yang C, Yang Z, Chen X, Liu T, Gou S, Chen C, Xiao J, Jin X, He Z, Dong L, Zhang Y, Luo N, Wu H, Wang C. Inverted U-Shaped Relationship between Central Venous Pressure and Intra-Abdominal Pressure in the Early Phase of Severe Acute Pancreatitis: A Retrospective Study. PLoS One 2015; 10:e0128493. [PMID: 26053865 PMCID: PMC4459987 DOI: 10.1371/journal.pone.0128493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 04/27/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Many studies have indicated that intra-abdominal pressure (IAP) is positively correlated with central venous pressure (CVP) in severe cases. However, although elevated IAP is common in patients with severe acute pancreatitis (SAP), its relationship with CVP remains unclear. Our study aimed to investigate the association of IAP with CVP in early-phase SAP patients. METHODS In total, 116 SAP patients were included in this retrospective study. On the first day of hospitalization, blood samples were collected for biochemical examination and cytokine concentration monitoring. Additionally, a urinary catheter and right subclavian vein catheter were inserted for IAP and CVP measurement, respectively. Other routine clinical data were also recorded. RESULTS Within 24 hours after hospitalization, CVP fluctuated and increased with increasing IAP up to 15.7 mmHg (P = 0.054) but decreased with increasing IAP when the IAP was > 15.7 mmHg (P < 0.001). After adjusting for abdominal perfusion pressure (APP) and mean arterial pressure (MAP), a similar distribution was observed. An inverted U-shaped trend between IAP and CVP was also present in the groups classified according to the patient's sex, local complications, ascites, and serum amylase levels. CONCLUSIONS CVP and IAP have an inverted U-shaped relationship, with a peak at an IAP of 15.7 mmHg in the early phase of SAP. After this peak, CVP decreases as IAP increases. These results have crucial implications for clinical fluid resuscitation in SAP patients. In particular, because one CVP value might be correlated with different IAP values in patients with the same CVP, the volume of fluid needed might be different.
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Affiliation(s)
- Chong Yang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
- Organ Transplant Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People’s Republic of China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, People’s Republic of China
| | - Zhiyong Yang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Xinglin Chen
- Key Laboratory of Geriatrics of Health Ministry, Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Tao Liu
- Surgical Oncology-Abdominal Department, Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Shanmiao Gou
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Changzhong Chen
- Microarray Core Facility, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Jun Xiao
- Surgical Oncology-Abdominal Department, Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Xin Jin
- Surgical Oncology-Abdominal Department, Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Zhiqiang He
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Liming Dong
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Yushun Zhang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Na Luo
- Center for Applied English Studies, the University of Hong Kong, Hong Kong, People’s Republic of China
| | - Heshui Wu
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
| | - Chunyou Wang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, People’s Republic of China
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Abstract
PURPOSE OF REVIEW Many devices are currently available for measuring cardiac output and function. Understanding the utility of these devices requires an understanding of the determinants of cardiac output and cardiac function, and the use of these parameters in the management of critically ill patients. This review stresses the meaning of the physiological measures that are obtained with these devices and how these values can be used. RECENT FINDINGS Evaluation of devices for haemodynamic monitoring can include just measurement of cardiac output, the potential to track spontaneous changes in cardiac output or changes produced by volume infusions or vasoactive drugs, or the ability to assess cardiac function. Each of these puts different demands on the need for accuracy, precision, and reliability of the devices, and thus devices must be evaluated based on the clinical need. SUMMARY Evaluation of cardiac function is useful when first dealing with an unstable patient, but for ongoing management measurement of cardiac output itself is key and even more so the trend in relationship to the patient's overall condition. This evaluation would be greatly benefited by the addition of objective measures of tissue perfusion.
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Choi YS, Lee BS, Chung SH, Kim JH, Kim EAR, Kim KS. Central venous pressure and renal function in very low birth weight infants during the early neonatal period. J Matern Fetal Neonatal Med 2015; 29:430-4. [DOI: 10.3109/14767058.2014.1002766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lee SJ, Ramar K, Park JG, Gajic O, Li G, Kashyap R. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest 2014; 146:908-915. [PMID: 24853382 DOI: 10.1378/chest.13-2702] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The surviving sepsis guidelines recommend early aggressive fluid resuscitation within 6 h of sepsis onset. Although rapid fluid administration may offer benefit, studies on the timing of resuscitation are lacking. We hypothesized that there is an association between quicker, adequate fluid resuscitation and patient outcome from sepsis onset time. METHODS This is a retrospective cohort study of consecutive adults with severe sepsis and septic shock admitted to a quaternary care medical ICU between January 2007 and December 2009. Data were collected from a previously validated electronic medical database. Multivariate regression modeling was performed, adjusting for age, admission weight, Sequential Organ Failure Assessment score, APACHE (Acute Physiology and Chronic Health Examination) III score, and total fluid administration within the first 6 h of sepsis onset time. RESULTS Of 651 patients with severe sepsis and septic shock screened, 594 had detailed fluid data. In a univariate analysis, the median amount of fluid within the first 3 h for survivors at discharge was 2,085 mL (940-4,080 mL) and for nonsurvivors, 1,600 mL (600-3,010 mL; P = .007). In comparison, during the latter 3 h, the median amount was 660 mL (290-1,485 mL) vs 800 mL (360-1,680 mL; P = .09), respectively. After adjusting for confounders, the higher proportion of total fluid received within the first 3 h was associated with decreased hospital mortality (OR, 0.34; 95% CI, 0.15-0.75; P = .008). CONCLUSIONS Earlier fluid resuscitation (within the first 3 h) is associated with a greater number of survivors with severe sepsis and septic shock.
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Affiliation(s)
- Sarah J Lee
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - John G Park
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Guangxi Li
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Liang F, Senzaki H, Kurishima C, Sughimoto K, Inuzuka R, Liu H. Hemodynamic performance of the Fontan circulation compared with a normal biventricular circulation: a computational model study. Am J Physiol Heart Circ Physiol 2014; 307:H1056-72. [DOI: 10.1152/ajpheart.00245.2014] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The physiological limitations of the Fontan circulation have been extensively addressed in the literature. Many studies emphasized the importance of pulmonary vascular resistance in determining cardiac output (CO) but gave little attention to other cardiovascular properties that may play considerable roles as well. The present study was aimed to systemically investigate the effects of various cardiovascular properties on clinically relevant hemodynamic variables (e.g., CO and central venous pressure). To this aim, a computational modeling method was employed. The constructed models provided a useful tool for quantifying the hemodynamic effects of any cardiovascular property of interest by varying the corresponding model parameters in model-based simulations. Herein, the Fontan circulation was studied compared with a normal biventricular circulation so as to highlight the unique characteristics of the Fontan circulation. Based on a series of numerical experiments, it was found that 1) pulmonary vascular resistance, ventricular diastolic function, and systemic vascular compliance play a major role, while heart rate, ventricular contractility, and systemic vascular resistance play a secondary role in the regulation of CO in the Fontan circulation; 2) CO is nonlinearly related to any single cardiovascular property, with their relationship being simultaneously influenced by other cardiovascular properties; and 3) the stability of central venous pressure is significantly reduced in the Fontan circulation. The findings suggest that the hemodynamic performance of the Fontan circulation is codetermined by various cardiovascular properties and hence a full understanding of patient-specific cardiovascular conditions is necessary to optimize the treatment of Fontan patients.
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Affiliation(s)
- Fuyou Liang
- Shanghai Jiao Tong University-Chiba University International Cooperative Research Center, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Hideaki Senzaki
- Department of Pediatrics and Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Kamoda, Kawagoe, Saitama, Japan
| | - Clara Kurishima
- Department of Pediatrics and Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Kamoda, Kawagoe, Saitama, Japan
| | - Koichi Sughimoto
- Department of Cardiac Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Ryo Inuzuka
- Pediatrics, University Hospital University of Tokyo, Tokyo, Japan; and
| | - Hao Liu
- Shanghai Jiao Tong University-Chiba University International Cooperative Research Center, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
- Graduate School of Engineering, Chiba University, Inage, Chiba, Japan
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Magder S. Is all on the level? Hemodynamics during supine versus prone ventilation. Am J Respir Crit Care Med 2014; 188:1390-1. [PMID: 24328770 DOI: 10.1164/rccm.201311-1957ed] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sheldon Magder
- 1 Department of Critical Care McGill University Health Centre Montreal, Quebec, Canada
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Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774-81. [PMID: 23774337 DOI: 10.1097/ccm.0b013e31828a25fd] [Citation(s) in RCA: 480] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a previous meta-analysis that concluded that central venous pressure should not be used to make clinical decisions regarding fluid management, central venous pressure continues to be recommended for this purpose. AIM To perform an updated meta-analysis incorporating recent studies that investigated indices predictive of fluid responsiveness. A priori subgroup analysis was planned according to the location where the study was performed (ICU or operating room). DATA SOURCES MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. STUDY SELECTION Clinical trials that reported the correlation coefficient or area under the receiver operating characteristic curve (AUC) between the central venous pressure and change in cardiac performance following an intervention that altered cardiac preload. From 191 articles screened, 43 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, and included healthy controls (n = 1) and ICU (n = 22) and operating room (n = 20) patients. DATA EXTRACTION Data were abstracted on study characteristics, patient population, baseline central venous pressure, the correlation coefficient, and/or the AUC between central venous pressure and change in stroke volume index/cardiac index and the percentage of fluid responders. Meta-analytic techniques were used to summarize the data. DATA SYNTHESIS Overall 57% ± 13% of patients were fluid responders. The summary AUC was 0.56 (95% CI, 0.54-0.58) with no heterogenicity between studies. The summary AUC was 0.56 (95% CI, 0.52-0.60) for those studies done in the ICU and 0.56 (95% CI, 0.54-0.58) for those done in the operating room. The summary correlation coefficient between the baseline central venous pressure and change in stroke volume index/cardiac index was 0.18 (95% CI, 0.1-0.25), being 0.28 (95% CI, 0.16-0.40) in the ICU patients, and 0.11 (95% CI, 0.02-0.21) in the operating room patients. CONCLUSIONS There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned.
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Cardiac output responses in a flow-driven protocol of resuscitation following cardiac surgery. J Crit Care 2013; 28:265-9. [DOI: 10.1016/j.jcrc.2012.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 08/23/2012] [Accepted: 09/11/2012] [Indexed: 12/11/2022]
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Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children? Pediatr Emerg Care 2013; 29:337-41. [PMID: 23426248 DOI: 10.1097/pec.0b013e31828512a5] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Previous studies demonstrated that the collapsibility index (percent decrease in inferior vena cava [IVC] diameter with inspiration) of 50% or greater and an IVC/aorta ratio of 0.8 or less correlated with a low intravascular volume. Our study sought to determine if bedside ultrasound (BUS) measurements of the IVC diameter correlate with central venous pressure (CVP) measurements as an indicator of intravascular volume status in acutely ill children. METHODS A convenience sample of children younger than 21 years who were admitted to the pediatric critical care unit and required CVP monitoring had BUS measurements of both IVC and aortic diameters with simultaneous CVP measurement. The collapsibility index (sagittal view) and IVC/aorta ratio (transverse view) were calculated from these measurements. A CVP of 8 mm Hg or less was considered as a marker for decreased intravascular volume. RESULTS Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = -0.23, P = 0.11) nor IVC/aorta (r = -0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population. CONCLUSIONS Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children.
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Abstract
Hemodynamic monitoring is used to identify deviations from hemodynamic goals and to assess responses to therapy. To accomplish these goals one must understand how the circulation is regulated. In this review I begin with an historical review of the work of Arthur Guyton and his conceptual understanding of the circulation and then present an approach by which Guyton's concepts can be applied at the bedside. Guyton argued that cardiac output and central venous pressure are determined by the interaction of two functions: cardiac function, which is determined by cardiac performance; and a return function, which is determined by the return of blood to the heart. This means that changes in cardiac output are dependent upon changes of one of these two functions or of both. I start with an approach based on the approximation that blood pressure is determined by the product of cardiac output and systemic vascular resistance and that cardiac output is determined by cardiac function and venous return. A fall in blood pressure with no change in or a rise in cardiac output indicates that a decrease in vascular resistance is the dominant factor. If the fall in blood pressure is due to a fall in cardiac output then the role of a change in the return function and cardiac function can be separated by the patterns of changes in central venous pressure and cardiac output. Measurement of cardiac output is a central component to this approach but until recently it was not easy to obtain and was estimated from surrogates. However, there are now a number of non-invasive devices that can give measures of cardiac output and permit the use of physiological principles to more rapidly appreciate the primary pathophysiology behind hemodynamic abnormalities and to provide directed therapy.
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Affiliation(s)
- Sheldon Magder
- McGill University Health Centre, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, Quebec, Canada H3A 1A1
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Lanspa MJ, Brown SM, Hirshberg EL, Jones JP, Grissom CK. Central venous pressure and shock index predict lack of hemodynamic response to volume expansion in septic shock: a prospective, observational study. J Crit Care 2012; 27:609-15. [PMID: 23084132 DOI: 10.1016/j.jcrc.2012.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/20/2012] [Accepted: 07/23/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE Volume expansion is a common therapeutic intervention in septic shock, although patient response to the intervention is difficult to predict. Central venous pressure (CVP) and shock index have been used independently to guide volume expansion, although their use is questionable. We hypothesize that a combination of these measurements will be useful. METHODS In a prospective, observational study, patients with early septic shock received 10-mL/kg volume expansion at their treating physician's discretion after brief initial resuscitation in the emergency department. Central venous pressure and shock index were measured before volume expansion interventions. Cardiac index was measured immediately before and after the volume expansion using transthoracic echocardiography. Hemodynamic response was defined as an increase in a cardiac index of 15% or greater. RESULTS Thirty-four volume expansions were observed in 25 patients. A CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less individually had a good negative predictive value (83% and 88%, respectively). Of 34 volume expansions, the combination of both a high CVP and a low shock index was extremely unlikely to elicit hemodynamic response (negative predictive value, 93%; P = .02). CONCLUSIONS Volume expansion in patients with early septic shock with a CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less is unlikely to lead to an increase in cardiac index.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
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