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Barajas MB, Riess ML, Hampton MJW, Li Z, Shi Y, Shotwell MS, Staudt G, Baudenbacher FJ, Lefevre RJ, Eagle SS. Peripheral Intravenous Waveform Analysis Responsiveness to Subclinical Hemorrhage in a Rat Model. Anesth Analg 2023; 136:941-948. [PMID: 37058731 DOI: 10.1213/ane.0000000000006349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Early detection and quantification of perioperative hemorrhage remains challenging. Peripheral intravenous waveform analysis (PIVA) is a novel method that uses a standard intravenous catheter to detect interval hemorrhage. We hypothesize that subclinical blood loss of 2% of the estimated blood volume (EBV) in a rat model of hemorrhage is associated with significant changes in PIVA. Secondarily, we will compare PIVA association with volume loss to other static, invasive, and dynamic markers. METHODS Eleven male Sprague Dawley rats were anesthetized and mechanically ventilated. A total of 20% of the EBV was removed over ten 5 minute-intervals. The peripheral intravenous pressure waveform was continuously transduced via a 22-G angiocatheter in the saphenous vein and analyzed using MATLAB. Mean arterial pressure (MAP) and central venous pressure (CVP) were continuously monitored. Cardiac output (CO), right ventricular diameter (RVd), and left ventricular end-diastolic area (LVEDA) were evaluated via transthoracic echocardiogram using the short axis left ventricular view. Dynamic markers such as pulse pressure variation (PPV) were calculated from the arterial waveform. The primary outcome was change in the first fundamental frequency (F1) of the venous waveform, which was assessed using analysis of variance (ANOVA). Mean F1 at each blood loss interval was compared to the mean at the subsequent interval. Additionally, the strength of the association between blood loss and F1 and each other marker was quantified using the marginal R2 in a linear mixed-effects model. RESULTS PIVA derived mean F1 decreased significantly after hemorrhage of only 2% of the EBV, from 0.17 to 0.11 mm Hg, P = .001, 95% confidence interval (CI) of difference in means 0.02 to 0.10, and decreased significantly from the prior hemorrhage interval at 4%, 6%, 8%, 10%, and 12%. Log F1 demonstrated a marginal R2 value of 0.57 (95% CI 0.40-0.73), followed by PPV 0.41 (0.28-0.56) and CO 0.39 (0.26-0.58). MAP, LVEDA, and systolic pressure variation displayed R2 values of 0.31, and the remaining predictors had R2 values ≤0.2. The difference in log F1 R2 was not significant when compared to PPV 0.16 (95% CI -0.07 to 0.38), CO 0.18 (-0.06 to 0.04), or MAP 0.25 (-0.01 to 0.49) but was significant for the remaining markers. CONCLUSIONS The mean F1 amplitude of PIVA was significantly associated with subclinical blood loss and most strongly associated with blood volume among the markers considered. This study demonstrates feasibility of a minimally invasive, low-cost method for monitoring perioperative blood loss.
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Affiliation(s)
- Matthew B Barajas
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Tennessee Valley Healthcare System Veterans Affairs Medical Center, Nashville, Tennessee
| | - Matthias L Riess
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Tennessee Valley Healthcare System Veterans Affairs Medical Center, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
| | - Matthew J W Hampton
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zhu Li
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Genevieve Staudt
- Department of Anesthesiology, Monroe Carroll Jr Vanderbilt Children's Hospital, Nashville, Tennessee
| | - Franz J Baudenbacher
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Ryan J Lefevre
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan S Eagle
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Sheridan WS, Wetterling F, Testani JM, Borlaug BA, Fudim M, Damman K, Gray A, Gaines P, Poloczek M, Madden S, Tucker J, Buxo T, Gaul R, Corcoran L, Sweeney F, Burkhoff D. Safety and performance of a novel implantable sensor in the inferior vena cava under acute and chronic intravascular volume modulation. Eur J Heart Fail 2023; 25:754-763. [PMID: 36891760 DOI: 10.1002/ejhf.2822] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/10/2023] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
AIMS The management of congestion is one of the key treatment targets in heart failure. Assessing congestion is, however, difficult. The purpose of this study was to investigate the safety and dynamic response of a novel, passive, inferior vena cava (IVC) sensor in a chronic ovine model. METHODS AND RESULTS A total of 20 sheep divided into three groups were studied in acute and chronic in vivo settings. Group I and Group II included 14 sheep in total with 12 sheep receiving the sensor and two sheep receiving a control device (IVC filter). Group III included an additional six animals for studying responses to volume challenges via infusion of blood and saline solutions. Deployment was 100% successful with all devices implanted; performing as expected with no device-related complications and signals were received at all observations. At similar volume states no significant differences in IVC area normalized to absolute area range were measured (55 ± 17% on day 0 and 62 ± 12% on day 120, p = 0.51). Chronically, the sensors were completely integrated with a thin, reendothelialized neointima with no loss of sensitivity to infused volume. Normalized IVC area changed significantly from 25 ± 17% to 43 ± 11% (p = 0.007) with 300 ml infused. In contrast, right atrial pressure required 1200 ml of infused volume prior to a statistically significant change from 3.1 ± 2.6 mmHg to 7.5 ± 2.0 mmHg (p = 0.02). CONCLUSION In conclusion, IVC area can be measured remotely in real-time using a safe, accurate, wireless, and chronic implantable sensor promising to detect congestion with higher sensitivity than filling pressures.
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Affiliation(s)
| | | | - Jeffrey Moore Testani
- Section of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Alastair Gray
- Department of Cardiology, Craigavon Area Hospital, Craigavon, UK
| | | | - Martin Poloczek
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | - Stephen Madden
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James Tucker
- FIRE1, Foundry Innovation and Research 1 Ltd, Dublin, Ireland
| | - Teresa Buxo
- FIRE1, Foundry Innovation and Research 1 Ltd, Dublin, Ireland
| | - Robert Gaul
- FIRE1, Foundry Innovation and Research 1 Ltd, Dublin, Ireland
| | - Louise Corcoran
- FIRE1, Foundry Innovation and Research 1 Ltd, Dublin, Ireland
| | - Fiachra Sweeney
- FIRE1, Foundry Innovation and Research 1 Ltd, Dublin, Ireland
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3
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Ivey-Miranda JB, Wetterling F, Gaul R, Sheridan S, Asher JL, Rao VS, Maulion C, Mahoney D, Mebazaa A, Gray AP, Burkhoff D, Cowie MR, Cox ZL, Butler J, Fudim M, McDonald K, Damman K, Borlaug BA, Testani JM. Changes in inferior vena cava area represent a more sensitive metric than change in filling pressures during experimental manipulation of intravascular volume and tone. Eur J Heart Fail 2021; 24:455-462. [PMID: 34837447 PMCID: PMC9306514 DOI: 10.1002/ejhf.2395] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/30/2021] [Accepted: 11/16/2021] [Indexed: 12/05/2022] Open
Abstract
Aims Remote monitoring of pulmonary artery pressure has reduced heart failure (HF) hospitalizations in chronic HF as elevation of pulmonary artery pressure provides information that can guide treatment. The venous system is characterized by high capacitance, thus substantial increases in intravascular volume can occur before filling pressures increase. The inferior vena cava (IVC) is a highly compliant venous conduit and thus a candidate for early detection of change in intravascular volume. We aimed to compare IVC cross‐sectional area using a novel sensor with cardiac filling pressures during experimental manipulation of volume status, vascular tone, and cardiac function. Methods and results Experiments were conducted in sheep to manipulate volume status (colloid infusion), vascular tone (nitroglycerin infusion) and cardiac function (rapid cardiac pacing). A wireless implantable IVC sensor was validated ex‐vivo and in‐vivo, and then used to measure the cross‐sectional area of the IVC. Right‐ and left‐sided cardiac filling pressures were obtained via right heart catheterization. The IVC sensor provided highly accurate and precise measurements of cross‐sectional area in ex‐vivo and in‐vivo validation. IVC area changes were more sensitive than the corresponding changes in cardiac filling pressures during colloid infusion (p < 0.001), vasodilatation (p < 0.001) and cardiac dysfunction induced by rapid pacing (p ≤ 0.02). Conclusions Inferior vena cava area can be remotely and accurately measured in real time with a wireless implantable sensor. Changes in IVC area are more sensitive than corresponding changes in filling pressures following experimental volume loading and fluid redistribution. Additional research is warranted to understand if remote monitoring of the IVC may have advantages over pressure‐based monitors in HF.
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Affiliation(s)
- Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA.,Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | | | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, Department of Anesthesia and Critical Care, Hôpital Lariboisière, DMU Parabol, APHP Nord, Paris, France
| | - Alastair P Gray
- . Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Martin R Cowie
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Hua Z, Xin D, Xiaoting W, Dawei L. High Central Venous Pressure and Right Ventricle Size Are Related to Non-decreased Left Ventricle Stroke Volume After Negative Fluid Balance in Critically Ill Patients: A Single Prospective Observational Study. Front Med (Lausanne) 2021; 8:715099. [PMID: 34532330 PMCID: PMC8438320 DOI: 10.3389/fmed.2021.715099] [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: 05/26/2021] [Accepted: 07/29/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Optimal adjustment of cardiac preload is essential for improving left ventricle stroke volume (LVSV) and tissue perfusion. Changes in LVSV caused by central venous pressure (CVP) are the most important concerns in the treatment of critically ill patients. Objectives: This study aimed to clarify the changes in LVSV after negative fluid balance in patients with elevated CVP, and to elucidate the relationship between the parameters of right ventricle (RV) filling state and LVSV changes. Methods: This prospective cohort study included patients with high central venous pressure (CVP) (≥8 mmHg) within 24 h of ICU admission in the Critical Medicine Department of Peking Union Medical College Hospital. Patients were classified into two groups based on the LVSV changes after negative fluid balance. The cutoff value was 10%. The hemodynamic and echo parameters of the two groups were recorded at baseline and after negative fluid balance. Results: A total of 71 patients included in this study. Forty in VI Group (LVOT VTI increased ≥10%) and 31 in VNI Group (LVOT VTI increased <10%). Of all patients, 56.3% showed increased LVSV after negative fluid balance. In terms of hemodynamic parameters at T0, patients in VI Group had a higher CVP (p < 0.001) and P(v-a)CO2 (p < 0.001) and lower ScVO2 (p < 0.001) relative to VNI Group, regarding the echo parameters at T0, the RVD/LVD ratio (p < 0.001), DIVC end-expiratory (p < 0.001), and ΔLVOT VTI (p < 0.001) were higher, while T0 LVOT VTI (p < 0.001) was lower, in VI Group patients. The multifactor logistic regression analysis suggested that a high CVP and RVD/LVD ratio ≥0.6 were significant associated with LVSV increase after negative fluid balance in critically patients. The AUC of CVP was 0.894. A CVP >10.5 mmHg provided a sensitivity of 87.5% and a specificity of 77.4%. The AUC of CVP combined with the RVD/LVD ratio ≥0.6 was 0.926, which provided a sensitivity of 92.6% and a specificity of 80.4%. Conclusion: High CVP and RVD/LVD ratio ≥0.6 were significant associated with RV stressed in critically patients. Negative fluid balance will not always lead to a decrease, even an increase, in LVSV in these patients.
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Affiliation(s)
- Zhao Hua
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ding Xin
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wang Xiaoting
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liu Dawei
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Sun T, Zhan J, Li F, Ji C, Wu H. Effect of microplastics on aquatic biota: A hormetic perspective. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 285:117206. [PMID: 33971425 DOI: 10.1016/j.envpol.2021.117206] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/06/2021] [Accepted: 04/16/2021] [Indexed: 05/17/2023]
Abstract
As emerging pollutants, microplastics (MPs) have been found globally in various freshwater and marine matrices. This study recompiled 270 endpoints of 3765 individuals from 43 publications, reporting the onset of enhanced biological performance and reduced oxidative stress biomarkers induced by MPs in aquatic organisms at environmentally relevant concentrations (≤1 mg/L, median = 0.1 mg/L). The stimulatory responses of consumption, growth, reproduction and survival ranged from 131% to 144% of the control, with a combined response of 136%. The overall inhibitory response of 9 oxidative stress biomarkers was 71% of the control, and commonly below 75%. The random-effects meta-regression indicated that the extents of MPs-induced responses were independent of habitat, MP composition, morphology, particle size and exposure duration. The results implied that the exposure to MPs at low and high concentrations might induce opposite/non-monotonic responses in aquatic biota. Correspondingly, the hormetic dose response relationships were found at various endpoints, such as reproduction, genotoxicity, immunotoxicity, neurotoxicity and behavioral alteration. Hormesis offers a novel perspective for understanding the dose response mode of aquatic organisms exposed to low and high concentrations of MPs, highlighting the necessity to incorporate the hormetic dose response model into the ecological/environmental risk assessment of MPs.
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Affiliation(s)
- Tao Sun
- CAS Key Laboratory of Coastal Environmental Processes and Ecological Remediation, Yantai Institute of Coastal Zone Research (YIC), Chinese Academy of Sciences (CAS); Shandong Key Laboratory of Coastal Environmental Processes, YICCAS, Yantai, 264003, PR China; University of Chinese Academy of Sciences, Beijing, 100049, PR China
| | - Junfei Zhan
- CAS Key Laboratory of Coastal Environmental Processes and Ecological Remediation, Yantai Institute of Coastal Zone Research (YIC), Chinese Academy of Sciences (CAS); Shandong Key Laboratory of Coastal Environmental Processes, YICCAS, Yantai, 264003, PR China; University of Chinese Academy of Sciences, Beijing, 100049, PR China
| | - Fei Li
- CAS Key Laboratory of Coastal Environmental Processes and Ecological Remediation, Yantai Institute of Coastal Zone Research (YIC), Chinese Academy of Sciences (CAS); Shandong Key Laboratory of Coastal Environmental Processes, YICCAS, Yantai, 264003, PR China; Center for Ocean Mega-Science, Chinese Academy of Sciences (CAS), Qingdao, 266071, PR China
| | - Chenglong Ji
- CAS Key Laboratory of Coastal Environmental Processes and Ecological Remediation, Yantai Institute of Coastal Zone Research (YIC), Chinese Academy of Sciences (CAS); Shandong Key Laboratory of Coastal Environmental Processes, YICCAS, Yantai, 264003, PR China; Laboratory for Marine Fisheries Science and Food Production Processes, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266237, PR China; Center for Ocean Mega-Science, Chinese Academy of Sciences (CAS), Qingdao, 266071, PR China
| | - Huifeng Wu
- CAS Key Laboratory of Coastal Environmental Processes and Ecological Remediation, Yantai Institute of Coastal Zone Research (YIC), Chinese Academy of Sciences (CAS); Shandong Key Laboratory of Coastal Environmental Processes, YICCAS, Yantai, 264003, PR China; Laboratory for Marine Fisheries Science and Food Production Processes, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266237, PR China; Center for Ocean Mega-Science, Chinese Academy of Sciences (CAS), Qingdao, 266071, PR China.
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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Gual-Capllonch F, Lupón J, Bancu I, Graterol F, Ferrer-Sistach E, Teis A, Santiago-Vacas E, Vallejo N, Juncà G, Bayes-Genis A. Preload dependence of pulmonary haemodynamics and right ventricular performance. Clin Res Cardiol 2021; 110:591-600. [PMID: 33624153 DOI: 10.1007/s00392-021-01820-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/08/2021] [Indexed: 11/25/2022]
Abstract
AIMS Systolic pulmonary artery pressure (SPAP) and right heart adaptation in relation to pre-existing preload are often disregarded. To determine volume-related changes in the pulmonary-right ventricle (RV) unit and the preload dependence of its components, we analysed pulmonary haemodynamics and right ventricular performance, taking advantage of the plasma volume removal associated to haemodialysis (HD). METHODS AND RESULTS Fifty-three stable patients on chronic HD with LVEF > 50% and without heart failure were recruited (mean age 63.0 ± 12.4 years; 31.2% women; hypertension in 89% and diabetes in 53%) and evaluated just before and after HD (mean ultrafiltration volume 2.4 ± 0.7 l). SPAP from both times were available in 39 patients. After HD, SPAP decreased (42.2 ± 12.6 to 33.7 ± 11.6 mmHg, p < 0.001) without modification of non-invasive pulmonary vascular resistance (1.75 ± 0.44 to 1.75 ± 0.40 eWU, p = 0.94). Age and drop in the E/e' ratio were the variables associated with greater reduction in PASP (p = 0.022 and p = 0.049, respectively). A significant reduction of right chamber sizes was observed, along with a diminution in measures of RV contractility, excluding RV longitudinal strain. Functional tricuspid regurgitation (FTR) diminution was observed in 26% of patients, occurring in every case with more than mild FTR. On multivariate analyses, left atrial size was the only predictor of pulmonary hypertension (defined as SPAP > 40 mmHg) (OR 1.29 (1.07-1.56), p = 0.006). CONCLUSION Rapid volemic changes may affect FTR grading, RV size and contractility, with RV longitudinal strain being less variable than conventional parameters. SPAP decreases after HD, and this reduction is related to age and greater diminution of the E/e' ratio.
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Affiliation(s)
- Francisco Gual-Capllonch
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Josep Lupón
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Ioana Bancu
- Nefrology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Fredzzia Graterol
- Nefrology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Elena Ferrer-Sistach
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
| | - Albert Teis
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
| | - Evelyn Santiago-Vacas
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
| | - Nuria Vallejo
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
| | - Gladys Juncà
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
| | - Antoni Bayes-Genis
- Heart Institute. Hospital Universitari Germans Trias I Pujol, Carretera de Canyet s/n 08916, Badalona, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
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Yassen AM. Pressure versus volume indices to guide fluid infusion early after living donor liver transplantation: A prospective randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Amr M. Yassen
- Department of Anesthesia and Intensive Care, Liver Transplantation Program , Gastroenterology Surgical Center , Mansoura University , Gehan Street , Mansoura, Egypt
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9
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Messina A, Pelaia C, Bruni A, Garofalo E, Bonicolini E, Longhini F, Dellara E, Saderi L, Romagnoli S, Sotgiu G, Cecconi M, Navalesi P. Fluid Challenge During Anesthesia. Anesth Analg 2018; 127:1353-1364. [DOI: 10.1213/ane.0000000000003834] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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10
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Toscani L, Aya HD, Antonakaki D, Bastoni D, Watson X, Arulkumaran N, Rhodes A, Cecconi M. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:207. [PMID: 28774325 PMCID: PMC5543539 DOI: 10.1186/s13054-017-1796-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Background The fluid challenge is considered the gold standard for diagnosis of fluid responsiveness. The objective of this study was to describe the fluid challenge techniques reported in fluid responsiveness studies and to assess the difference in the proportion of ‘responders,’ (PR) depending on the type of fluid, volume, duration of infusion and timing of assessment. Methods Searches of MEDLINE and Embase were performed for studies using the fluid challenge as a test of cardiac preload with a description of the technique, a reported definition of fluid responsiveness and PR. The primary outcome was the mean PR, depending on volume of fluid, type of fluids, rate of infusion and time of assessment. Results A total of 85 studies (3601 patients) were included in the analysis. The PR were 54.4% (95% CI 46.9–62.7) where <500 ml was administered, 57.2% (95% CI 52.9–61.0) where 500 ml was administered and 60.5% (95% CI 35.9–79.2) where >500 ml was administered (p = 0.71). The PR was not affected by type of fluid. The PR was similar among patients administered a fluid challenge for <15 minutes (59.2%, 95% CI 54.2–64.1) and for 15–30 minutes (57.7%, 95% CI 52.4–62.4, p = 1). Where the infusion time was ≥30 minutes, there was a lower PR of 49.9% (95% CI 45.6–54, p = 0.04). Response was assessed at the end of fluid challenge, between 1 and 10 minutes, and >10 minutes after the fluid challenge. The proportions of responders were 53.9%, 57.7% and 52.3%, respectively (p = 0.47). Conclusions The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1796-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Toscani
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cristo Re Hospital, Via delle Calasanziane 25, 00167, Rome, Italy
| | - Hollmann D Aya
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK. .,Anaesthetic Department, East Surrey Hospital, Surrey & Sussex Healthcare Trust, Canada Avenue, Redhill, Surrey, RH1 5 RH, UK.
| | - Dimitra Antonakaki
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cardiology Department, Broomfield Hospital, Mid-Essex Healthcare Trust, Court Road, Broomfield, Chelmsford, CM1 7ET, UK
| | - Davide Bastoni
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Dipartimento di Medicina Sperimentale, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ximena Watson
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Nish Arulkumaran
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Andrew Rhodes
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
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Kapoor PM, Bhardwaj V, Sharma A, Kiran U. Global end-diastolic volume an emerging preload marker vis-a-vis other markers - Have we reached our goal? Ann Card Anaesth 2017; 19:699-704. [PMID: 27716702 PMCID: PMC5070331 DOI: 10.4103/0971-9784.191554] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A reliable estimation of cardiac preload is helpful in the management of severe circulatory dysfunction. The estimation of cardiac preload has evolved from nuclear angiography, pulmonary artery catheterization to echocardiography, and transpulmonary thermodilution (TPTD). Global end-diastolic volume (GEDV) is the combined end-diastolic volumes of all the four cardiac chambers. GEDV has been demonstrated to be a reliable preload marker in comparison with traditionally used pulmonary artery catheter-derived pressure preload parameters. Recently, a new TPTD system called EV1000™ has been developed and introduced into the expanding field of advanced hemodynamic monitoring. GEDV has emerged as a better preload marker than its previous conventional counterparts. The advantage of it being measured by minimum invasive methods such as PiCCO™ and newly developed EV1000™ system makes it a promising bedside advanced hemodynamic parameter.
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Affiliation(s)
- P M Kapoor
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
| | | | - Amita Sharma
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
| | - Usha Kiran
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
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12
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Hemodynamic monitoring of the injured patient: From central venous pressure to focused echocardiography. J Trauma Acute Care Surg 2016; 80:499-510. [PMID: 26713977 DOI: 10.1097/ta.0000000000000938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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13
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Ansari BM, Zochios V, Falter F, Klein AA. Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review. Anaesthesia 2015; 71:94-105. [DOI: 10.1111/anae.13246] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/29/2022]
Affiliation(s)
- B. M. Ansari
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - V. Zochios
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - F. Falter
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
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14
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Escobar B, Taurá P, Martínez-Palli G, Fondevila C, Balust J, Beltrán J, Fernández J, García-Pagán JC, García-Valdecasas JC. Stroke volume response to liver graft reperfusion stress in cirrhotic patients. World J Surg 2014; 38:927-35. [PMID: 24132825 DOI: 10.1007/s00268-013-2289-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In patients with advanced cirrhosis, stressful stimuli may reveal a silent reduced cardiac performance. During liver transplantation (LT), graft reperfusion strongly stresses the heart and may unmask latent myocardial dysfunction. AIM The objective of this study was to assess heart response to acutely increased preload after liver graft reperfusion and correlate this response with preoperative data and outcome. METHODS Preoperative clinical, echocardiographic, and hemodynamic data, and patient outcome were retrospectively recorded for 235 liver recipients who had no known cardiac disease. Myocardial dysfunction was defined as less than 10 % increase of stroke volume after graft reperfusion (non-responder). RESULTS We found 84 (35.7 %) non-responder patients. The non-responders showed higher Model for end-stage liver disease scores (p = 0.046), left atrial diameter (LAD) (p = 0.040), hepatic vein pressure gradient (p = 0.055), and hyperdynamic state than responders. The percentages of patients with hyponatremia (p = 0.048) and alcohol etiology (p = 0.025) were also higher among non-responders. Independent predictors of inadequate cardiac response in the multivariate analysis were low preoperative systemic vascular resistance (SVRI) [odds ratio (OR) 3.09, 95 % CI 1.15-4.82; p = 0.027] and enlargement of LAD (OR 2.08, 95 % CI 1.49-2.74; p = 0.044). Non-response was associated with higher rates of early cardiovascular events [hazard ratio (HR) 2.84, 95 % CI 1.09-4.22; p = 0.039] and higher length of intensive care unit stay (p = 0.038). No differences were found in 1-year survival rates. CONCLUSIONS Latent cardiac dysfunction among LT recipients, considered to be abnormal stroke volume response to unclamping of portal vein, is very prevalent. SVRI and LAD were independent predictors of inadequate responses. This condition deserves special attention since it may aggravate the early postoperative course of LT.
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Affiliation(s)
- Bibiana Escobar
- Department of Anesthesiology, Hospital Clinic, Barcelona, Spain,
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16
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WILKMAN E, KUITUNEN A, PETTILÄ V, VARPULA M. Fluid responsiveness predicted by elevation of PEEP in patients with septic shock. Acta Anaesthesiol Scand 2014; 58:27-35. [PMID: 24341692 DOI: 10.1111/aas.12229] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The assessment of whether a patient is fluid responsive can be difficult in clinical practice. Invasive filling pressures are inadequate indicators of preload and fluid responsiveness in critically ill patients. Dynamic indices may be unreliable in clinical practice because of arrhythmias or spontaneous breathing efforts. Elevation of positive end-expiratory pressure (PEEP) causes cardiorespiratory interactions, which may produce signs of hypovolaemia. Our aim was to assess whether haemodynamic changes during a short elevation of PEEP would predict fluid responsiveness in patients with septic shock. METHODS We performed a prospective observational study in 20 patients with septic shock on mechanical ventilation. We assessed the following changes in haemodynamic variables during a temporary elevation of PEEP from 10 cm H2O to 20 cm H2O during an end-expiratory pause: mean arterial pressure (MAP), systolic arterial pressure, pulse pressure, central venous pressure, pulmonary artery occlusion pressure, left ventricular end diastolic area and aortic velocity-time integral. We defined fluid responsiveness as an increase in cardiac output of 15% to a subsequent fluid challenge. RESULTS Decrease in MAP related to elevation of PEEP predicted fluid responsiveness (P = 0.003). The best cut-off value of ΔMAP for clinical use was -8%, with a negative predictive value for fluid responsiveness of 100%. CONCLUSION In patients with septic shock, the absence of decrease in MAP during an elevation of PEEP may be used to identify patients who will not increase their cardiac output in response to fluid challenge.
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Affiliation(s)
- E. WILKMAN
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
| | - A. KUITUNEN
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Intensive Care Unit; Department of Intensive Care; Tampere University Hospital; Tampere Finland
| | - V. PETTILÄ
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Department of Clinical Sciences; University of Helsinki; Helsinki Finland
| | - M. VARPULA
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Department of Internal Medicine; Heart and Lung Center, Division of Cardiology; Helsinki University Central Hospital; Helsinki Finland
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Effect of pulse pressure on the predictability of stroke volume variation for fluid responsiveness in patients with coronary disease. J Crit Care 2013; 28:318.e1-7. [DOI: 10.1016/j.jcrc.2012.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 09/03/2012] [Accepted: 09/07/2012] [Indexed: 01/08/2023]
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Corrected right ventricular end-diastolic volume and initial distribution volume of glucose correlate with cardiac output after cardiac surgery. J Anesth 2013; 27:512-20. [PMID: 23455772 DOI: 10.1007/s00540-013-1558-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Appropriate adjustment of cardiac preload is essential to maintain cardiac output (CO), especially in patients after cardiac surgery. This study was intended to determine whether index of right ventricular end-diastolic volume (RVEDVI), corrected RVEDVI using ejection fraction (cRVEDVI), index of initial distribution volume of glucose (IDVGI), or cardiac filling pressures are correlated with cardiac index (CI) following cardiac surgery in the presence or absence of arrhythmias. METHODS Eighty-six consecutive cardiac surgical patients were studied. Patients were divided into two groups: the non-arrhythmia (NA) group (n = 72) and the arrhythmia (A) group (n = 14). Three sets of measurements were performed: on admission to the ICU and daily on the first 2 postoperative days. The relationship between each cardiac preload variable and cardiac index (CI) was evaluated. A p value less than 0.05 indicated statistically significant differences. RESULTS Each studied variable was not different between the two groups immediately after admission to the ICU. cRVEDVI had a linear correlation with CI in both group (NA group: r = 0.67, n = 216, p < 0.001; A group: r = 0.77, n = 42, p < 0.001), but RVEDVI had a poor correlation with CI (NA group: r = 0.27, n = 216, p < 0.001; A group: r = 0.19, n = 42, p = 0.036). IDVGI had a linear correlation with CI (NA group: r = 0.49, n = 216, p < 0.001; A group: r = 0.61, n = 42, p < 0.001), Cardiac filling pressures had no correlation with CI. CONCLUSION Our results demonstrated that cRVEDVI and IDVGI were correlated with CI in the presence or absence of arrhythmias. cRVEDVI and IDVGI have potential as indirect cardiac preload markers following cardiac surgery.
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Su BC, Tsai YF, Cheng CW, Yu HP, Yang MW, Lee WC, Lin CC. Stroke volume variation derived by arterial pulse contour analysis is a good indicator for preload estimation during liver transplantation. Transplant Proc 2012; 44:429-32. [PMID: 22410035 DOI: 10.1016/j.transproceed.2011.12.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Accurate determination of preload during liver transplantation is essential. Continuous right ventricular end diastolic volume index (RVEDVI) has been shown to be a better preload indicator during liver transplantation than the filling pressures. However, recent evidence has shown that dynamic variables, in this case stroke volume variation (SVV), are also good indicators of preload responsiveness. In this study, we evaluated the correlation between SVV, which we derived from arterial pulse contour analysis and RVEDVI. METHODS In this study, we looked for possible relationships between SVV obtained through FloTrac/Vigileo monitor, central venous pressure (CVP), pulmonary arterial occlusion pressure (PAOP), and RVEDVI in 30 patients undergoing liver transplantation. Measurements were taken at 11 defined points during different phases across liver transplantation. Each set of measurement was taken during a steady state, which means at least 15 minutes elpased after any changes occured in either the infusion rate of catecholamines or ventilator settings. Pearson's test was used for correlation estimation. RESULTS There was a statistically significant (P<.01) relationship between SVV and RVEDVI with a correlation coefficient of -0.87. The correlations between CVP (r=0.42), PAOA (r=0.46), and RVEDVI were less strong. CONCLUSION We conclude that SVV is a good indicator for preload estimation during liver transplantation. A higher SVV value is associated with a more hypovolemic fluid status.
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Affiliation(s)
- B C Su
- Department of Anesthesia, Chang Gung Memorial Hospital-Linkou, and College of Medicine, Chang Gung University, Kwei-Shan Taoyuan, Taiwan, People's Republic of China
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Butler AL. Goal-directed therapy in small animal critical illness. Vet Clin North Am Small Anim Pract 2011; 41:817-38, vii. [PMID: 21757095 DOI: 10.1016/j.cvsm.2011.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Monitoring critically ill patients can be a daunting task even for experienced clinicians. Goal-directed therapy is a technique involving intensive monitoring and aggressive management of hemodynamics in patients with high risk of morbidity and mortality. The aim of goal-directed therapy is to ensure adequate tissue oxygenation and survival. This article reviews commonly used diagnostics in critical care medicine and what the information gathered signifies and discusses clinical decision making on the basis of diagnostic test results. One example is early goal-directed therapy for severe sepsis and septic shock. The components and application of goals in early goal-directed therapy are discussed.
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Affiliation(s)
- Amy L Butler
- Veterinary Referral and Emergency Center, 318 Northern Boulevard, Clarks Summit, PA 18411, USA.
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22
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Habicher M, Perrino A, Spies CD, von Heymann C, Wittkowski U, Sander M. Contemporary fluid management in cardiac anesthesia. J Cardiothorac Vasc Anesth 2010; 25:1141-53. [PMID: 20947379 DOI: 10.1053/j.jvca.2010.07.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Marit Habicher
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Mukkamala R, Xu D. Continuous and less invasive central hemodynamic monitoring by blood pressure waveform analysis. Am J Physiol Heart Circ Physiol 2010; 299:H584-99. [PMID: 20622106 PMCID: PMC2944477 DOI: 10.1152/ajpheart.00303.2010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 07/05/2010] [Indexed: 12/24/2022]
Abstract
Blood pressure waveform analysis may permit continuous (i.e., automated) and less invasive (i.e., safer and simpler) central hemodynamic monitoring in the intensive care unit and other clinical settings without requiring any instrumentation beyond what is already in use or available. This practical approach has been a topic of intense investigation for decades and may garner even more interest henceforth due to the evolving demographics as well as recent trends in clinical hemodynamic monitoring. Here, we review techniques that have appeared in the literature for mathematically estimating clinically significant central hemodynamic variables, such as cardiac output, from different blood pressure waveforms. We begin by providing the rationale for pursuing such techniques. We then summarize earlier techniques and thereafter overview recent techniques by our collaborators and us in greater depth while pinpointing both their strengths and weaknesses. We conclude with suggestions for future research directions in the field and a description of some potential clinical applications of the techniques.
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Affiliation(s)
- Ramakrishna Mukkamala
- Department of Electrical and Computer Engineering, Michigan State University, East Lansing, Michigan 48824-1226, USA.
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Abstract
This article focuses on static methods for determining preload, specifically pressure and volumetric indices measured at the bedside. The underlying ventricular function will determine where the patient is located on Frank-Starling ventricular function curve and the patient's response to a fluid challenge. The proper interpretation and use of such measures, coupled with an understanding of their limitations and knowledge of alternative methods, is necessary to guide properly volume resuscitation in the critically ill.
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Cannesson M, Desebbe O, Piriou V, Lehot JJ. Monitorage continu et automatisé de la précharge dépendance en anesthésie et en réanimation : intérêts et limites. ACTA ACUST UNITED AC 2010; 29:452-63. [DOI: 10.1016/j.annfar.2010.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 03/04/2010] [Indexed: 10/19/2022]
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Hein M, Roehl AB, Baumert JH, Rossaint R, Steendijk P. Continuous right ventricular volumetry by fast-response thermodilution during right ventricular ischemia: Head-to-head comparison with conductance catheter measurements*. Crit Care Med 2009; 37:2962-7. [DOI: 10.1097/ccm.0b013e3181b027a5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Continuous right ventricular end-diastolic volume in comparison with left ventricular end-diastolic area. Eur J Anaesthesiol 2009; 26:272-8. [PMID: 19276913 DOI: 10.1097/eja.0b013e328319be8e] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Intraoperative management of patients with end-stage liver disease undergoing liver transplantation requires fluid administration to increase cardiac output and oxygen delivery to the tissues. Filling pressures have been widely shown to correlate poorly with changes in cardiac output in the critically ill patient. Continuous right ventricular end-diastolic volume index (cRVEDVI) and left ventricular end-diastolic area index (LVEDAI) monitoring have been increasingly used for preload assessment. The aim of this study was to compare cRVEDVI, LVEDAI, central venous pressure and pulmonary artery occlusion pressure with respect to stroke volume index (SVI) during liver transplantation. METHODS Measurements were made in 20 patients at four predefined steps during liver transplantation. Univariate and multivariate panel-data fixed effect regression models (across phases of the surgical procedure) were fitted to assess associations between SVI and cRVEDVI, pulmonary artery occlusion pressure, central venous pressure and LVEDAI after adjusting for ejection fraction (categorized as <or=30, 31-40, >40). RESULTS SVI was associated with continuous right ventricular ejection fraction. The model showing the best fit to the data was that including cRVEDVI: even after adjusting for continuous right ventricular ejection fraction and phase, the regression coefficient of cRVEDVI in predicting SVI was statistically significant and indicated an increase in SVI of 0.21 ml m(-2) for each increase of 1 ml m(-2). At the multivariate analysis, an increase in LVEDAI of 1 cm m(-2) led to an increase in SVI of 1.47 ml m(-2) (P = 0.054). CONCLUSION cRVEDVI and LVEDAI gave a better reflection of preload than filling pressure, even if only cRVEDVI reached statistical significance.
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Breukers RMBGE, Trof RJ, Groeneveld ABJ. Cardiac Filling Volumes and Pressures in Assessing Preload Responsiveness during Fluid Challenges. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Update on preload indexes: More volume than pressure. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sankoff J, Zidulka A. Non-invasive method for the rapid assessment of central venous pressure: description and validation by a single examiner. West J Emerg Med 2008; 9:201-5. [PMID: 19561745 PMCID: PMC2672285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 07/04/2008] [Accepted: 07/14/2008] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study describes a means of assessing the external jugular venous pressure (JVP) as an indicator of normal or elevated central venous pressure (CVP). METHODS Intensive care unit patients having CVP monitoring were examined. With patients in bed, the external jugular vein (EJV) was occluded at the base of the neck and observed to distend. The occlusion was then removed and the vein observed for collapse. Complete collapse was hypothesized to indicate a non-elevated CVP (</=8cm of water). In those patients whose EJV collapsed incompletely, the vein was then occluded with the finger near the angle of the jaw. With the occlusion maintained, the vein was milked downwards with the other hand to cause its emptying and was then observed for filling from below. Filling from below was hypothesized to indicate an elevated CVP (>8cm of water). RESULTS In 12 of the 40 patients examined, the EJV could not be assessed (EJV not seen at all: 5, and difficult to visualize: 7). For the remaining 28 patients 11 had a CVP > 8 cm, while 17 had a CVP patients, of </= 8. EJV assessment was 100% accurate (95% Confidence Interval 88-100) in predicting whether or not a patient's CVP was greater or less than 8 cm of water. CONCLUSION EJV assessment, when visible, is accurate to clinically assess a patient's CVP in the hands of the author. Further studies are needed to see if they are reproducible by other observer.
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Affiliation(s)
- Jeffrey Sankoff
- University of Colorado School of Medicine, Division of Emergency Medicine, Department of Surgery,Address for Correspondence: Jeffrey Sankoff MD. Division of Emergency Medicine, Department of Surgery, University of Colorado School of Medicine, Leprino Office Building, 7th Floor, 12401 E. 17th Avenue, B-215, Aurora, CO 80045.
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Hein M, Baumert JH, Roehl AB, Pasch L, Schnoor J, Coburn M, Rossaint R. Xenon alters right ventricular function. Acta Anaesthesiol Scand 2008; 52:1056-63. [PMID: 18840104 DOI: 10.1111/j.1399-6576.2008.01696.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In contrast to other volatile anesthetics, xenon produces less cardiovascular depression with fewer fluctuations of various hemodynamic parameters, but reduces cardiac output (CO) in vivo. Besides an increase in left ventricular afterload and reduction of heart rate, an impairment of the right ventricular function might be an additional pathophysiological mechanism for the reduction of CO. Therefore, we used an animal model to study the effects of xenon as a supplemental anesthetic on right ventricular function, especially right ventricular afterload. METHODS Right ventricular function was monitored with a volumetric pulmonary artery catheter in 11 pigs during general anesthesia with thiopental. Six animals received additional 70% (volume) xenon (equivalent to 0.55 MAC minimum alveolar concentration). Parameters for systolic function, afterload, and preload were calculated at baseline and during 50 min of xenon application, and in a corresponding control group. Significant differences were detected by multivariate analyses of variance for repeated measures. RESULTS Xenon reduced CO on average by 30% and increased pulmonary arterial elastance by 60%, which led to a reduction of the right ventricular ejection fraction by 25%. Whereas right ventricular preload remained stable, maximal slope of pulmonary artery pressure and the right ventricular elastance increased. No effect on the ratio of stroke work and end-diastolic volume was found. CONCLUSION The reduction in CO during xenon anesthesia was partly due to an impairment of the right ventricular function, mainly caused by an increased afterload, without an impairment of systolic ventricular function.
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Affiliation(s)
- M Hein
- Department of Anesthesiology, University Hospital of Aken, Aachen, Germany.
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Rocca GD, Costa MG, Feltracco P, Biancofiore G, Begliomini B, Taddei S, Coccia C, Pompei L, Di Marco P, Pietropaoli P. Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study. Liver Transpl 2008; 14:327-32. [PMID: 18306366 DOI: 10.1002/lt.21288] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as < or =30, 31-40, and >40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.
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Affiliation(s)
- Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University of Udine, Azienda Ospedaliera Universitaria, Udine, Italy.
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Sturgess DJ, Joyce C, Marwick TH, Venkatesh B. A clinician's guide to predicting fluid responsiveness in critical illness: applied physiology and research methodology. Anaesth Intensive Care 2007; 35:669-78. [PMID: 17933152 DOI: 10.1177/0310057x0703500504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. In this way it might be possible to avoid unnecessary volume replacement in critically ill patients. Cardiac preload is a concept that accounts for the relationship between ventricular filling and stroke volume. It has been challenging to apply this concept to clinical practice. For this reason, the study of fluid responsiveness is of increasing research and clinical interest. The clinical application of predicting fluid responsiveness requires an understanding of relevant physiological principles. Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the cutrent literature will be considered.
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Affiliation(s)
- D J Sturgess
- School of Medicine, University of Queensland, Princess Alexandra Hospital, Wolloongabba, Queensland, Australia
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Robin E, Costecalde M, Lebuffe G, Vallet B. Clinical relevance of data from the pulmonary artery catheter. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10 Suppl 3:S3. [PMID: 17164015 PMCID: PMC3226125 DOI: 10.1186/cc4830] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The usefulness of parameters measured using the pulmonary artery catheter has been challenged because no benefit in patient outcome has been observed in clinical trials. However, technological advances have been made, including continuous measurement of cardiac output (CO), mixed venous saturation (SvO2), and right ventricle end-diastolic volume (CEDV) have been made. Pulmonary artery occlusion pressure (PAOP), CEDV and right atrial pressure (RAP) are not good predictors of fluid load responsiveness except when very low. Despite this methodological limitation, variation of these parameters during fluid loading remains a good indicator of fluid challenge tolerance. Accuracy of continuous thermodilution and SvO2 measurement has been demonstrated in vitro and at bedside. A decrease in SvO2 is a global index of an inadequate oxygen delivery (DO2)/oxygen requirement relationship. In this setting, a therapeutic decision to improve determinants of SvO2 should be considered with the help of all other PAC parameters. Technological improvement transforms PAC in a real time integrated physiological device and allows one to observe the impact of therapeutic intervention. What we need now is a clinical trial with a PAC-guided treatment algorithm taking into account the above integrated PAC parameters.
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Affiliation(s)
- Emmanuel Robin
- Department of Anesthesiology and Critical Care, University Hospital, Lille, France.
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Spöhr F, Hettrich P, Bauer H, Haas U, Martin E, Böttiger BW. Comparison of two methods for enhanced continuous circulatory monitoring in patients with septic shock. Intensive Care Med 2007; 33:1805-10. [PMID: 17549452 DOI: 10.1007/s00134-007-0703-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 04/19/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare a modified pulmonary artery catheter (PAC) and pulse-contour analysis by the PiCCO (Pulsion Medical Systems, Munich, Germany) system for continuous assessment of cardiac output in patients with septic shock. In addition, to assess the relationships between an index of global end-diastolic volume (GEDV) derived by the PiCCO system with traditional PAC-derived indicators of filling: central venous pressure; pulmonary artery occlusion pressure; and right ventricular end-diastolic volume (RVEDV). DESIGN Prospective cohort study. SETTING Surgical intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS 14 patients with septic shock. INTERVENTIONS None. MEASUREMENTS AND RESULTS A significant correlation was found between continuous cardiac output by PAC (CCO(PAC)) and by pulse-contour analysis (r (2) = 0.714, p < 0.0001), accompanied by a bias of 0.1 l min(-1) and a precision of 2.7 l min(-1). The correlation between CCO(PAC) and cardiac output measured by transcardiopulmonary thermodilution was also significant (r (2) = 0.781, p < 0.0001). There was a bias for the two methods of 0.2 l min(-1), and a precision of 2.2 lmin(-1). The GEDV showed no correlation with central venous pressure, pulmonary artery occlusion pressure, or RVEDV. CONCLUSION In patients with septic shock, the averaged bias in continuous measurement of cardiac output by both a modified pulmonary artery catheter and pulse-contour analysis was small, but variability was large. No correlation was found between GEDV and RVEDV. The clinical importance of different cardiac filling parameters needs further investigation.
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Affiliation(s)
- F Spöhr
- Department of Anaesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Santamore WP, Gefen N, Avramovich A, Berger P, Kashem A, Barnea O. Right atrial effects on right ventricular ejection fraction derived from thermodilution measurements. J Cardiothorac Vasc Anesth 2007; 21:644-9. [PMID: 17905267 DOI: 10.1053/j.jvca.2007.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The thermodilution technique provides a convenient means to monitor cardiac output, right ventricular (RV) ejection fraction (EF), and volumes at the bedside. To calculate RVEF from the pulmonary artery temperature curve, the bolus thermodilution technique assumes that right atrial (RA) temperature returns to baseline value within 1 beat following the cold saline injection. The authors hypothesized that this assumption is the reason why the thermodilution technique consistently underestimates RVEF. DESIGN A theoretical analysis and animal study. SETTING Laboratory, university, multi-institutional. PARTICIPANTS Animals. INTERVENTIONS Cold saline injections. MEASUREMENTS AND MAIN RESULTS In 2 porcine experiments, after a rapid injection of cold saline into right atrium, RA temperature took several heartbeats to return to baseline. In a theoretical analysis, if after the cold saline injection RA temperature returned to baseline in 1 beat (RAEF = 1), then thermodilution-derived RVEF(T) = actual RVEF(A). In contrast, if RA temperature took several beats to return to baseline (RAEF = RVEF), then RVEF(T) consistently underestimated RVEF(A). A least square fit of RVEF(A) versus RVEF(T) resulted in RVEF(A) = 1.0 x RVEF(T) + 0.11. Applying this correction (adding 0.11 to RVEF(T)) to the data gave relatively small errors in estimating RVEF over a wide EF range. CONCLUSIONS After injecting cold saline into the right atrium, RA temperature takes several heart beats to return to baseline temperature, leading to underestimating RVEF and overestimating RV volumes. The pulsed thermal energy approach by injecting heat into the RV avoids these problems, but the impact of its small temperature signal on RVEF measurements needs to be determined.
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Affiliation(s)
- William P Santamore
- Department of Physiology, Division of Cardiovascular Research, Temple University, Philadelphia, PA 19140, USA.
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Lee JY, Bang SO, Shim JK, Lee JH, Won YJ, Kwak YL. Does Predictors of Preload Measured from Continuous Right Ventricular End-diastolic Volume Index Monitored Pulmonary Artery Catheter Reflect Stroke Volume Index in Off Pump Coronary Artery Bypass? Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.2.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sou Ouk Bang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hwa Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ju Won
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Gatheral T, Bennett ED. Year in review 2005: critical care--cardiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:225. [PMID: 16919175 PMCID: PMC1751018 DOI: 10.1186/cc4983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This review summarizes key research papers published in the fields of cardiology and intensive care during 2005 in Critical Care. The papers have been grouped into categories: haemodynamic monitoring; goal-directed therapy; cardiac enzymes and critical care; metabolic considerations in cardiovascular performance; thrombosis prevention; physiology; and procedures and techniques.
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Jellema WT, Groeneveld ABJ, Wesseling KH, Thijs LG, Westerhof N, van Lieshout JJ. Heterogeneity and prediction of hemodynamic responses to dobutamine in patients with septic shock. Crit Care Med 2006; 34:2392-8. [PMID: 16849997 DOI: 10.1097/01.ccm.0000233871.52553.cd] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To establish the heterogeneity of hemodynamic responses to dobutamine in patients with septic shock and to identify the predictive factors of these hemodynamic responses. DESIGN Prospective study. SETTING AND PATIENTS A total of 12 patients with septic shock in a tertiary medical intensive care unit. INTERVENTIONS A 20-min dobutamine infusion at 5 microg.kg(-1).min(-1) with subsequent increments to 8, 12.6, and 20 microg.kg(-1).min(-1), on two consecutive days. Responses were dichotomized into changes in heart rate (HR) or stroke volume index (SVI) of >10% and < or =10% at the maximal dobutamine infusion. MEASUREMENTS AND MAIN RESULTS No differences were found in survival, Acute Physiology and Chronic Health Evaluation II score, maximal dobutamine doses, or pharmacokinetics of dobutamine between HR and SVI groups. In DeltaHR > 10% vs. DeltaHR < or = 10%, baseline HR was lower, and baseline mixed venous oxygen tension and saturation were higher. During dobutamine infusion, mean arterial pressure decreased in DeltaHR > 10%. Cardiac index and the systemic oxygen delivery index increased and the systemic vascular resistance index decreased at unchanged SVI. Pressure work index increased and the ratio of the diastolic to systolic aortic pressure time indices decreased but not to <0.6. In DeltaHR < or = 10%, systemic vascular resistance index and the ratio of the diastolic to systolic aortic pressure time indices decreased (but remained >0.6) without changes in SVI or cardiac index. Baseline hemodynamic and metabolic variables did not differ between SVI groups. In DeltaSVI > 10%, cardiac index increased with dobutamine, but Pao2 and the systemic oxygen delivery index decreased. In DeltaSVI < or = 10%, HR and the systemic oxygen delivery index increased; mean arterial pressure, left ventricular stroke work index, systemic vascular resistance index, and the ratio of the diastolic to systolic aortic pressure time indices decreased. CONCLUSIONS Patients with a positive chronotropic response to dobutamine had lower baseline HR values, and a chronotropic rather than inotropic response predicted an increase in cardiac index and systemic oxygen delivery index. Incremental dosages of dobutamine did not compromise indirectly measured myocardial oxygen balance.
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Affiliation(s)
- Wilbert T Jellema
- Cardiovascular Research Institute Amsterdam, the Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
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Headley JM. Arterial pressure-based technologies: a new trend in cardiac output monitoring. Crit Care Nurs Clin North Am 2006; 18:179-87, x. [PMID: 16728303 DOI: 10.1016/j.ccell.2006.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
New trends in cardiovascular monitoring use the arterial pulse as a less invasive means of assessing cardiac output. When adopting a new technology into practice, three questions need to be answered: (1) is the method technologically sound?, (2) is it based on physiologic principles?, and (3) are the applications clinically important? This article provides a clinical review on the technology, physiology, and applications of a new arterial pressure-based method of determining cardiac output and stroke volume variation as an additional parameter for fluid status assessment.
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Affiliation(s)
- Jan M Headley
- Edwards Lifesciences LLC, One Edwards Way, Irvine, CA 91264, USA.
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Sablotzki A, Starzmann W, Scheubel R, Grond S, Czeslick EG. Selective pulmonary vasodilation with inhaled aerosolized milrinone in heart transplant candidates. Can J Anaesth 2006; 52:1076-82. [PMID: 16326679 DOI: 10.1007/bf03021608] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Selective pulmonary vasodilation is an advantageous method for testing the responsiveness of the pulmonary vasculature of heart transplant candidates. A pilot study was under-taken to test the hypothesis that inhaled aerosolized milrinone may cause selective pulmonary vasodilation. METHODS 18 consecutive male heart transplant candidates with either dilated or ischemic cardiomyopathy were included in this open clinical study. Nine of the patients had significant pulmonary hypertension with a mean pulmonary arterial pressure > 30 mmHg. After baseline measurements, 2 mg of milrinone was administered by ultrasonic nebulization. Pulmonary and systemic hemodynamics were measured ten, 30, and 60 min after inhalation. RESULTS After inhalation for ten minutes, milrinone induced a significant reduction of mean pulmonary arterial pressure (32.7 +/- 9.1 vs 37.7 +/- 7.5 mmHg, P = 0.01), pulmonary vascular resistance index (296 +/- 150 vs 396 +/- 151 dyn.sec(-1).cm(-5).m(2), P = 0.02) and transpulmonary gradient (10.6 +/- 5.5 vs 15 +/- 4.9, P = 0.01) only in patients with significant pulmonary hypertension. There was no significant effect on mean arterial pressure or systemic vascular resistance at any time after inhalation in either group. Furthermore, there was no influence on extravascular lung water or intrathoracic blood volume. CONCLUSIONS We conclude that inhaled aerosolized milrinone for a short period selectively dilates the pulmonary vasculature in heart transplant candidates with elevated pulmonary arterial pressure, without producing systemic side effects. Further comparative studies are necessary to evaluate possible advantages of milrinone compared to other inhaled vasodilators.
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Affiliation(s)
- Armin Sablotzki
- Clinic of Anesthesiology and Intensive Care Medicine, Martin-Luther-University of Halle-Wittenberg, Halle, Germany.
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Sablotzki A, Hentschel T, Hofmann S, Simm A, Mühling J, Czeslick E. Inhaled aerosolized iloprost in the evaluation of heart transplant candidates—experiences with 45 cases. J Clin Anesth 2006; 18:108-13. [PMID: 16563327 DOI: 10.1016/j.jclinane.2005.08.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Accepted: 08/11/2005] [Indexed: 11/19/2022]
Abstract
PURPOSE Pulmonary hypertension represents a significant predictor of postoperative right heart insufficiency and increased mortality in patients undergoing orthotopic heart transplantation. As the use of intravenous vasodilators is limited by their systemic effects, we evaluated the pulmonary and systemic hemodynamic effects of inhaled aerosolized iloprost in heart transplant candidates with elevated pulmonary vascular resistance. METHODS Forty-five male heart transplant candidates with dilated or ischemic cardiomyopathy were included in the study. After assessing baseline hemodynamics, 20 microg of aerosolized iloprost was administered by ultrasonic inhalation. All patients were breathing spontaneously. RESULTS Inhalation of iloprost reduced pulmonary vascular resistance index (395 +/- 205 vs 327 +/- 222 dyne.s.cm(-5).m(-2); P < 0.05) and mean pulmonary arterial pressure (28.7 +/- 10 vs 24.3 +/- 10 mm Hg; P < 0.05). An additional improvement of ventricular performance with an increase of cardiac index (2.7 +/- 0.7 vs 3.0 +/- 0.8 L.min(-1).m(-2); P < 0.05) and a decrease of pulmonary capillary wedge pressure (16.6 +/- 7.7 vs 13.4 +/- 7.3 mm Hg; P < 0.05) was accompanied by a slight decrease of systemic vascular resistance (1280 +/- 396 vs 1172 +/- 380 dyne.s.cm(-5); P < 0.05). However, the mean arterial pressure remained uninfluenced. CONCLUSIONS Inhaled aerosolized iloprost effectively reduces mean pulmonary arterial pressure and also induces an increase in cardiac index. Further advantages of iloprost inhalation are the lack of adverse reactions and ease of administration. Iloprost represents a useful drug to screen for vascular reactivity in cardiac transplantation patients.
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Affiliation(s)
- Armin Sablotzki
- Clinic of Anesthesiology and Intensive Care Medicine, Martin-Luther-University of Halle/Wittenberg, Germany.
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