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Berboth L, Zirngast B, Manninger M, Steendijk P, Tschöpe C, Scherr D, Hinghofer-Szalkay HG, Goswami N, Petersen LG, Mächler H, Alogna A. Graded lower body negative pressure induces intraventricular negative pressures and incremental diastolic suction: a pressure volume study in a porcine model. J Appl Physiol (1985) 2022; 133:20-26. [PMID: 35546125 DOI: 10.1152/japplphysiol.00110.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lower body negative pressure (LBNP) has been a tool to study compensatory mechanisms to central hypovolemia for decades. However, underlying hemodynamic mechanisms were mostly assessed non-invasively and remain unclear. We hypothesized that incremental LBNP reduces diastolic filling and thereby affects left ventricular (LV) diastolic suction (DS). Here, we investigated the impact of graded LBNP at 3 different levels of seal as well as during beta-adrenergic stimulation by invasive pressure-volume (PV) analysis. Eight Landrace pigs were instrumented closed-chest for PV assessment. LBNP was applied at three consecutive locations: I) cranial, 10cm below xiphoid process; II) medial, half-way between cranial and caudal; III) caudal, at the iliac spine. Level III) was repeated under dobutamine infusion. At each level, baseline measurements were followed by application of incremental LBNP of -15, -30 and -45 mmHg. LBNP induced varying degrees of preload-dependent hemodynamic changes, with cranial LBNP inducing more pronounced effects than caudal. According to the Frank-Starling mechanism, graded LBNP progressively reduced LV stroke volume (LV SV) following a decrease in LV end-diastolic volume. Negative intraventricular minimal pressures were observed during dobutamine-infusion as well as higher levels of LBNP. Of note, incremental LV negative pressures were accompanied by increasing DS volumes, derived by extrapolating the volume at zero transmural pressure, the so-called equilibrium volume (V0), related to LV SV. In conclusion, graded preload reduction shifts the PV loop to smaller volumes and end-systolic volume below V0, which induces negative LV pressures and increases LV suction. Accordingly, LBNP induced central hypovolemia is associated with increased DS.
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Affiliation(s)
- Leonhard Berboth
- Department of Internal Medicine and Cardiology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Zirngast
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Martin Manninger
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Paul Steendijk
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Scherr
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | | | - Nandu Goswami
- Institute of Physiology, Medical University of Graz, Graz, Austria, Austria
| | - Lonnie G Petersen
- Department of Radiology, University of California, San Diego, La Jolla, CA, United States.,Mechanical and Aerospace Engineering, University of California, San Diego, La Jolla, CA, United States
| | - Heinrich Mächler
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Charité, Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
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Schulz L, Geri G, Vieillard‐Baron A, Vignon P, Parkin G, Aneman A. Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study. Acta Anaesthesiol Scand 2021; 65:320-328. [PMID: 33169357 DOI: 10.1111/aas.13735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best strategy to identify patients in whom fluid loading increases cardiac output (CO) following cardiac surgery remains debated. This study examined the utility of a calculated mean systemic filling pressure analogue (Pmsa ) and derived variables to explain the response to a fluid bolus. METHODS The Pmsa was calculated using retrospective, observational cohort data in the early postoperative period between admission to the intensive care unit and extubation within 6 hours. The venous return pressure gradient (VRdP) was calculated as Pmsa - central venous pressure. Concurrent changes induced by a fluid bolus in the ratio of the VRdP over Pmsa , the volume efficiency (Evol ), were studied to assess fluid responsiveness. Changes between Pmsa and derived variables and CO were analysed by Wilcoxon rank-sum test, hierarchial clustering and multiple linear regression. RESULTS Data were analysed for 235 patients who received 489 fluid boluses. The Pmsa increased with consecutive fluid boluses (median difference [range] 1.3 [0.5-2.4] mm Hg, P = .03) with a corresponding increase in VRdP (median difference 0.4 [0.2-0.6] mm Hg, P = .04). Hierarchical cluster analysis only identified Evol and the change in CO within one cluster. The multiple linear regression between Pmsa and its derived variables and the change in CO (overall r2 = .48, P < .001) demonstrated the best partial regression between the continuous change in CO and the concurrent Evol (r = .55, P < .001). CONCLUSION The mean systemic filling Pmsa enabled a comprehensive interpretation of fluid responsiveness with volume efficiency useful to explain the change in CO as a continuous phenomenon.
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Affiliation(s)
- Luis Schulz
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
| | - Guillaume Geri
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Antoine Vieillard‐Baron
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018 CESP Team 5 University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Philippe Vignon
- Medical‐surgical Intensive Care Unit Limoges University Hospital Limoges France
- INSERM CIC 1435 Limoges University Hospital Limoges France
- Faculty of Medicine University of Limoges Limoges France
| | - Geoffrey Parkin
- Intensive Care Unit Monash Medical Centre Clayton Vic. Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital South Western Sydney Local Health District Liverpool NSW Australia
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney NSW Australia
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Schulz LF, Geri G, Vieillard‐Baron A, Vignon P, Parkin G, Aneman A. Assessment of volume status and volume responsiveness in the ICU: Protocol for an observational, multicentre cohort study. Acta Anaesthesiol Scand 2019; 63:1102-1108. [PMID: 31119723 DOI: 10.1111/aas.13385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Expansion of the intravascular compartment is common to treat haemodynamic instability in ICU patients. The most useful and accurate variables to guide and evaluate a fluid challenge remain debated and incompletely investigated resulting in significant variability in practice. The analogue mean systemic pressure has been reported as a measure of the intravascular volume state. METHODS This is a protocol and statistical analysis plan for a review of the application of an analogue of the mean systemic pressure and the use of derived variables to assess the volume state and volume responsiveness. A pulmonary artery catheter was used in 286 postoperative cardiac surgical patients to monitor cardiac output before and after a fluid bolus in addition to arterial and central venous pressures. With otherwise similar monitoring, echocardiography was used in 540 general ICU patients to determine cardiac outputs and indices related to intravascular filling. The responses to a fluid bolus or the passive leg raising manoeuvre will be investigated using continuous and dichotomous definitions of volume responsiveness. The results will be stratified according to the method of monitoring cardiac output. CONCLUSIONS This study investigating 2 cohorts that encompass a wide variety of reasons for haemodynamic instability will illustrate the applicability of the analogue mean systemic pressure and derived variables to assess the volume state and responsiveness. The results may guide the rationale and design of interventional studies.
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Affiliation(s)
- Luis F. Schulz
- Intensive Care Unit Liverpool Hospital Liverpool BC NSW Australia
| | - Guillaume Geri
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris, University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018, CESP, Team 5, University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Antoine Vieillard‐Baron
- Intensive Care Unit Assistance Publique‐Hôpitaux de Paris, University Hospital Ambroise Paré Boulogne‐Billancourt France
- INSERM U‐1018, CESP, Team 5, University of Versailles Saint‐Quentin en Yvelines Villejuif France
- Faculty of Medicine Paris Ile‐de‐France Ouest University of Versailles Saint‐Quentin en Yvelines Villejuif France
| | - Philippe Vignon
- Medical‐Surgical Intensive Care Unit Limoges University Hospital Limoges France
- INSERM CIC 1435Limoges University Hospital Limoges France
- Faculty of Medicine University of Limoges Limoges France
| | - Geoffrey Parkin
- Intensive Care Unit Monash Medical Centre Clayton VIC Australia
| | - Anders Aneman
- Intensive Care Unit Liverpool Hospital Liverpool BC NSW Australia
- Faculty of Medicine The University of New South Wales Sydney NSW Australia
- Faculty of Medicine and Health Sciences Macquarie University Sydney NSW Australia
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Tannvik TD, Rimehaug AE, Wigen MS, Løvstakken L, Kirkeby-Garstad I. Ventriculo-arterial interaction may be assessed by Oscillatory Power Fraction. Clin Physiol Funct Imaging 2019; 39:308-314. [PMID: 31038817 DOI: 10.1111/cpf.12573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/25/2019] [Indexed: 11/29/2022]
Abstract
The rate of energy transfer from the left ventricle to the aorta is viewed in terms of mean power (MP) and total power (TP). The difference between MP and TP is due to the pulsatility of the circulation and is known as oscillatory power (OP). OP is considered the energy spent to accelerate the blood flow. The aim of this study was to investigate the baseline left ventricular oscillatory power fraction (OP/TP) and how this was affected by acute cardiovascular dysfunction and altered preload. Twenty-eight patients undergoing elective coronary artery bypass graft surgery were included. Before administration of anaesthesia, we simultaneously recorded an arterial pressure curve and instantaneous cardiac outflow with pulsed wave Doppler. Postoperatively, prior to extubation, these measurements were repeated in neutral, Trendelenburg and reverse-Trendelenburg position. The final measurements were taken on the awake patient the day after the operation. TP is the mean of the instantaneous product of the flow and pressure curves. MP was calculated by multiplying mean arterial pressure with mean cardiac output. The oscillatory power fraction is therefore calculated as (TP-MP)/TP. The oscillatory power fraction in neutral position decreased from 23% preoperatively to 16% immediately postoperatively (P<0·001) and increased again to 19% the first postoperative day (P = 0·001). The oscillatory power fraction also increased from 16% in neutral to 19% in Trendelenburg (P = 0·001) and decreased comparing to neutral, to 14% in reverse-Trendelenburg (P = 0·04). The oscillatory power fraction is situation-dependent and is influenced by both the operation and the altered preload.
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Affiliation(s)
- Tomas Dybos Tannvik
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Audun Eskeland Rimehaug
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Morten Smedsrud Wigen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Lasse Løvstakken
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Anaesthesia and Intensive Care, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norges Teknisk-Naturvitenskapelige Universitet, Trondheim, Norway
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Cooke K, Sharvill R, Sondergaard S, Aneman A. Volume responsiveness assessed by passive leg raising and a fluid challenge: a critical review focused on mean systemic filling pressure. Anaesthesia 2017; 73:313-322. [DOI: 10.1111/anae.14162] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2017] [Indexed: 12/29/2022]
Affiliation(s)
- K. Cooke
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
| | - R. Sharvill
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
| | - S. Sondergaard
- Centre of Elective Surgery; Silkeborg Regional Hospital; Denmark
| | - A. Aneman
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney Australia
- Faculty of Medicine and Health Sciences; Macquarie University; Sydney NSW Australia
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