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Park I, Park JH, Koo BW, Kim JH, Jeon YT, Na HS, Oh AY. Predicting stroke volume variation using central venous pressure waveform: a deep learning approach. Physiol Meas 2024; 45:095007. [PMID: 39214128 DOI: 10.1088/1361-6579/ad75e4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 08/30/2024] [Indexed: 09/04/2024]
Abstract
Objective. This study evaluated the predictive performance of a deep learning approach to predict stroke volume variation (SVV) from central venous pressure (CVP) waveforms.Approach. Long short-term memory (LSTM) and the feed-forward neural network were sequenced to predict SVV using CVP waveforms obtained from the VitalDB database, an open-source registry. The input for the LSTM consisted of 10 s CVP waveforms sampled at 2 s intervals throughout the anesthesia duration. Inputs of the feed-forward network were the outputs of LSTM and demographic data such as age, sex, weight, and height. The final output of the feed-forward network was the SVV. The performance of SVV predicted by the deep learning model was compared to SVV estimated derived from arterial pulse waveform analysis using a commercialized model, EV1000.Main results. The model hyperparameters consisted of 12 memory cells in the LSTM layer and 32 nodes in the hidden layer of the feed-forward network. A total of 224 cases comprising 1717 978 CVP waveforms and EV1000/SVV data were used to construct and test the deep learning models. The concordance correlation coefficient between estimated SVV from the deep learning model were 0.993 (95% confidence interval, 0.992-0.993) for SVV measured by EV1000.Significance. Using a deep learning approach, CVP waveforms can accurately approximate SVV values close to those estimated using commercial arterial pulse waveform analysis.
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Affiliation(s)
- Insun Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Hyon Park
- Department of Radiology, Armed Forces Daejeon Hospital, Daejeon, Republic of Korea
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi 173, Bundang, Seongnam, Gyeonggi 13620, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Funcke S, Schmidt G, Bergholz A, Argente Navarro P, Azparren Cabezón G, Barbero-Espinosa S, Diaz-Cambronero O, Edinger F, García-Gregorio N, Habicher M, Klinkmann G, Koch C, Kröker A, Mencke T, Moral García V, Zitzmann A, Lezius S, Pepić A, Sessler DI, Sander M, Haas SA, Reuter DA, Saugel B. Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial. Br J Anaesth 2024; 133:277-287. [PMID: 38797635 PMCID: PMC11282469 DOI: 10.1016/j.bja.2024.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. METHODS In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery. RESULTS We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis. CONCLUSIONS Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications. CLINICAL TRIAL REGISTRATION NCT03021525.
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Affiliation(s)
- Sandra Funcke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Schmidt
- Department of Anesthesiology, Operative Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pilar Argente Navarro
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | - Gonzalo Azparren Cabezón
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Silvia Barbero-Espinosa
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Oscar Diaz-Cambronero
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Nuria García-Gregorio
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Gerd Klinkmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Department of Extracorporeal Therapy Systems, Rostock, Germany
| | - Christian Koch
- Department of Anesthesiology, Operative Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Alina Kröker
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Mencke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Victoria Moral García
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Amelie Zitzmann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Amra Pepić
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
| | - Sebastian A Haas
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Daniel A Reuter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Centre of Rostock, Rostock, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
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Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Skubas NJ, Callum J, Bathla A, Keshavarz H, Fergusson D, Wu B, Stanworth S, Shehata N. Intravenous albumin in cardiac and vascular surgery: a systematic review and meta-analysis. Br J Anaesth 2024; 132:237-250. [PMID: 38101966 DOI: 10.1016/j.bja.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/23/2023] [Accepted: 11/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Intravenous albumin is commonly utilised in cardiovascular surgery for priming of the cardiopulmonary bypass circuit, volume replacement, or both, although the evidence to support this practice is uncertain. The aim was to compare i.v. albumin with synthetic colloids and crystalloids for paediatric and adult patients undergoing cardiovascular surgery for all-cause mortality and other perioperative outcomes. METHODS A systematic review and meta-analysis of randomised controlled trials (RCTs) of i.v. albumin compared with synthetic colloids and crystalloids on the primary outcome of all-cause mortality was conducted. Secondary outcomes included renal failure, blood loss, duration of hospital or intensive care unit stay, cardiac index, and blood component use; subgroups were analysed by age, comparator fluid, and intended use (priming, volume, or both). We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CCRT) from 1946 to November 23, 2022. RESULTS Of 42 RCTs, mortality was assessed in 15 trials (2711 cardiac surgery patients) and the risk difference was 0.00, 95% confidence interval (CI) -0.01 to 0.01, I2=0%. Among secondary outcomes, i.v. albumin resulted in smaller fluid balance, mean difference -0.55 L, 95% CI -1.06 to -0.4, I2=90% (nine studies, 1975 patients) and higher albumin concentrations, mean difference 7.77 g L-1, 95% CI 3.73-11.8, I2=95% (six studies, 325 patients). CONCLUSIONS Intravenous albumin use was not associated with a difference in morbidity and mortality in patients undergoing cardiovascular surgery, when compared with comparator fluids. The lack of improvement in important outcomes with albumin and its higher cost suggests it should be used restrictively. SYSTEMATIC REVIEW PROTOCOL PROSPERO; CRD42020171876.
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Affiliation(s)
- Nikolaos J Skubas
- Department of Cardiothoracic Anaesthesiology, Anaesthesiology Institute, Cleveland Clinic, and Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | | | | | | | - Bovey Wu
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | | | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Division of Hematology, Mount Sinai Hospital, Toronto, ON, Canada
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Ripollés-Melchor J, Colomina MJ, Aldecoa C, Clau-Terre F, Galán-Menéndez P, Jiménez-López I, Jover-Pinillos JL, Lorente JV, Monge García MI, Tomé-Roca JL, Yanes G, Zorrilla-Vaca A, Escaraman D, García-Fernández J. A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:458-466. [PMID: 37669701 DOI: 10.1016/j.redare.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/22/2022] [Indexed: 09/07/2023]
Abstract
In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.
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Affiliation(s)
| | - M J Colomina
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain
| | - C Aldecoa
- Grupo Español de Rehabilitación Multimodal (ReDGERM), Zaragoza, Spain; Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Río Hortega, Valladolid, Spain
| | - F Clau-Terre
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - P Galán-Menéndez
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - I Jiménez-López
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J L Jover-Pinillos
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de los Lirios, Alcoy, Spain
| | - J V Lorente
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - M I Monge García
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Jerez de la Frontera, Cádiz, Spain
| | - J L Tomé-Roca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - G Yanes
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Zorrilla-Vaca
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Brigham and Women's Hospital, Boston, MA, United States
| | - D Escaraman
- Centro Médico Nacional La Raza, Mexico City, Mexico
| | - J García-Fernández
- Grupo de Fluidoterapia y Monitorización Hemodinámica de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Madrid, Spain; Hospital Universitario Puerta de Hierro, Majadahonda, Spain
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Crowe S. Understanding nursing perceptions of intravenous fluid management practices. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S36-S40. [PMID: 37495415 DOI: 10.12968/bjon.2023.32.14.s36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE Intravenous (IV) fluids are routinely used in hospitalized patients. As IV fluids are an everyday occurrence, their importance is often overlooked. Many patients receive large volumes of fluid during resuscitation to aid in the promotion of tissue perfusion. Nurses regularly administer IV fluids as part of maintenance infusions or as life-saving therapies and, therefore, need to understand these fluids' impact on their patients. Understanding nurses' existing perceptions of IV fluid management practices are crucial to improving practice. METHODS This study used an online survey to gather information on nursing perceptions of IV fluids. Four hundred and sixty-two Canadian nurses from diverse backgrounds were surveyed, including registered nurses, licensed practical nurses and student nurses. RESULTS The study found that the majority of participants agreed that IV fluids, including type, amount, and rationale for infusion, were important. They also agreed that fluids could impact patient outcomes. However, the study found that, despite recognizing the value and importance of fluid management, many nurses struggled with recognizing how to determine a patient's fluid status versus fluid responsiveness. CONCLUSION This study supports improving nursing education to understand better the differences between fluid volume status and volume responsiveness. Our study also provides evidence that nurses need access to more sophisticated tools to conduct dynamic assessments and better meet patients' needs.
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Affiliation(s)
- Sarah Crowe
- Critical Care, Surrey Memorial Hospital, Fraser Health, 13750 - 96th Avenue, Surrey, BC, V3V 1Z2, Canada
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Messina A, Sotgiu G, Saderi L, Puci M, Negri K, Robba C, Sanfilippo F, Romagnoli S, Cecconi M. Phenotypes of hemodynamic response to fluid challenge during anesthesia: a cluster analysis. Minerva Anestesiol 2023; 89:653-662. [PMID: 36943710 DOI: 10.23736/s0375-9393.23.16992-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The fluid challenge (FC) response is usually evaluated as binary, which may be inadequate to describe the complex interactions between heart function and vascular tone response after fluid administration. We applied a clustering approach to assess the different phenotypes of cardiovascular responses to FC administration, considering the associations of all the baseline variables potentially influencing pressure and flow response to a FC. Secondarily, we evaluated the reliability of baseline hemodynamic variables in discriminating fluid responsiveness, which is considered the standard approach at the bedside. METHODS Five merged datasets from elective surgical patients receiving a FC dose ≥4 mL/kg, infused over 10 minutes. In a principal component approach, hierarchical clustering was used to define hemodynamic phenotypes of response to FC administration. Hierarchical cluster analysis with Ward linkage was carried out to define similar patient groups using the Gower distance for the mixed combination of continuous and categorical variables. No a priori criteria of fluid responsiveness were applied. The area (AUC) under the pre-FC variables' receiver operating characteristic curves (ROC) was also built to predict fluid responsiveness, defined as SVI ≥10% after FC. RESULTS We analyzed 223 patients. The cluster analysis identified three hemodynamic clusters of patients: cluster 1 (98 patients, 44.0%) showed an average increase of mean arterial pressure (MAP) and Stroke Volume Index (SVI) of 17.3% (11.9-23.1) and 13.1% (0.5-23.4) at the end of FC, respectively. These patients showed baseline flow and pressure variables slightly below physiological ranges, with high pulse pressure variation (PPV). Cluster 2 (68 patients, 30.5%) showed no increase of MAP and SVI at the end of FC. These patients showed baseline flow and pressure variables within physiological ranges, with low hear rate (HR) and PPV. Cluster 3 (57 patients, 25.5%) showed no MAP increase and an SVI increase of 13.1 (2.1-19.6). These patients showed baseline pressure variables within physiological ranges, low flow variables associated to high HR and PPV. The pulse pressure variation (PPV) showed an AUC of 0.82 (0.03), with a grey zone ranging from 6% to 12%, including 86 (38.5%) patients. CONCLUSIONS Clustering analysis identified three hemodynamic clusters with different response phenotypes to FC. This promising approach may enhance the ability to detect fluid responsiveness at the bedside, by considering the specific association of parameters and not the presence of a single one, such as the PPV. In fact, in our cohort the reliability of the PPV was limited, showing high sensibility and specificity only above 12% and below 6%, respectively, and a grey zone including 38.5% of patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy -
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy -
| | - Giovanni Sotgiu
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Mariangela Puci
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Katerina Negri
- Department of Anesthesia and Intensive Care, University of Milan, Milan, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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8
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Ripollés-Melchor J, Aldecóa C, Lorente JV, Ruiz-Escobar A, Monge-García MI, Jiménez I, Jover-Pinillos JL, Galán-Menendez P, Tomé-Roca JL, Fernández-Valdes-Balgo P, Colomina MJ. Fluid challenges in operating room: A planned sub study of the Fluid Day observational study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:311-318. [PMID: 37276966 DOI: 10.1016/j.redare.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/21/2022] [Indexed: 06/07/2023]
Abstract
BACKGROUND Intraoperative fluid administration is a ubiquitous intervention in surgical patients. But inadequate fluid administration may lead to poor postoperative outcomes. Fluid challenges (FCs), in or outside the so-called goal-directed fluid therapy, allows testing the cardiovascular system and the need for further fluid administration. Our primary aim was to evaluate how anesthesiologists conduct FCs in the operating room in terms of type, volume, variables used to trigger a FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC. METHODS This was a planned substudy of an observational study conducted in 131 centres in Spain in patients undergoing surgery. RESULTS A total of 396 patients were enrolled and analysed in the study. The median [interquartile range] amount of fluid given during a FC was 250ml (200-400). The main indication for FC was a decrease in systolic arterial pressure in 246 cases (62.2%). The second was a decrease in mean arterial pressure (54.4%). Cardiac output was used in 30 patients (7.58%), while stroke volume variation in 29 of 385 cases (7.32%). The response to the initial FC did not have an impact when prescribing further fluid administration. CONCLUSIONS The current indication and evaluation of FC in surgical patients is highly variable. Prediction of fluid responsiveness is not routinely used, and inappropriate variables are frequently evaluated for assessing the hemodynamic response to FC, which may result in deleterious effects.
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Affiliation(s)
- J Ripollés-Melchor
- Department of Anesthesia and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain; Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain.
| | - C Aldecóa
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesiology and Surgical Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - J V Lorente
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia and Critical Care, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - A Ruiz-Escobar
- Department of Anesthesia and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - M I Monge-García
- Department of Anesthesia and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain; Edwards Lifesciences, Irvine, California, United States
| | - I Jiménez
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J L Jover-Pinillos
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia, Hospital Verge dels Lliris, Alcoy, Alicante, Spain
| | - P Galán-Menendez
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - J L Tomé-Roca
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - P Fernández-Valdes-Balgo
- Department of Anesthesia and Critical Care, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - M J Colomina
- Fluid Therapy and Hemodynamic Monitoring Group of the Spanish Society of Anesthesiology and Critical Care (SEDAR), Spain; Department of Anesthesia and Critical Care, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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9
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Edwards MR, Forbes G, Walker N, Morton DG, Mythen MG, Murray D, Anderson I, Mihaylova B, Thomson A, Taylor M, Hollyman M, Phillips R, Young K, Kahan BC, Pearse RM, Grocott MPW. Fluid Optimisation in Emergency Laparotomy (FLO-ELA) Trial: study protocol for a multi-centre randomised trial of cardiac output-guided fluid therapy compared to usual care in patients undergoing major emergency gastrointestinal surgery. Trials 2023; 24:313. [PMID: 37149623 PMCID: PMC10163929 DOI: 10.1186/s13063-023-07275-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 05/08/2023] Open
Abstract
INTRODUCTION Postoperative morbidity and mortality in patients undergoing major emergency gastrointestinal surgery are a major burden on healthcare systems. Optimal management of perioperative intravenous fluids may reduce mortality rates and improve outcomes from surgery. Previous small trials of cardiac-output guided haemodynamic therapy algorithms in patients undergoing gastrointestinal surgery have suggested this intervention results in reduced complications and a modest reduction in mortality. However, this existing evidence is based mainly on elective (planned) surgery, with little evaluation in the emergency setting. There are fundamental clinical and pathophysiological differences between the planned and emergency surgical setting which may influence the effects of this intervention. A large definitive trial in emergency surgery is needed to confirm or refute the potential benefits observed in elective surgery and to inform widespread clinical practice. METHODS The FLO-ELA trial is a multi-centre, parallel-group, open, randomised controlled trial. 3138 patients aged 50 and over undergoing major emergency gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intra-venous fluid, or usual care without cardiac output monitoring. The trial intervention will be carried out during surgery and for up to 6 h postoperatively. The trial is funded through an efficient design call by the National Institute for Health and Care Research Health Technology Assessment (NIHR HTA) programme and uses existing routinely collected datasets for the majority of data collection. The primary outcome is the number of days alive and out of hospital within 90 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation. Participant recruitment started in September 2017 with a 1-year internal pilot phase and is ongoing at the time of publication. DISCUSSION This will be the largest contemporary randomised trial examining the effectiveness of perioperative cardiac output-guided haemodynamic therapy in patients undergoing major emergency gastrointestinal surgery. The multi-centre design and broad inclusion criteria support the external validity of the trial. Although the clinical teams delivering the trial interventions will not be blinded, significant trial outcome measures are objective and not subject to detection bias. TRIAL REGISTRATION ISRCTN 14729158. Registered on 02 May 2017.
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Affiliation(s)
- Mark R Edwards
- Department of Anaesthesia, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.
- Perioperative & Critical Care Research Group, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust / University of Southampton, Southampton, UK.
| | - Gordon Forbes
- Department of Biostatistics & Health Informatics, King's College London, London, UK
| | - Neil Walker
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Dion G Morton
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Monty G Mythen
- University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - Dave Murray
- James Cook University Hospital, Middlesbrough, UK
| | - Iain Anderson
- Salford Royal NHS Foundation Trust, Salford, UK
- University of Manchester, Manchester, UK
| | - Borislava Mihaylova
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Mary University of London, London, Queen, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Matt Taylor
- Department of Critical Care, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | | | - Rachel Phillips
- School of Public Health, Imperial College London, London, UK
| | | | - Brennan C Kahan
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - Rupert M Pearse
- Faculty of Medicine & Dentistry, Mary University of London, London, Queen, UK
| | - Michael P W Grocott
- Perioperative & Critical Care Research Group, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust / University of Southampton, Southampton, UK
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Fukui K, Wirkus JM, Hartmann EK, Schmidtmann I, Pestel GJ, Griemert EV. Non-invasive assessment of Pulse Wave Transit Time (PWTT) is a poor predictor for intraoperative fluid responsiveness: a prospective observational trial (best-PWTT study). BMC Anesthesiol 2023; 23:60. [PMID: 36849887 PMCID: PMC9969649 DOI: 10.1186/s12871-023-02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Aim of this study is to test the predictive value of Pulse Wave Transit Time (PWTT) for fluid responsiveness in comparison to the established fluid responsiveness parameters pulse pressure (ΔPP) and corrected flow time (FTc) during major abdominal surgery. METHODS Forty patients undergoing major abdominal surgery were enrolled with continuous monitoring of PWTT (LifeScope® Modell J BSM-9101 Nihon Kohden Europe GmbH, Rosbach, Germany) and stroke volume (Esophageal Doppler Monitoring CardioQ-ODM®, Deltex Medical Ltd, Chichester, UK). In case of hypovolemia (difference in pulse pressure [∆PP] ≥ 9%, corrected flow time [FTc] ≤ 350 ms) a fluid bolus of 7 ml/kg ideal body weight was administered. Receiver operating characteristics (ROC) curves and corresponding areas under the curve (AUCs) were used to compare different methods of determining PWTT. A Wilcoxon test was used to discriminate fluid responders (increase in stroke volume of ≥ 10%) from non-responders. The predictive value of PWTT for fluid responsiveness was compared by testing for differences between ROC curves of PWTT, ΔPP and FTc using the methods by DeLong. RESULTS AUCs (area under the ROC-curve) to predict fluid responsiveness for PWTT-parameters were 0.61 (raw c finger Q), 0.61 (raw c finger R), 0.57 (raw c ear Q), 0.53 (raw c ear R), 0.54 (raw non-c finger Q), 0.52 (raw non-c finger R), 0.50 (raw non-c ear Q), 0.55 (raw non-c ear R), 0.63 (∆ c finger Q), 0.61 (∆ c finger R), 0.64 (∆ c ear Q), 0.66 (∆ c ear R), 0.59 (∆ non-c finger Q), 0.57 (∆ non-c finger R), 0.57 (∆ non-c ear Q), 0.61 (∆ non-c ear R) [raw measurements vs. ∆ = respiratory variation; c = corrected measurements according to Bazett's formula vs. non-c = uncorrected measurements; Q vs. R = start of PWTT-measurements with Q- or R-wave in ECG; finger vs. ear = pulse oximetry probe location]. Hence, the highest AUC to predict fluid responsiveness by PWTT was achieved by calculating its respiratory variation (∆PWTT), with a pulse oximeter attached to the earlobe, using the R-wave in ECG, and correction by Bazett's formula (AUC best-PWTT 0.66, 95% CI 0.54-0.79). ∆PWTT was sufficient to discriminate fluid responders from non-responders (p = 0.029). No difference in predicting fluid responsiveness was found between best-PWTT and ∆PP (AUC 0.65, 95% CI 0.51-0.79; p = 0.88), or best-PWTT and FTc (AUC 0.62, 95% CI 0.49-0.75; p = 0.68). CONCLUSION ΔPWTT shows poor ability to predict fluid responsiveness intraoperatively. Moreover, established alternatives ΔPP and FTc did not perform better. TRIAL REGISTRATION Prior to enrolement on clinicaltrials.gov (NC T03280953; date of registration 13/09/2017).
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Affiliation(s)
- Kimiko Fukui
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Johannes M Wirkus
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics Medical (IMBEI), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Gunther J Pestel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131, Mainz, Germany.
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Barbosa OA, Marçal E, Araújo DABS, Melo LS, Rocha HAL. Development and perceived usability evaluation of an interactive smartphone application for the teaching of hemodynamics and evaluation of arterial pulse pressure variation. BMC Med Inform Decis Mak 2023; 23:31. [PMID: 36759835 PMCID: PMC9912663 DOI: 10.1186/s12911-023-02131-5] [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: 02/22/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The use of fluids is the most frequently used therapy for circulatory shock. Its inadequate use has adverse effects, requiring hemodynamic goals, highlighting the use of pulse pressure variation due to its high accuracy. One of the problems related to this method is the difficulties in measuring the pulse pressure variation (PPV) in most monitors for clinical use. We assessed the qualitative aspects of perceived usability of a smartphone application (app), which, based on a photograph of the patient's arterial pulse wave, can help measure PPV and help in the diagnosis and management of shock cases. METHODS To assess the software perceived usability, we used the System Usability Scale (SUS) applied to 30 physicians in 2 tertiary hospitals in Brazil. The software accuracy was measured using a sequence of 3 images with different values of pulse pressure variation, comparing the obtained values with the gold standard. The educational interface of the app was evaluated qualitativelyfrom the spontaneous testimonies of the selected test participants.The project was approved by the Research Ethics Committee of Centro Universitário Christus. RESULTS The analysis showed an average SUS of 86.3 points on a scale of 1-100 (above 80.3 is considered the best in terms of interface). The assessment of the application's accuracy when evaluating pulse pressure variation showed that the average variation of the measurements taken by the participants was small, with a good measure of repeatability and reproducibility. The app's educational interface was qualitatively evaluated, being praised by the users. CONCLUSIONS It can be concluded that the developed mobile application showed excellent qualitative aspects of perceived usability results. More studies with this app will be required to evaluate the potential to help professionals with hemodynamic evaluation in emergency and intensive care settings.
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Affiliation(s)
- Orivaldo Alves Barbosa
- grid.510399.70000 0000 9839 2890Unichristus University Center, Rua Papi Junior, 1223, 5th Floor, Fortaleza, CE 0430-235 Brazil
| | - Edgar Marçal
- grid.8395.70000 0001 2160 0329Federal University of Ceará, Fortaleza, CE Brazil
| | | | - Lucas Severo Melo
- grid.8395.70000 0001 2160 0329Federal University of Ceará, Fortaleza, CE Brazil
| | - Hermano Alexandre Lima Rocha
- Unichristus University Center, Rua Papi Junior, 1223, 5th Floor, Fortaleza, CE, 0430-235, Brazil. .,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
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12
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Perioperative changes in fluid distribution and haemodynamics in acute high-risk abdominal surgery. Crit Care 2023; 27:20. [PMID: 36647120 PMCID: PMC9841944 DOI: 10.1186/s13054-023-04309-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. METHODS Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. RESULTS We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. CONCLUSION Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could lead to overhydration. Trial registration clinicaltrials.gov. (NCT03997721), Registered 23 May 2019, first participant enrolled 01 June 2019.
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Affiliation(s)
- Mirjana Cihoric
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Henrik Kehlet
- grid.475435.4Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark Denmark
| | - Jakob Højlund
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Morten Laksáfoss Lauritsen
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Katrine Kanstrup
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Nicolai Bang Foss
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
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13
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Messina A, Colombo D, Lionetti G, Calabrò L, Negri K, Robba C, Cammarota G, Costantini E, Cecconi M. Pressure response to fluid challenge administration in hypotensive surgical patients: a post-hoc pharmacodynamic analysis of five datasets. J Clin Monit Comput 2022; 37:449-459. [PMID: 36197548 DOI: 10.1007/s10877-022-00918-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/17/2022] [Indexed: 10/10/2022]
Abstract
In this study we evaluated the effect of fluid challenge (FC) administration in elective surgical patients with low or normal blood pressure. Secondarily, we appraised the pharmacodynamic effect of FC in normotensive and hypotensive patients. We assessed five merged datasets of patients with a baseline mean arterial pressure (MAP) above or below 65 mmHg and assessed the changes of systolic, diastolic, mean and dicrotic arterial pressures, dynamic indexes of fluid responsiveness and arterial elastance over a 10-min infusion. The hemodynamic effect was assessed by considering the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), the time when the maximal value was observed (tmax) and change from baseline at 5-min (d5) after FC end. A stroke volume index increase > 10% with respect to the baseline value after FC administration indicated fluid response. Two hundred-seventeen patients were analysed [102 (47.0%) fluid responders]. On average, FC restored a MAP [Formula: see text] 65 mmHg after 5 min. The AUCs and the dmax of pressure variables and arterial elastance of hypotensive patients were all significantly greater than normotensive patients. Pressure variables and arterial elastance changes in the hypotensive group were all significantly higher at d5 as compared to the normotensive group. In hypotensive patients, FC restores a MAP [Formula: see text] 65 mmHg after 5 min from infusion start. The hemodynamic profile of FC in hypotensive and normotensive patients is different; both the magnitude of pressure augmentation and duration is greater in the hypotensive group.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy.
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Italy
| | | | | | - Katerina Negri
- Department of Anesthesia and Intensive Care, Università degli studi di Milano, Milan, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | | | | | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
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‘If you don't take a temperature, you can't find a fever’: relevance to continuous arterial pressure monitoring. Br J Anaesth 2022; 129:464-468. [DOI: 10.1016/j.bja.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
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15
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Hamilton DB, Jooma Z. Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.4.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- DB Hamilton
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
| | - Z Jooma
- Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand,
South Africa
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16
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Gricourt Y, Prin Derre C, Demattei C, Bertran S, Louart B, Muller L, Simon N, Lefrant JY, Cuvillon P, Jaber S, Roger C. A Pilot Study Assessing a Closed-Loop System for Goal-Directed Fluid Therapy in Abdominal Surgery Patients. J Pers Med 2022; 12:jpm12091409. [PMID: 36143194 PMCID: PMC9505637 DOI: 10.3390/jpm12091409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This prospective multicentre pilot study of patients scheduled for elective major abdominal surgery aimed to validate the fluid challenge (FC) proposed by the closed-loop (CL) system via anaesthesiologist assessment. Methods: This was a phase II trial consisting of two inclusion stages (SIMON method). Each FC (250 mL saline solution for 10 min) proposed by the CL was systematically validated by the anaesthesiologist who could either confirm or refuse the FC or give FC without the CL system. A ≥ 95% agreement between the CL and the anaesthesiologist was considered acceptable. Results: The study was interrupted after interim analysis of the first 19 patients (10 men, median age = 61 years, median body mass index = 26 kg/m2). The anaesthesiologists accepted 165/205 (80%) of fluid boluses proposed by the CL. Median cardiac index (CI) was 2.9 (interquartile: IQ (2.7; 3.4) L/min/m2) and the median coefficient of variation (CV) for CI was 13% (10; 17). Fifteen out of nineteen patients (79%) had a mean CI > 2.5 L/min/m2 or spent > 85% surgery time with pulse pressure variation < 13%. No adverse events related to the CL were reported. Conclusion: In this study of patients scheduled for elective major abdominal surgery, the agreement between CL and anaesthesiologist for giving fluid challenge was 80%, suggesting that CL cannot replace the physician but could help in decision making.
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Affiliation(s)
- Yann Gricourt
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Camille Prin Derre
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Christophe Demattei
- Laboratoire de Biostatistique, Epidémiologie Clinique, Santé Publique Innovation et Méthodologie (BESPIM), Pôle Pharmacie, Santé Publique, Nîmes University Hospital, 30900 Nîmes, France
| | - Sébastien Bertran
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Polyclinique Grand Sud, 350 Avenue Saint-André de Codols, 30000 Nîmes, France
| | - Benjamin Louart
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Laurent Muller
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Natacha Simon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Jean-Yves Lefrant
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
- Correspondence: ; Tel.: +33-4-66-68-30-50; Fax: +33-4-66-68-38-41
| | - Philippe Cuvillon
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B St Eloi Hospital, 80 Avenue Augustin Fliche, 34295 Montpellier, France
| | - Claire Roger
- IMAGINE, UR-UM 107, University of Montpellier, Division of Anaesthesia Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, 30900 Nîmes, France
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Non-invasive continuous blood pressure monitoring using the ClearSight system for pregnant women at high risks of post-partum hemorrhage: comparison with invasive blood pressure monitoring during cesarean section. Obstet Gynecol Sci 2022; 65:325-334. [PMID: 35754365 PMCID: PMC9304436 DOI: 10.5468/ogs.22063] [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: 02/17/2022] [Accepted: 05/31/2022] [Indexed: 11/08/2022] Open
Abstract
Objective This study aimed to investigate the accuracy and precision of continuous, non-invasive blood pressure obtained using the ClearSight system by comparing it with invasive arterial blood pressure, and to assess the hemodynamic changes using the ClearSight system in patients undergoing cesarean section. Methods Arterial pressure was measured invasively with an intra-arterial catheter and non-invasively using the ClearSight system during cesarean section in patients with placenta previa or placenta accreta. Blood pressure measurements obtained using these two means were then compared. Results Total 1,277 blood pressure measurement pairs were collected from 21 patients. Under Bland-Altman analysis, the ClearSight system demonstrated an acceptable accuracy with a bias and standard deviation of 8.8±13.4 mmHg for systolic blood pressure, -6.3±7.1 mmHg for diastolic blood pressure, and -2.7±8.0 mmHg for median blood pressure. Cardiac index levels were significantly elevated during fetal delivery and 5 minutes after placental removal, and systemic vascular resistance index levels were significantly decreased during fetal delivery and 40 minutes after placental removal. Conclusion In patients undergoing cesarean section, the ClearSight system showed excellent accuracy and precision compared to that of the currently used invasive monitoring system.
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Morakul S, Prachanpanich N, Permsakmesub P, Pinsem P, Mongkolpun W, Trongtrakul K. Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery. Front Med (Lausanne) 2022; 9:881267. [PMID: 35783653 PMCID: PMC9247540 DOI: 10.3389/fmed.2022.881267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionExcessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period.MethodsPatients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM—PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR.ResultsOf 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66–0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%).ConclusionsΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.
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Xu Y, Guo J, Wu Q, Chen J. Efficacy of using tidal volume challenge to improve the reliability of pulse pressure variation reduced in low tidal volume ventilated critically ill patients with decreased respiratory system compliance. BMC Anesthesiol 2022; 22:137. [PMID: 35508962 PMCID: PMC9066736 DOI: 10.1186/s12871-022-01676-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/06/2022] [Indexed: 02/08/2023] Open
Abstract
Background The prediction accuracy of pulse pressure variation (PPV) for fluid responsiveness was proposed to be unreliable in low tidal volume (Vt) ventilation. It was suggested that changes in PPV obtained by transiently increasing Vt to 8 ml/kg accurately predicted fluid responsiveness even in subjects receiving low Vt. We assessed whether the changes in PPV induced by a Vt challenge predicted fluid responsiveness in our critically ill subjects ventilated with low Vt 6 ml/kg. Methods This study is a prospective single-center study. PPV and other parameters were measured at a Vt of 6 mL/kg, 8 mL/kg, and after volume expansion. The prediction accuracy of PPV and other parameters for fluid responsiveness before and after tidal volume challenge was also analyzed using receiver operating characteristic (ROC) curves. Results Thirty-one of the 76 subjects enrolled in the study were responders (41%). Respiratory system compliance of all subjects decreased significantly (26 ± 4.3). The PPV values were significantly higher in the responder group than the non-responder group before (8.8 ± 2.7 vs 6.8 ± 3.1) or after (13.0 ± 1.7 vs 8.5 ± 3.0) Vt challenge. In the receiver operating characteristic curve (ROC) analysis, PPV6 showed unsatisfactory predictive capability with an area under the curve (AUC) of 0.69 (95%CI, 0.57–0.79, p = 0.002) at a Vt of 6 mL/kg. PPV8 andΔPPV6–8 showed good predictive capability with an AUC of 0.90 (95% CI, 0.81–0.96, p < 0.001) and 0.90 (95% CI, 0.80–0.95, P < 0.001) respectively. The corresponding cutoff values were 11% for PPV8 and 2% for ΔPPV6–8. Conclusions PPV shows a poor operative performance as a predictor of fluid responsiveness in critically ill subjects ventilated with a tidal volume of 6 mL/ kg. Vt challenge could improve the predictive accuracy of PPV to a good but not excellent extent when respiratory system compliance decreased significantly. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01676-8.
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Affiliation(s)
- Yujun Xu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Guo
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Junjun Chen
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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20
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Tang R, Peng J, Wang D. Central Venous Pressure Measurement Is Associated With Improved Outcomes in Patients With or at Risk for Acute Respiratory Distress Syndrome: An Analysis of the Medical Information Mart for Intensive Care IV Database. Front Med (Lausanne) 2022; 9:858838. [PMID: 35419383 PMCID: PMC8995425 DOI: 10.3389/fmed.2022.858838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Central venous pressure (CVP) monitoring is widely used in the intensive care unit (ICU). However, the formal utility of CVP measurement to altering patient outcomes among ICU patients with or at risk for acute respiratory distress syndrome (ARDS) has never been investigated. Our study aimed to explore the association of CVP measurement with 28-day mortality specifically in that population. Methods This study was based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients were divided into CVP and no CVP groups according to whether they had CVP measurement within 24 h of admission to the ICU. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the association between CVP measurement and 28-day mortality, and propensity score matching (PSM) and propensity score-based overlap weighting (OW) were employed to verify the stability of our results. Results A total of 10,198 patients with or at risk for ARDS were included in our study, of which 4,647 patients (45.6%) belonged to the CVP group. Multivariate logistic regression showed that the early measurement of CVP was independently associated with lower 28-day mortality (OR: 0.49; 95% CI: 0.42–0.57; p < 0.001). This association remained robust after PSM and OW (both p < 0.001). Patients in the CVP group had shorter ICU stay, lower in-hospital mortality, more fluid on day 1 and higher clearance of blood lactate than those in the no CVP group. Conclusion Early CVP measurement is associated with an improvement in 28-day mortality among a general population of critically ill patients with or at risk for ARDS.
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Affiliation(s)
- Rui Tang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junnan Peng
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoxin Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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21
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Roy S, Kothari N, Goyal S, Sharma A, Kumar R, Kaloria N, Bhatia P. Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022:S0104-0014(22)00051-3. [PMID: 35430190 PMCID: PMC10362455 DOI: 10.1016/j.bjane.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. METHODS One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. RESULTS Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). CONCLUSIONS Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.
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Affiliation(s)
- Shayak Roy
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Nikhil Kothari
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Shilpa Goyal
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Ankur Sharma
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India.
| | - Rakesh Kumar
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Narender Kaloria
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
| | - Pradeep Bhatia
- All India Institute of Medical Sciences (AIIMS), Department of Anaesthesiology & Critical Care, Jodhpur, India
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22
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Ni TT, Zhou ZF, He B, Zhou QH. Inferior Vena Cava Collapsibility Index Can Predict Hypotension and Guide Fluid Management After Spinal Anesthesia. Front Surg 2022; 9:831539. [PMID: 35252337 PMCID: PMC8891151 DOI: 10.3389/fsurg.2022.831539] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose We hypothesized that inferior vena cava collapsibility index (IVCCI)-guided fluid management would reduce the incidence of postspinal anesthesia hypotension in patients undergoing non-cardiovascular, non-obstetric surgery. Methods A receiver operating characteristic (ROC) curve was used to determine the diagnostic value of IVCCI for predicting hypotension after induction of spinal anesthesia and calculate the cut-off value. Based on the cut-off variation value, the following prospective randomized controlled trial aimed to compare the incidence of postspinal anesthesia hypotension between the IVCCI-guided fluid administration group and the standard fluid administration group. Secondary outcomes included the rate of vasoactive drug administration, the amount of fluid administered, and the incidence of nausea and vomiting. Results ROC curve analysis revealed that IVCCI had a sensitivity of 83.9%, a specificity of 76.3%, and a positive predictive value of 84% for predicting postspinal anesthesia hypotension at a cut-off point of >42%. The area under the curve (AUC) was 0.834 (95% confidence interval: 0.740–0.904). According to the cut-off variation value of 42%, the IVCCI-guided group exhibited a lower incidence of hypotension than the standard group [9 (15.3%) vs. 20 (31.7%), P = 0.032]. Total fluid administered was lower in the IVCCI-guided group than in the standard group [330 (0–560) mL vs. 345 (285–670) mL, P = 0.030]. Conclusions Prespinal ultrasound scanning of the IVCCI provides a reliable predictor of hypotension following spinal anesthesia at a cut-off point of >42%. IVCCI-guided fluid management before spinal anesthesia can reduce the incidence of hypotension following spinal anesthesia.
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Affiliation(s)
- Ting-ting Ni
- Department of Anesthesiology, Ningbo No.7 Hospital, Ningbo, China
| | - Zhen-feng Zhou
- Department of Anesthesiology, Hangzhou Women's Hospital, The Affiliated Women's Hospital of Hangzhou Normal University, Hangzhou, China
| | - Bo He
- Department of Gynecology, Ningbo No.7 Hospital, Ningbo, China
| | - Qing-he Zhou
- Department of Anesthesiology, The First Affiliated Hospital, Jiaxing University, Jiaxing, China
- *Correspondence: Qing-he Zhou
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Tusman G, Acosta CM, Wallin M, Hallbäck M, Esperatti M, Peralta G, Gonzalez ME, Sipmann FS. PERIOPERATIVE CONTINUOUS NON-INVASIVE CARDIAC OUTPUT MONITORING IN CARDIAC SURGERY PATIENTS BY A NOVEL CAPNODYNAMIC METHOD. J Cardiothorac Vasc Anesth 2022; 36:2900-2907. [DOI: 10.1053/j.jvca.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
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24
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Kouz K, Bergholz A, Timmermann LM, Brockmann L, Flick M, Hoppe P, Briesenick L, Schulte-Uentrop L, Krause L, Maheshwari K, Sessler DI, Saugel B. The Relation Between Mean Arterial Pressure and Cardiac Index in Major Abdominal Surgery Patients: A Prospective Observational Cohort Study. Anesth Analg 2021; 134:322-329. [PMID: 34854823 DOI: 10.1213/ane.0000000000005805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac output is an important hemodynamic variable and determines oxygen delivery. In contrast to blood pressure, cardiac output is rarely measured even in high-risk surgical patients, suggesting that clinicians consider blood pressure to be a reasonable indicator of systemic blood flow. However, the relationship depends on constant vascular tone and volume, both of which routinely vary during anesthesia and surgery. We therefore tested the hypothesis that there is no clinically meaningful correlation between mean arterial pressure and cardiac index in major abdominal surgery patients. METHODS In this prospective observational study, we assessed the relationship between mean arterial pressure and cardiac index in 100 patients having major abdominal surgery under general anesthesia. RESULTS The pooled within-patient correlation coefficient calculated using meta-analysis methods was r = 0.34 (95% confidence interval, 0.28-0.40). Linear regression using a linear mixed effects model of cardiac index on mean arterial pressure revealed that cardiac index increases by 0.014 L·min-1·m-2 for each 1 mm Hg increase in mean arterial pressure. The 95% Wald confidence interval of this slope was 0.011 to 0.018 L·min-1·m-2·mm Hg-1 and thus within predefined equivalence margins of -0.03 and 0.03 L·min-1·m-2·mm Hg-1, thereby demonstrating lack of clinically meaningful association between mean arterial pressure and cardiac index. CONCLUSIONS There is no clinically meaningful correlation between mean arterial pressure and cardiac index in patients having major abdominal surgery. Intraoperative blood pressure is thus a poor surrogate for cardiac index.
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Affiliation(s)
- Karim Kouz
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Alina Bergholz
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Lea M Timmermann
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Lennart Brockmann
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Moritz Flick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Phillip Hoppe
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Luisa Briesenick
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Leonie Schulte-Uentrop
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamal Maheshwari
- Department of Outcomes Research.,Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Bernd Saugel
- From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine.,Outcomes Research Consortium, Cleveland, Ohio
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Ramsingh D, Staab J, Flynn B. Application of perioperative hemodynamics today and potentials for tomorrow. Best Pract Res Clin Anaesthesiol 2021; 35:551-564. [PMID: 34801217 DOI: 10.1016/j.bpa.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Hemodynamic (HD) monitoring remains integral to the assessment and management of perioperative and critical care patients. This review article seeks to provide an update on the different types of flow-guided HD monitoring technologies available, highlight their limitations, and review the therapies associated with the application of these technologies. Additionally, we will also comment on the expanding roles of HD monitoring in the future.
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Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology Loma Linda University Medical Center, Loma Linda, CA, USA; VP for Clinical and Medical Affairs, Edwards Lifesciences Critical Care Division, USA.
| | - Jared Staab
- Director of Perioperative Ultrasound, Program Director Critical Care Anesthesiology Fellowship, Department of Anesthesiology, University of Kansas Medical Center, USA.
| | - Brigid Flynn
- Chief, Division of Critical Care, Co-Director Cardiothoracic ICUChair Anesthesia Research Committee, Department of Anesthesiology, University of Kansas Medical, USA.
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26
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Quenot JP, Amrouche I, Lefrant JY, Klouche K, Jaber S, Du Cheyron D, Duranteau J, Maizel J, Rondeau E, Javouhey E, Gaillot T, Robert R, Dellamonica J, Souweine B, Bohé J, Barbar SD, Sejourné C, Vinsonneau C. Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices. Blood Purif 2021; 51:698-707. [PMID: 34736254 DOI: 10.1159/000518919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life. METHODS We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices. RESULTS We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in >75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (>75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200-300 mL/min and 400-600 mL/min, respectively. The dose of dialysis for continuous RRT was 25-35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine). CONCLUSION This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.
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Affiliation(s)
- Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon Bourgogne, Dijon, France.,Equipe Lipness, Centre de Recherche INSERM UMR1231, LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France.,INSERM CIC 1432, Module Epidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
| | - Idris Amrouche
- Service de Médecine Intensive-Réanimation, CHU Dijon Bourgogne, Dijon, France
| | - Jean-Yves Lefrant
- EA 2992 IMAGINE, Université de Montpellier, Montpellier, France.,Pôle Anesthésie Réanimation Douleur Urgence, CHU, Nîmes, France
| | - Kada Klouche
- Intensive Care Unit, Anaesthesiology and Intensive Care Department, Lapeyronie Hospital University Hospital and INM University Montpellier, INSERM, Montpellier, France
| | - Samir Jaber
- Department of Anesthesia and Critical Care Medicine, University of Montpellier Saint Eloi Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Damien Du Cheyron
- BoReal Study Group, Medical Intensive Care Unit, Caen University Hospital, Caen, France
| | - Jacques Duranteau
- Anesthesia and Intensive Care Department, Hôpitaux Universitaires Paris Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital de Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin-Bicêtre, France
| | - Julien Maizel
- BoReal Study Group, Medical Intensive Care Unit and EA7517, Amiens University Hospital, Amiens, France
| | - Eric Rondeau
- Department of Nephrology and Transplantation, AP-HP, Hôpital Tenon, Paris, France.,INSERM UMR-S 1155, Hospital Tenon, Paris, France.,Urgences Néphrologiques et Transplantation Rénale, Sorbonne Université, Paris, France
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Hospices Civils de Lyon, University of Lyon, Lyon, France.,Hospices Civils of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Théophile Gaillot
- Service de Pédiatrie, Hôpital Sud, CHU de Rennes, Rennes, France.,CIC-P Inserm 0203 Université Rennes, Rennes, France
| | - René Robert
- Réanimation Médicale, CHU La Milétrie, Poitiers, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, l'Archet Hospital, University Hospital of Nice, Nice, France
| | - Bertrand Souweine
- Service de Réanimation Médicale, CHU de Clermont-Ferrand, Clermont Ferrand, France
| | - Julien Bohé
- Service d'Anesthésie-Réanimation-Médecine Intensive, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Saber Davide Barbar
- Department of Anaesthesiology, Critical Care and Emergency Medicine, CHU Nïmes, University Montpellier, Nîmes, France
| | - Caroline Sejourné
- BoReal Study Group, Intensive Care Unit, Hôpital de Bethune, Bethune, France
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A performance comparison of the most commonly used minimally invasive monitors of cardiac output. Can J Anaesth 2021; 68:1668-1682. [PMID: 34374024 DOI: 10.1007/s12630-021-02085-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Shock is common in critically ill and injured patients. Survival during shock is highly dependent on rapid restoration of tissue oxygenation with therapeutic goals based on cardiac output (CO) optimization. Despite the clinical availability of numerous minimally invasive monitors of CO, limited supporting performance data are available. METHODS Following approval of the University of Saskatchewan Animal Research Ethics Board, we assessed the performance and trending ability of PiCCOplus™, FloTrac™, and CardioQ-ODM™ across a range of CO states in pigs. In addition, we assessed the ability of invasive mean arterial blood pressure (iMAP) to follow changes in CO using a periaortic transit-time flow probe as the reference method. Statistical analysis was performed with function-fail, bias and precision, percent error, and linear regression at all flow, low-flow (> 1 standard deviation [SD] below the mean), and high-flow (> 1 SD above the mean) CO conditions. RESULTS We made a total of 116,957 paired CO measurements. The non-invasive CO monitors often failed to provide a CO value (CardioQ-ODM: 40.6% failed measurements; 99% confidence interval [CI], 38.5 to 42.6; FloTrac: 9.6% failed measurements; 99% CI, 8.7 to 10.5; PiCCOplus: 4.7% failed measurements; 99% CI, 4.5 to 4.9; all comparisons, P < 0.001). The invasive mean arterial pressure provided zero failures, failing less often than any of the tested CO monitors (all comparisons, P < 0.001). The PiCCOplus was most interchangeable with the flow probe at all flow states: PiCCOplus (20% error; 99% CI, 19 to 22), CardioQ-ODM (25% error; 99% CI, 23 to 27), FloTrac (34% error; 99% CI, 32 to 38) (all comparisons, P < 0.001). At low-flow states, CardioQ-ODM (43% error; 99% CI, 32 to 63) and Flotrac (45% error; 99% CI, 33 to 70) had similar interchangeability (P = 0.07), both superior to PiCCOplus (48% error; 99% CI, 42 to 60) (P < 0.001). Regarding CO trending, the CardioQ-ODM (correlation coefficient, 0.82; 99% CI, 0.81 to 0.83) was statistically superior to other monitors including iMAP, but at low flows iMAP (correlation coefficient, 0.58; 99% CI, 0.58 to 0.60) was superior to all minimally invasive CO monitors (all comparisons P < 0.001). CONCLUSIONS None of the minimally invasive monitors of CO performed well at all tested flows. Invasive mean arterial blood pressure most closely tracked CO change at critical flow states.
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Russo A, Romanò B. Intraoperative management and hemodynamic monitoring for ma- jor abdominal surgery : a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background : Several trials suggest that postoperative outcomes may be improved by the use of hemodynamic monitoring, but a survey by the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology (ESA) showed that cardiac output is monitored by only 34% of ASA and ESA respondents and central venous pressure is monitored by 73% of ASA respondents and 84% of ESA respondents.
Moreover, 86.5% of ASA respondents and 98.1% of ESA respondents believe that their current hemodynamic management could be improved (1). The interaction of general anesthesia and surgical stress is the main problem and the leading cause for postoperative morbidity and mortality. The choice of a suitable hemodynamic monitoring system for patients at high anesthesiological risk is of crucial importance to reduce the incidence of major postoperative complications. The aim of the present review is to summarize the benefits of a defined path beginning before surgery, and discuss the available evidence supporting the efficacy and safety of an individualized hemodynamic approach for major abdominal surgery.
Objective : To evaluate the clinical effectiveness of a perioperative hemodynamic therapy algorithm in high risk patients
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Lee KY, Yoo YC, Cho JS, Lee W, Kim JY, Kim MH. The Effect of Intraoperative Fluid Management According to Stroke Volume Variation on Postoperative Bowel Function Recovery in Colorectal Cancer Surgery. J Clin Med 2021; 10:jcm10091857. [PMID: 33922880 PMCID: PMC8123187 DOI: 10.3390/jcm10091857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
Stroke volume variation (SVV) has been used to predict fluid responsiveness; however, it remains unclear whether goal-directed fluid therapy using SVV contributes to bowel function recovery in abdominal surgery. This prospective randomized controlled trial aimed to compare bowel movement recovery in patients undergoing colon resection surgery between groups using traditional or SVV-based methods for intravenous fluid management. We collected data between March 2015 and July 2017. Bowel function recovery was analyzed based on the gas-passing time, sips of water time, and soft diet (SD) time. Finally, we analyzed data from 60 patients. There was no significant between-group difference in the patients’ characteristics. Compared with the control group (n = 30), the SVV group (n = 30) had a significantly higher colloid volume and lower crystalloid volume. Moreover, the gas-passing time (77.8 vs. 85.3 h, p = 0.034) and SD time (67.6 vs. 85.1 h, p < 0.001) were significantly faster in the SVV group than in the control group. Compared with the control group, the SVV group showed significantly lower scores of pain on a numeric rating scale and morphine equivalent doses during post-anesthetic care, at 24 postoperative hours, and at 48 postoperative hours. Our findings suggested that, compared with the control group, the SVV group showed a faster postoperative SD time, reduced acute postoperative pain intensity, and lower rescue analgesics. Therefore, SVV-based optimal fluid management is expected to potentially contribute to postoperative bowel function recovery in patients undergoing colon resection surgery.
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Affiliation(s)
- Ki-Young Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
| | - Young-Chul Yoo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
| | - Jin-Sun Cho
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
| | - Wootaek Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Ji-Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Myoung-Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (K.-Y.L.); (Y.-C.Y.); (J.-S.C.); (W.L.); (J.-Y.K.)
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
- Correspondence: ; Tel.: +82-2-2019-6095; Fax: +82-2-312-7185
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Fellahi JL, Futier E, Vaisse C, Collange O, Huet O, Loriau J, Gayat E, Tavernier B, Biais M, Asehnoune K, Cholley B, Longrois D. Perioperative hemodynamic optimization: from guidelines to implementation-an experts' opinion paper. Ann Intensive Care 2021; 11:58. [PMID: 33852124 PMCID: PMC8046882 DOI: 10.1186/s13613-021-00845-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a "validity criteria checklist" before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients.
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Affiliation(s)
- Jean-Luc Fellahi
- Service D'Anesthésie-Réanimation, Hôpital Louis Pradel, 59 boulevard Pinel, 69500, Hospices Civils de Lyon, Lyon, France.
- Laboratoire CarMeN, Université Claude Bernard Lyon 1, Inserm U1060, Lyon, France.
| | - Emmanuel Futier
- Département de Médecine Périopératoire, Anesthésie-Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- Université Clermont Auvergne, CNRS; Inserm U1103, 63000, Clermont-Ferrand, France
| | - Camille Vaisse
- Service D'Anesthésie-Réanimation, Hôpital Timone, AP-HM, Marseille, France
| | - Olivier Collange
- Service D'Anesthésie-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- Université de Strasbourg, Strasbourg, France
| | - Olivier Huet
- Département D'Anesthésie-Réanimation, CHRU de La Cavale Blanche, Brest, France
- Université de Bretagne Occidentale, Brest, France
| | - Jerôme Loriau
- Service de Chirurgie Digestive, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Etienne Gayat
- Département d'Anesthésie-Réanimation, Hôpital Lariboisière, DMU PARABOL, AP-HP Nord et Université de Paris, Paris, France
- UMR-S 942, Inserm, Paris, France
| | - Benoit Tavernier
- Pôle d'Anesthésie-Réanimation, CHU Lille, Univ. Lille, ULR 2694-METRICS, Lille, France
| | - Matthieu Biais
- Pôle d'Anesthésie-Réanimation, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
- Université de Bordeaux, France, Inserm 1034, Pessac, France
| | - Karim Asehnoune
- Service d'Anesthésie-Réanimation Chirurgicale, Pôle Anesthésie Réanimations, Hôtel-Dieu, CHU de Nantes, Nantes, France
- Université de Nantes, Nantes, France
| | - Bernard Cholley
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Université de Paris, Paris, France
- Inserm UMR S1140, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat Claude Bernard, AP-HP Nord, Paris, France
- Université de Paris, Paris, France
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Fukushima T, Shoji K, Tanaka A, Aoyagi Y, Okui S, Sekiguchi M, Shiba A, Hiroe T, Mio Y. Indwelling catheters increase altered mental status and urinary tract infection risk: A retrospective Cohort Study. Ann Med Surg (Lond) 2021; 64:102186. [PMID: 33747493 PMCID: PMC7972973 DOI: 10.1016/j.amsu.2021.102186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 10/28/2022] Open
Abstract
Background Although indwelling urinary catheters (IUCs) are used intraoperatively and may cause complications (e.g., delirium), only few robust studies have investigated the association between intraoperative IUC use and complications. We hypothesized that IUC use might increase the postoperative incidence of altered mental status and/or urinary catheter infection. Materials and methods In this retrospective single-center cohort study, we analyzed the data of adult patients undergoing surgery at our facility between January 2013 and December 2018. The primary endpoint was altered mental status and/or incidence of urinary catheter infections. The patients were divided into IUC and control groups. A multivariable logistic regression model was used to identify the predictors of postoperative complications, and a multivariable Cox proportional hazards regression model was used to analyze hospital discharge in unmatched and inverse propensity-weighted patients. Results Of the 14,284 patients that were reviewed, we analyzed 5112 patients (control group, 44.0%; IUC group, 56.0%). Almost all procedures comprised less invasive surgeries. The prevalence of postoperative altered mental status and postoperative urinary catheter infection were 3.56% and 0.04%, respectively. After inverse propensity weighting, all baseline characteristics were similar between the two groups. However, patients with IUCs had a higher risk of postoperative complications (adjusted odds ratio, 1.97; 95% confidence interval [CI], 1.50-2.59) and prolonged hospital stays (hazard ratio, 0.84; 95% CI, 0.80-0.89). Conclusion In patients undergoing less invasive surgery, IUCs may be associated with a relatively high risk of altered mental status or urinary catheter infection. These data may facilitate preoperative discussions regarding the perioperative use of IUCs.
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Key Words
- AKI, acute kidney injury
- ASA-PS, American Society of Anesthesiology physical status
- ASD, absolute standardized differences
- CAM-ICU, Confusion Assessment Method for the ICU
- CDC, Center for Disease Control and Prevention
- CI, confidence interval
- Delirium
- ICU, intensive care unit
- IPW, inverse probability weighting
- IUCs, indwelling urinary catheters
- OR, odds ratio
- Perioperative complication
- SCr, serum creatinine levels
- Urinary catheter
- Urinary tract infection
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Affiliation(s)
- Toko Fukushima
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Kazuhiro Shoji
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Atsuko Tanaka
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Yukari Aoyagi
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Shoko Okui
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Marie Sekiguchi
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Ayako Shiba
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan.,The Jikei University School of Medicine, Department of Anesthesiology, Tokyo, Japan
| | - Takanori Hiroe
- Kyoto University Graduate School of Medicine, Department of Biostatistics, Kyoto, Japan
| | - Yasushi Mio
- Tokyo Jikei University Katsushika Medical Center, Department of Anesthesiology, Tokyo, Japan
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Wang Y, Qian J, Qian S, Liu C, Chen Y, Lu G, Zhang Y, Ren X. An email-based survey of practice regarding hemodynamic monitoring and management in children with septic shock in China. Transl Pediatr 2021; 10:587-597. [PMID: 33850817 PMCID: PMC8039781 DOI: 10.21037/tp-20-374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Understanding current hemodynamic monitoring (HM) practice patterns is essential to determine education and training strategies in China. The survey was to describe the practice of HM and management in children with septic shock in China. METHODS We conducted an Email-based survey of members of sub-association of pediatric intensive care physicians. The questionnaire consisted of 22 questions and gathered the following information: (I) general information on the hospitals, respective ICUs and participants, (II) the availability of technical equipment and parameters of HM and (III) management simulation of septic shock in three clinical case vignettes. RESULTS Surveys were received from 68 institutions (87.2%) and 368 questionnaires (response-rate 45.1%) were included. Basic HM (93-100%) were reported as the most utilized parameters, followed by advanced HM which included central venous pressure (CVP) (56.0%), cardiac output (53.5%), and central venous oxygen saturation (36.7%), 61.1% (225/368) of respondents stated the utilization of non-invasive HM equipment. The factors such as ICU specialist training center (P=0.003) and more than 30 cases of septic shock per year (P=0.002) were related to the utilization of non-invasive monitoring equipment. In the simulated case vignette, 49.7% (183/368) of respondents reported performing fluid responsiveness and volume status (FR-VS) assessment. Despite differences in training centers (P=0.005) and educational backgrounds (P=0.030), FR-VS assessment was not related to the volume expansion decision. CONCLUSIONS There is a large variability in use advanced HM parameters, an increasing awareness and acceptance of non-invasive HM devices and a potential need for hemodynamic education and training in pediatric intensive care medicine in China.
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Affiliation(s)
- Ying Wang
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Juan Qian
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Suyun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Chunfeng Liu
- Pediatric Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yibing Chen
- Pediatric Intensive Care Unit, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Guoping Lu
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Yucai Zhang
- Pediatric Intensive Care Unit, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xiaoxu Ren
- Pediatric Intensive Care Unit, Children's Hospital affiliated to Capital Institute of Pediatrics, Beijing, China
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Ghanem MA, El-Hefnawy AS. Basic hemodynamics and noninvasive cardiac output (Bioimpedance ICON Cardiometer): A diagnostic reliability during percutaneous nephrolithotomy bleeding under spinal anesthesia. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1889747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Mohamed A. Ghanem
- Associate Professor of Anesthesia and Surgical Intensive Care, Anesthesia Department, Faculty of Medicine, Mansoura University, Al Mansurah, Egypt
| | - Ahmed S. El-Hefnawy
- Professor of Urology. Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Al Mansurah, Egypt
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Fischer MO, Debroczi S, Gérard JL, Hanouz JL, Buléon C. Perioperative non-invasive haemodynamic optimisation using photoplethysmography: CON. Anaesth Crit Care Pain Med 2021; 40:100805. [PMID: 33486015 DOI: 10.1016/j.accpm.2021.100805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Marc-Olivier Fischer
- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France.
| | - Stéphane Debroczi
- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France
| | - Jean-Louis Gérard
- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France
| | - Jean-Luc Hanouz
- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France
| | - Clément Buléon
- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France
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- Pôle Anesthésie Réanimations SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, F-14 000 Caen, France
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Zhao BC, Lei SH, Yang X, Zhang Y, Qiu SD, Liu WF, Li C, Liu KX. Assessment of prognostic value of intraoperative oliguria for postoperative acute kidney injury: a retrospective cohort study. Br J Anaesth 2020; 126:799-807. [PMID: 33342539 DOI: 10.1016/j.bja.2020.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 11/01/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Oliguria is often viewed as a sign of renal hypoperfusion and an indicator for volume expansion during surgery. However, the prognostic association and the predictive utility of intraoperative oliguria for postoperative acute kidney injury (AKI) are unclear. METHODS We conducted a retrospective cohort study on patients undergoing major thoracic surgery in an academic hospital to assess the association of intraoperative oliguria with postoperative AKI and its predictive value. To contextualise our findings, we included our results in a meta-analysis of observational studies on the importance of oliguria during noncardiac surgery. RESULTS In our cohort study, 3862 patients were included; 205 (5.3%) developed AKI after surgery. Intraoperative urine output of 0.3 ml kg-1 h-1 was the optimal threshold for oliguria in multivariable analysis. Patients with oliguria had an increased risk of AKI (adjusted odds ratio: 2.60; 95% confidence interval: 1.24-5.05). However, intraoperative oliguria had a sensitivity of 5.9%, specificity of 98%, positive likelihood ratio of 2.74, and negative likelihood ratio of 0.96, suggesting poor predictive ability. Moreover, it did not improve upon the predictive performance of a multivariable model, based on discrimination and reclassification indices. Our findings were generally consistent with the results of a systematic review and meta-analysis, including six additional studies. CONCLUSIONS Intraoperative oliguria has moderate association with, but poor predictive ability for, postoperative AKI. It remains of clinical interest as a risk factor potentially modifiable to interventions.
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Affiliation(s)
- Bing-Cheng Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao Yang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ya Zhang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-Da Qiu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-Feng Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Cai Li
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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Miller TE, Mythen M, Shaw AD, Hwang S, Shenoy AV, Bershad M, Hunley C. Association between perioperative fluid management and patient outcomes: a multicentre retrospective study. Br J Anaesth 2020; 126:720-729. [PMID: 33317803 DOI: 10.1016/j.bja.2020.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Postoperative complications increase hospital length of stay and patient mortality. Optimal perioperative fluid management should decrease patient complications. This study examined associations between fluid volume and noncardiac surgery patient outcomes within a large multicentre US surgical cohort. METHODS Adults undergoing noncardiac procedures from January 1, 2012 to December 31, 2017, with a postoperative length of stay ≥24 h, were extracted from a large US electronic health record database. Patients were segmented into quintiles based on recorded perioperative fluid volumes with Quintile 3 (Q3) serving as the reference. The primary outcome was defined as a composite of any complications during the surgical admission and a postoperative length of stay ≥7 days. Secondary outcomes included in-hospital mortality, respiratory complications, and acute kidney injury. RESULTS A total of 35 736 patients met the study criteria. There was a U-shaped pattern with highest (Q5) and lowest (Q1) quintiles of fluid volumes having increased odds of complications and a postoperative length of stay ≥7 days (Q5: odds ratio [OR] 1.51 [95% confidence interval {CI}: 1.30-1.74], P<0.001; Q1: OR 1.20 [95% CI: 1.04-1.38], P=0.011) compared with Q3. Patients in Q5 had greater odds of more severe acute kidney injury compared with Q3 (OR 1.52 [95% CI: 1.22-1.90]; P<0.001) and respiratory complications (OR 1.44 [95% CI: 1.17-1.77]; P<0.001). CONCLUSIONS Both very high and very low perioperative fluid volumes were associated with an increase in complications after noncardiac surgery.
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Affiliation(s)
- Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Monty Mythen
- University College London Hospitals, National Institute for Health Research, Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Seungyoung Hwang
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Apeksha V Shenoy
- Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA
| | - Michael Bershad
- Global Health Economics & Reimbursement, Edwards Lifesciences, Irvine, CA, USA
| | - Charles Hunley
- Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL, USA.
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de Courson H, Chauvet J, Le Gall L, Georges D, Boyer P, Verchère E, Nouette-Gaulain K, Biais M. Utility of changes in end-tidal carbon dioxide after volume expansion to assess fluid responsiveness in the operating room: a prospective observational study. Br J Anaesth 2020; 125:672-679. [DOI: 10.1016/j.bja.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 12/12/2022] Open
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Geyer ED, Miller R, Kim SS, Tobias JD, Nafiu OO, Tumin D. Quality and Impact of Survey Research Among Anesthesiologists: A Systematic Review. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:587-599. [PMID: 32904509 PMCID: PMC7456338 DOI: 10.2147/amep.s259908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/24/2020] [Indexed: 06/11/2023]
Abstract
New technology has facilitated survey research of anesthesia professional society members. We evaluated prevailing metrics of quality and impact of published research studies based on surveys of anesthesiologists. We hypothesized that adherence to recommended practices (such as use of reminders) would be associated with increased survey response rates, and that higher response rates would be associated with higher article impact. Using the MEDLINE database, we identified 45 English-language research articles published in 2010-2017 reporting original data from surveys of anesthesiologists. The median response rate was 37% (IQR: 25-46%). Recommended survey practices, including the use of reminders (p = 0.861) and validated questionnaires (p = 0.719), were not correlated with response rates. In turn, survey response rates were not associated with measures of article impact (p = 0.528). The impact of published research based on surveys of anesthesiologists, as measured by citation scores (p = 0.493) and Altmetrics (p = 0.826), may be driven primarily by the novel data or questions raised using survey methodology, but does not appear to be associated with response rates. Improving reporting of survey methodology and understanding possible sources of non-response bias are important for future studies in this area.
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Affiliation(s)
- Emily D Geyer
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Pediatrics, East Carolina University, Greenville, NC, USA
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Pulse Oximeter Plethysmograph Variation During Hemorrhage in Beta-Blocker-Treated Swine. J Surg Res 2020; 256:468-475. [PMID: 32798994 DOI: 10.1016/j.jss.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/25/2020] [Accepted: 07/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Beta-blockers blunt the stress response to hemorrhage. Our aim was to investigate the feasibility of noninvasive pulse oximeter plethysmographic waveform variation (PoPV) for predicting blood volume loss in an esmolol-treated swine hemorrhagic shock model. MATERIALS AND METHODS Controlled hemorrhage was induced in eight male domestic pigs. In four pigs, a total of 15% and 30% blood volume was drawn step-by-step over 10 min in each step (controlled hemorrhage-only pigs). In the other four pigs, the heart rate (HR) was reduced and maintained by 30% from baseline by esmolol infusion before controlled hemorrhage (esmolol-treated pigs). Diagnostic abilities of HR, pulse pressure variation (PPV), PoPV, and mean arterial pressure for 15% and 30% blood volume loss were determined by the area under the receiver operating characteristic curve (AUC). RESULTS PoPV was well correlated with PPV in controlled hemorrhage-only pigs (r = 0.717) and esmolol-treated pigs (r = 0.532). In controlled hemorrhage-only pigs, HR (AUC = 0.841 and 0.864), PPV (0.878 and 0.843), and PoPV (0.779 and 0.793) accurately predicted 15% and 30% of blood volume loss. In esmolol-treated pigs, the diagnostic ability of HR was decreased (AUC = 0.766 and 0.733). However, diagnostic abilities of PPV (0.848 and 0.804) and PoPV (0.808 and 0.842) were not deteriorated. CONCLUSIONS The diagnostic ability of HR for blood volume loss was blunted by esmolol. However, those of PPV and PoPV were not altered. PoPV may be considered to be a useful noninvasive tool to predict blood volume loss in injured patients taking beta-blockers.
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Pinsky MR, Wertz A, Clermont G, Dubrawski A. Parsimony of Hemodynamic Monitoring Data Sufficient for the Detection of Hemorrhage. Anesth Analg 2020; 130:1176-1187. [PMID: 32287125 DOI: 10.1213/ane.0000000000004564] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Individualized hemodynamic monitoring approaches are not well validated. Thus, we evaluated the discriminative performance improvement that might occur when moving from noninvasive monitoring (NIM) to invasive monitoring and with increasing levels of featurization associated with increasing sampling frequency and referencing to a stable baseline to identify bleeding during surgery in a porcine model. METHODS We collected physiologic waveform (WF) data (250 Hz) from NIM, central venous (CVC), arterial (ART), and pulmonary arterial (PAC) catheters, plus mixed venous O2 saturation and cardiac output from 38 anesthetized Yorkshire pigs bled at 20 mL/min until a mean arterial pressure of 30 mm Hg following a 30-minute baseline period. Prebleed physiologic data defined a personal stable baseline for each subject independently. Nested models were evaluated using simple hemodynamic metrics (SM) averaged over 20-second windows and sampled every minute, beat to beat (B2B), and WF using Random Forest Classification models to identify bleeding with or without normalization to personal stable baseline, using a leave-one-pig-out cross-validation to minimize model overfitting. Model hyperparameters were tuned to detect stable or bleeding states. Bleeding models were compared use both each subject's personal baseline and a grouped-average (universal) baseline. Timeliness of bleed onset detection was evaluated by comparing the tradeoff between a low false-positive rate (FPR) and shortest time to bleed detection. Predictive performance was evaluated using a variant of the receiver operating characteristic focusing on minimizing FPR and false-negative rates (FNR) for true-positive and true-negative rates, respectively. RESULTS In general, referencing models to a personal baseline resulted in better bleed detection performance for all catheters than using universal baselined data. Increasing granularity from SM to B2B and WF progressively improved bleeding detection. All invasive monitoring outperformed NIM for both time to bleeding detection and low FPR and FNR. In that regard, when referenced to personal baseline with SM analysis, PAC and ART + PAC performed best; for B2B CVC, PAC and ART + PAC performed best; and for WF PAC, CVC, ART + CVC, and ART + PAC performed equally well and better than other monitoring approaches. Without personal baseline, NIM performed poorly at all levels, while all catheters performed similarly for SM, with B2B PAC and ART + PAC performing the best, and for WF PAC, ART, ART + CVC, and ART + PAC performed equally well and better than the other monitoring approaches. CONCLUSIONS Increasing hemodynamic monitoring featurization by increasing sampling frequency and referencing to personal baseline markedly improves the ability of invasive monitoring to detect bleed.
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Affiliation(s)
- Michael R Pinsky
- From the University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony Wertz
- Carnegie Mellon University, School of Computer Science, Auton Lab, Pittsburgh, Pennsylvania
| | - Gilles Clermont
- From the University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Artur Dubrawski
- Carnegie Mellon University, School of Computer Science, Auton Lab, Pittsburgh, Pennsylvania
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Fischer MO, Fiant AL, Debroczi S, Boutros M, Pasqualini L, Demonchy M, Flais F, Alves A, Gérard JL, Buléon C, Hanouz JL. Perioperative non-invasive haemodynamic optimisation using photoplethysmography: A randomised controlled trial and meta-analysis. Anaesth Crit Care Pain Med 2020; 39:421-428. [DOI: 10.1016/j.accpm.2020.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/08/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022]
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42
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Shim JW, Kim KR, Jung Y, Park J, Lee HM, Kim YS, Moon YE, Hong SH, Chae MS. Role of intraoperative oliguria in risk stratification for postoperative acute kidney injury in patients undergoing colorectal surgery with an enhanced recovery protocol: A propensity score matching analysis. PLoS One 2020; 15:e0231447. [PMID: 32302336 PMCID: PMC7164643 DOI: 10.1371/journal.pone.0231447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection recommends balanced perioperative fluid therapy. According to recent guidelines, zero-balance fluid therapy is recommended in low-risk patients, and immediate correction of low urine output during surgery is discouraged. However, several reports have indicated an association of intraoperative oliguria with postoperative acute kidney injury (AKI). We investigated the impact of intraoperative oliguria in the colorectal ERAS setting on the incidence of postoperative AKI. PATIENTS AND METHODS From January 2017 to August 2019, a total of 453 patients underwent laparoscopic colorectal cancer resection with the ERAS protocol. Among them, 125 patients met the criteria for oliguria and were propensity score (PS) matched to 328 patients without intraoperative oliguria. After PS matching had been performed, 125 patients from each group were selected and the incidences of AKI were compared between the two groups. Postoperative kidney function and surgical outcomes were also evaluated. RESULTS The incidence of AKI was significantly higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (26.4% vs. 11.2%, respectively, P = 0.002). Also, the eGFR reduction on postoperative day 0 was significantly greater in the intraoperative oliguria than non-intraoperative oliguria group (-9.02 vs. -1.24 mL/min/1.73 m2 respectively, P < 0.001). In addition, the surgical complication rate was higher in the intraoperative oliguria group than in the non-intraoperative oliguria group (18.4% vs. 9.6%, respectively, P = 0.045). CONCLUSIONS Despite the proven benefits of perioperative care with the ERAS protocol, caution is required in patients with intraoperative oliguria to prevent postoperative AKI. Further studies regarding appropriate management of intraoperative oliguria in association with long-term prognosis are needed in the colorectal ERAS setting.
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Affiliation(s)
- Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyoung Rim Kim
- Department of Anesthesiology and Pain Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoonju Jung
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Suk Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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43
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Fischer MO, Joosten A, Desebbe O, Boutros M, Debroczi S, Broch O, Malbrain ML, Ameloot K, Hofer CK, Bubenek-Turconi ŞI, Monnet X, Diouf M, Lorne E. Interchangeability of cardiac output measurements between non-invasive photoplethysmography and bolus thermodilution: A systematic review and individual patient data meta-analysis. Anaesth Crit Care Pain Med 2020; 39:75-85. [DOI: 10.1016/j.accpm.2019.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/29/2019] [Accepted: 05/27/2019] [Indexed: 01/30/2023]
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44
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Zheng C, Guo C. Intraoperative Urine Output Is Associated with Postoperative Outcome in Pediatric Population Undergone Major Abdominal Operations. Ther Clin Risk Manag 2020; 15:1453-1460. [PMID: 31908465 PMCID: PMC6927263 DOI: 10.2147/tcrm.s228528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/05/2019] [Indexed: 11/23/2022] Open
Abstract
Aim Few data support the advantage of confirming a low urine output target during Roux-en-Y hepaticojejunostomy, which was widely used as an indication for fluid administration. We aimed at evaluating postoperative outcomes in terms of urine output in pediatric patients undergoing elective Roux-en-Y hepaticojejunostomy. Methods We retrospectively reviewed 689 patients who had undergone Roux-en-Y hepaticojejunostomy between January 2007 and August 2014 at the Children’s Hospital of the Chongqing Medical University. Patients were dichotomized according to the average amount of corrected urine output (6.01 mL/kg*h) as a cut-off point. The primary endpoint was the occurrence of renal complications. The secondary endpoints included prompt postoperative gastrointestinal function recovery, postoperative complications and hospital length of stay. Results The lower urine output had a proportional association with lesser amounts of crystalloid fluids (12.99±6.52 and 17.36±7.74 mL/kg*h for low and high urine output, respectively, p=0.006). For patients with a lower urine output, there were trends toward lower incidence rates of grade II postoperative complications (OR, 0.68; 95CI, 0.45–1.03; p=0.041) and accelerated recovery of gastrointestinal function, as indicated by the first flatus (p=0.015) and first bowel movement (p=0.008); however, the occurrence of renal complications did not show significant differences between the groups. The total length of hospital stay was shorter in patients with low urine output (7.59±1.24 days) than that in patients with a high urine output (8.01±2.31 days, p = 0.016). Conclusion Lower urine output is associated with a lower incidence rate II postoperative complications and accelerated recovery of gastrointestinal function, without increasing the occurrence of renal complications in pediatric patient undergone hepaticojejunostomy. The optimal amount of urine output and associated fluid administration should be further investigated.
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Affiliation(s)
- Chao Zheng
- Department of Orthopedics, Children's Hospital, Chongqing Medical University, Chongqing 400014, People's Republic of China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chunbao Guo
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.,Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
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45
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Czajka S, Marczenko K, Włodarczyk M, Szczepańska AJ, Olakowski M, Mrowiec S, Krzych ŁJ. Fluid Therapy in Patients Undergoing Abdominal Surgery: A Bumpy Road Towards Individualized Management. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1324:63-72. [PMID: 33230636 DOI: 10.1007/5584_2020_597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Prudent intraoperative fluid replacement therapy, inotropes, and vasoactive drugs should be guided by adequate hemodynamic monitoring. The study aimed to evaluate the single-centre practice on intraoperative fluid therapy in abdominal surgery (AS). The evaluation, based on a review of medical files, included 235 patients (103 men), aged 60 ± 15 years who underwent AS between September and November 2017. Fluid therapy was analyzed in terms of quality and quantity. There were 124 high-risk patients according to the American Society of Anaesthesiologists Classification (ASA Class 3+) and 89 high-risk procedures performed. The median duration of procedures was 175 (IQR 106-284) min. Eleven patients died post-operatively. The median fluids volume was 10.4 mL/kg/h of anaesthesia, including 9.1 mL/kg/h of crystalloids and 2.7 mL/kg/h of synthetic colloids. Patients undergoing longer than the median procedures received significantly fewer fluids than those who underwent shorter procedures. The volume of fluids in the longer procedures depended on the procedural risk classification and was significantly greater in high-risk patients undergoing high-risk surgery. Patients who died received significantly more fluids than survivors. In all patients, a non-invasive blood pressure monitoring was used and only six patients had therapy guided by metabolic equilibrium. The fluid therapy used was liberal but complied with the recommendations regarding the type of fluid and risk-adjusted dosing. Hemodynamic monitoring was suboptimal and requires modifications. In conclusion, the optimization of intraoperative fluid therapy requires a balanced and standardized approach consistent with treatment procedures.
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Affiliation(s)
- Szymon Czajka
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
| | - Konstanty Marczenko
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Martyna Włodarczyk
- Students' Scientific Society, Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna J Szczepańska
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Marek Olakowski
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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46
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Ait-Hamou Z, Teboul JL, Anguel N, Monnet X. How to detect a positive response to a fluid bolus when cardiac output is not measured? Ann Intensive Care 2019; 9:138. [PMID: 31845003 PMCID: PMC6915177 DOI: 10.1186/s13613-019-0612-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/03/2019] [Indexed: 01/01/2023] Open
Abstract
Background Volume expansion is aimed at increasing cardiac output (CO), but this variable is not always directly measured. We assessed the ability of changes in arterial pressure, pulse pressure variation (PPV) and heart rate (HR) or of a combination of them to detect a positive response of cardiac output (CO) to fluid administration. Methods We retrospectively included 491 patients with circulatory failure. Before and after a 500-mL normal saline infusion, we measured CO (PiCCO device), HR, systolic (SAP), diastolic (DAP), mean (MAP) and pulse (PP) arterial pressure, PPV, shock index (HR/SAP) and the PP/HR ratio. Results The fluid-induced changes in HR were not correlated with the fluid-induced changes in CO. The area under the receiver operating characteristic curve (AUROC) for changes in HR as detectors of a positive fluid response (CO increase ≥ 15%) was not different from 0.5. The fluid-induced changes in SAP, MAP, PP, PPV, shock index (HR/SAP) and the PP/HR ratio were correlated with the fluid-induced changes in CO, but with r < 0.4. The best detection was provided by increases in PP, but it was rough (AUROC = 0.719 ± 0.023, best threshold: increase ≥ 10%, sensitivity = 72 [66–77]%, specificity = 64 [57–70]%). Neither the decrease in shock index nor the changes in other indices combining changes in HR, shock index, PPV and PP provided a better detection of a positive fluid response than changes in PP. Conclusion A positive response to fluid was roughly detected by changes in PP and not detected by changes in HR. Changes in combined indices including the shock index and the PP/HR ratio did not provide a better diagnostic accuracy.
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Affiliation(s)
- Zakaria Ait-Hamou
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France. .,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Univ Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Univ Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France
| | - Nadia Anguel
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Univ Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Univ Paris-Saclay, Faculté de médecine, Le Kremlin-Bicêtre, France
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Schneck E, Schulte D, Habig L, Ruhrmann S, Edinger F, Markmann M, Habicher M, Rickert M, Koch C, Sander M. Hypotension Prediction Index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomised blinded prospective interventional trial. J Clin Monit Comput 2019; 34:1149-1158. [DOI: 10.1007/s10877-019-00433-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/26/2019] [Indexed: 12/18/2022]
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48
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Ruiz-Vargas A, Morris SA, Hartley RH, Arkwright JW. Optical flow sensor for continuous invasive measurement of blood flow velocity. JOURNAL OF BIOPHOTONICS 2019; 12:e201900139. [PMID: 31102344 DOI: 10.1002/jbio.201900139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 06/09/2023]
Abstract
Continuous monitoring of intrapulse measurement of blood flow in humans is currently not achievable with clinically available instruments. In this paper, we demonstrate a method of measuring the instantaneous variations in flow during pulsatile blood flow with an optical flow sensor comprising a fiber Bragg grating sensor and illumination from a 565 nm Light-Emitting-Diode. The LED illumination heats the blood and fluctuations in temperature, due to variations in flow, are detected by the fiber sensor. A set of experiments at different flow rates (20 to 900 mL/min) are performed in a simulated cardiac circulation setup with pulsatile flow. Data are compared with an in-line time of flight ultrasound flow sensor. Our results show that the optical and ultrasonic signals correlate with Pearson coefficients ranging from -0.83 to -0.98, dependent on the pulsatile frequency. Average flow determined by ultrasound and the optical fiber sensor showed a parabolic relationship with R2 = 0.99. An abrupt step change in flow induced by occlusion and release of the circuit tubing demonstrated that the optical fiber and ultrasound sensor had similar response. The method described is capable of intrapulse blood flow measurement under pulsatile flow conditions, with potential applications in medicine where continuous blood flow sensing is desired.
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Affiliation(s)
- Albert Ruiz-Vargas
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Scott A Morris
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Neonatal Unit, Flinders Medical Centre, Adelaide, Australia
| | | | - John W Arkwright
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, Australia
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49
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Yang Q, Xie K, Xiong L. Anaesthesiology in China: present and future. Br J Anaesth 2019; 123:559-564. [PMID: 31543268 DOI: 10.1016/j.bja.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/12/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Qianzi Yang
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Keliang Xie
- Department of Anaesthesiology, Tianjin Institute of Anaesthesiology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Lize Xiong
- Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China; Department of Anaesthesiology and Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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50
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Rossi Neto JM. Continuous Non-Invasive Cardiac Output: Myth or Reality. Arq Bras Cardiol 2019; 113:240-241. [PMID: 31483019 PMCID: PMC6777891 DOI: 10.5935/abc.20190163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- João Manoel Rossi Neto
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP -
Brazil
- Grupo Fleury, São Paulo, SP - Brazil
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