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Iizuka Y, Yoshinaga K, Amitani S, Nishiyama S, Fukano K, Miyazawa K, Kitajima A, Sawada I, Otsuka Y, Sanui M. Prediction of preload dependency using phenylephrine-induced peripheral perfusion index during general anaesthesia: a prospective observational study. BMC Anesthesiol 2024; 24:88. [PMID: 38431582 PMCID: PMC10908037 DOI: 10.1186/s12871-024-02478-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Tracking preload dependency non-invasively to maintain adequate tissue perfusion in the perioperative period can be challenging.The effect of phenylephrine on stroke volume is dependent upon preload. Changes in stroke volume induced by phenylephrine administration can be used to predict preload dependency. The change in the peripheral perfusion index derived from photoplethysmography signals reportedly corresponds with changes in stroke volume in situations such as body position changes in the operating room. Thus, the peripheral perfusion index can be used as a non-invasive potential alternative to stroke volume to predict preload dependency. Herein, we aimed to determine whether changes in perfusion index induced by the administration of phenylephrine could be used to predict preload dependency. METHODS We conducted a prospective single-centre observational study. The haemodynamic parameters and perfusion index were recorded before and 1 and 2 min after administering 0.1 mg of phenylephrine during post-induction hypotension in patients scheduled to undergo surgery. Preload dependency was defined as a stroke volume variation of ≥ 12% before phenylephrine administration at a mean arterial pressure of < 65 mmHg. Patients were divided into four groups according to total peripheral resistance and preload dependency. RESULTS Forty-two patients were included in this study. The stroke volume in patients with preload dependency (n = 23) increased after phenylephrine administration. However, phenylephrine administration did not impact the stroke volume in patients without preload dependency (n = 19). The perfusion index decreased regardless of preload dependency. The changes in the perfusion index after phenylephrine administration exhibited low accuracy for predicting preload dependency. Based on subgroup analysis, patients with high total peripheral resistance tended to exhibit increased stroke volume following phenylephrine administration, which was particularly prominent in patients with high total peripheral resistance and preload dependency. CONCLUSION The findings of the current study revealed that changes in the perfusion index induced by administering 0.1 mg of phenylephrine could not predict preload dependency. This may be attributed to the different phenylephrine-induced stroke volume patterns observed in patients according to the degree of total peripheral resistance and preload dependency. TRIAL REGISTRATION University Hospital Medical Information Network (UMIN000049994 on 9/01/2023).
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Affiliation(s)
- Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Koichi Yoshinaga
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan.
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311- 1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Shizuka Amitani
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Seiya Nishiyama
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kentaro Fukano
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Keika Miyazawa
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Asuka Kitajima
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Ikumi Sawada
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Mallat J, Lemyze M, Fischer MO. Passive leg raising test induced changes in plethysmographic variability index to assess fluid responsiveness in critically ill mechanically ventilated patients with acute circulatory failure. J Crit Care 2024; 79:154449. [PMID: 37857068 DOI: 10.1016/j.jcrc.2023.154449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/20/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Passive leg raising (PLR) reliably predicts fluid responsiveness but requires a real-time cardiac index (CI) measurement or the presence of an invasive arterial line to achieve this effect. The plethysmographic variability index (PVI), an automatic measurement of the respiratory variation of the perfusion index, is non-invasive and continuously displayed on the pulse oximeter device. We tested whether PLR-induced changes in PVI (ΔPVIPLR) could accurately predict fluid responsiveness in mechanically ventilated patients with acute circulatory failure. METHODS This was a secondary analysis of an observational prospective study. We included 29 mechanically ventilated patients with acute circulatory failure in this study. We measured PVI (Radical-7 device; Masimo Corp., Irvine, CA) and CI (Echocardiography) before and during a PLR test and before and after volume expansion of 500 mL of crystalloid solution. A volume expansion-induced increase in CI of >15% defined fluid responsiveness. To investigate whether ΔPVIPLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and gray zones for ΔPVIPLR. RESULTS Of the 29 patients, 27 (93.1%) received norepinephrine. The median tidal volume was 7.0 [IQR: 6.6-7.6] mL/kg ideal body weight. Nineteen patients (65.5%) were classified as fluid responders (increase in CI > 15% after volume expansion). Relative ΔPVIPLR accurately predicted fluid responsiveness with an AUROC of 0.89 (95%CI: 0.72-0.98, p < 0.001). A decrease in PVI ≤ -24.1% induced by PLR detected fluid responsiveness with a sensitivity of 95% (95%CI: 74-100%) and a specificity of 80% (95%CI: 44-97%). Gray zone was acceptable, including 13.8% of patients. The correlations between the relative ΔPVIPLR and changes in CI induced by PLR and by volume expansion were significant (r = -0.58, p < 0.001, and r = -0.65, p < 0.001; respectively). CONCLUSIONS In sedated and mechanically ventilated ICU patients with acute circulatory failure, PLR-induced changes in PVI accurately predict fluid responsiveness with an acceptable gray zone. TRIAL REGISTRATION ClinicalTrials.govNCT03225378.
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Affiliation(s)
- Jihad Mallat
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Malcolm Lemyze
- Department of Critical Care Medicine, Arras Hospital, 6200 Arras, France
| | - Marc-Olivier Fischer
- Institut Aquitain du Cœur, Clinique Saint Augustin, ELSAN, 114 Avenue d'Arès, 33 074 Bordeaux Cedex, France
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Kim H, Lee S, Koh WU, Cho J, Park SW, Kim KS, Ro YJ, Kim HJ. Norepinephrine prevents hypotension in older patients under spinal anesthesia with intravenous propofol sedation: a randomized controlled trial. Sci Rep 2023; 13:21009. [PMID: 38030738 PMCID: PMC10686984 DOI: 10.1038/s41598-023-48178-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023] Open
Abstract
Reducing hypotension is crucial as hypotension is the most common side effect of spinal anesthesia, and in older patients with various comorbidities, it can lead to fatality. We hypothesized that continuous infusion of norepinephrine could effectively prevent hypotension in older patients undergoing hip surgery under spinal anesthesia with propofol sedation. The study randomly assigned patients aged ≥ 70 years to either a control (Group C, n = 35) or a norepinephrine group (Group N, n = 35). After spinal anesthesia, continuous infusion of propofol and normal saline or norepinephrine was initiated. The number of hypotensive episodes, the primary outcome, as well as other intraoperative hemodynamic events and postoperative complications were compared. In total, 67 patients were included in the final analysis. The number of hypotensive episodes was significantly higher in Group C than in Group N (p < 0.001). Furthermore, Group C required a greater amount of fluid to maintain normovolemia (p = 0.008) and showed less urine output (p = 0.019). However, there was no difference in postoperative complications between the two groups. Continuous intravenous infusion of prophylactic norepinephrine prevented hypotensive episodes, reduced the requirement of fluid, and increased the urine output in older patients undergoing unilateral hip surgery under spinal anesthesia with propofol sedation.Clinical trial registration number: KCT0005046 ( https://cris.nih.go.kr ). IRB number: 2020-0533 (Institutional Review Board of Asan Medical Center, approval date: 13/APR/2020).
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Affiliation(s)
- Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sooho Lee
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary's Hospital, Incheon, Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jooyeon Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sung Wook Park
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Keon Sik Kim
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Young-Jin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Kim YJ, Seo JH, Lee HC, Kim HS. Pleth variability index during preoxygenation could predict anesthesia-induced hypotension: A prospective, observational study. J Clin Anesth 2023; 90:111236. [PMID: 37639751 DOI: 10.1016/j.jclinane.2023.111236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/10/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
STUDY OBJECTIVE To determine whether changes in the pleth variability index (PVi) during preoxygenation with forced ventilation for 1 min could predict anesthesia-induced hypotension. DESIGN Prospective, observational study. SETTING A tertiary teaching hospital. PATIENTS Ninety-six patients who underwent general anesthesia using total intravenous anesthesia were enrolled. INTERVENTIONS Upon the patient's arrival at the preoperative waiting area, a PVi sensor was affixed to their fourth fingertip. For preoxygenation, forced ventilation of 8 breaths/min in a 1:2 inspiratory-expiratory ratio was conducted using the guidance of an audio file. One minute after preoxygenation, anesthetic administration was initiated. Blood pressure was measured for the next 15 min. MEASUREMENTS We calculated the difference (dPVi) and percentage of change (%PVi) between the PVi values immediately before and after forced ventilation. Anesthesia-induced hypotension was defined as a mean arterial pressure of <60 mmHg within 15 min after the infusion of anesthetics. MAIN RESULTS Overall, 87 patients were included in the final analysis. Anesthesia-induced hypotension occurred in 31 (35.6%) of the 87 patients. Receiver operating characteristic curve analyses identified a cut-off value of -2 for dPVi, with an area under the curve of 0.691 (95% confidence interval [CI], 0.564-0.818; P < 0.001) and a cut-off value of -7.6% for %PVi, with an area under the curve of 0.711 (95% CI, 0.589-0.832; P < 0.001). Further, multivariate logistic regression analysis showed that a low %PVi with an odds ratio of 9.856 (95% CI, 3.131-31.032; P < 0.001) was a significant determinant of anesthesia-induced hypotension. CONCLUSIONS Hypotension frequently occurs during general anesthesia induction and can impact outcomes. Additionally, the percentage change in the PVi before and after preoxygenation using deep breathing can be used to predict anesthesia-induced hypotension.
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Affiliation(s)
- Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, 03080 Seoul, South Korea.
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Zhuang C, Yang R, Xu Y, Song Y, Zhang Y, Liu J, Yang F, Huang X, Liu J, Wang X, Wang Y, Wang L. The Safety Assessment of Irrigation Fluid Management for Shoulder Arthroscopy and Its Effect on Postoperative Efficacy. Orthop Surg 2023; 15:2016-2024. [PMID: 36573289 PMCID: PMC10432476 DOI: 10.1111/os.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE Fluid extravasation is a potentially dangerous complication associated with shoulder arthroscopy. Most relevant studies have involved respiratory system, while the primary purpose was to reveal the effects of the fluid extravasation on cardiovascular system and postoperative function. METHODS The clinical data of 92 patients was retrospective analyzed, in which 84 cases with rotator cuff injury, three cases with shoulder instability, three cases with fractures of the greater tuberosity of the humerus, and two cases with frozen shoulder. All the patients were undergoing shoulder arthroscopy. The relationship between the basic information of the patients and cardiac index (CI) or pulse pressure variation (PPV) were evaluated by linear regression analysis. The change of CI or PPV at different states were evaluated by the one-way analysis of variance. The liquid retention (TR) and postoperative clinical outcomes was analyzed using linear regression. RESULTS The preoperative CI was affected by anesthesia status and body position, while PPV was not affected. Multivariate mixed-effects model analysis of CI found that there was a statistically significant difference in groups of older than 55 years old and those with obesity (BMI > 24). After the operation, the retention of irrigation fluid significantly influenced the circumference of the deltoid (P < 0.001 (95%CI: [0.30, 1.00])), but not on the circumference of the deltoid, neck, and arm. The multivariate analysis of the American Shoulder and Elbow Surgery (ASES) scores at 3 and 6 months after surgery showed that the fluid retention volume was correlated with the ASES score at 3 months after surgery, especially when the retention volume was greater than 2 L (P = 0.001 (95%). %CI: [-12.49, -3.22]). CONCLUSION The retention of irrigation fluid after shoulder arthroscopic surgery causes swelling of local limbs, and has an effect on peripheral blood vessels, which is mainly reflected in its influence on PPV and the postoperative function. Therefore, surgeons need to improve their surgical technique, shorten the operation time and reduce fluid retention.
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Affiliation(s)
- Chengyu Zhuang
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Renhao Yang
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yang Xu
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yanyan Song
- Department of Biostatistics, Clinical Research InstituteShanghai JiaoTong University School of medicineShanghaiChina
| | - Yin Zhang
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jingfeng Liu
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Fan Yang
- Department of Anesthesiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaohong Huang
- Department of Operating Room, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jia Liu
- Department of Operating Room, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaoning Wang
- Department of Operating Room, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ying Wang
- Department of Anesthesiology, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lei Wang
- Department of Orthopedics, Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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Zhao TYM, Chen D, Xu ZX, Wang HL, Sun H. Comparison of bispectral index and patient state index as measures of sedation depth during surgeries using remimazolam tosilate. BMC Anesthesiol 2023; 23:208. [PMID: 37322424 PMCID: PMC10268360 DOI: 10.1186/s12871-023-02172-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 06/09/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The Bispectral Index (BIS) and the Patient State Index (PSI) are commonly used measures to assess intraoperative sedation depth. However, model differences lead to different results, which in turn interferes with clinicians' judgment on the depth of anesthesia. Remimazolam tosilate (RT) for injection is a new benzodiazepine used in sedation. In its clinical application, there are few effective indicators for sedation depth monitoring. To close this gap, this study aims to compare BIS and PSI in measuring the sensitivity and specificity of intraoperative RT and to explore the safety of RT for intraspinal anesthesia in elderly patients. METHODS This study included 40 patients undergoing elective electro-prostatectomy with intraspinal anesthesia, who were monitored by BIS and PSI simultaneously during operation. Remimazolam tosylate 0.1 mg/kg was intravenously administered after the intraspinal anesthesia when patients were in a completely painless status. Then BIS, PSI, the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scores and vital signs were observed and recorded per minute for 10 min. Pearson's correlation analysis and linear regression model were used to compare BIS and PSI sedation scores, and to test their associations with the MOAA/S score, respectively. ROC curves were drawn to compare the sensitivity and specificity of BIS and PSI. Changes of vital signs were presented as mean ± standard deviation. Perioperative liver and kidney function indicators were analyzed using a paired t-test to evaluate the safety of RT for intraspinal anesthesia in the elderly patients. RESULTS According to Pearson's correlation analysis, a significant (P < 0.01) correlation between BIS and PSI was found when used to monitor intraoperative sedation of RT (r = 0.796). Significant associations between BIS and MOAA/S (r = 0.568, P < 0.01), and between PSI and MOAA/S (r = 0.390, P < 0.01) were also found. The areas under the ROC curves of BIS and PSI were 0.801 ± 0.022 and 0.734 ± 0.026, respectively, suggesting that both measures may predict patients' state of consciousness and BIS was more accurate than PSI. Vital signs remained stable throughout the study. No abnormal changes of clinical significance were found based on laboratory test results of liver and kidney function. CONCLUSION BIS and PSI are strongly associated for monitoring the sedation of RT intraoperatively. Both methods can accurately reflect sedation depth. According to correlation analyses with MOAA/S scale and ROC curves, BIS is more accurate than PSI during such intraoperative monitoring. In addition, RT can be safely used in elderly patients under intraspinal anesthesia for supportive sedation, with stable vital signs and sound kidney and liver safety profiles. TRIAL REGISTRATION http://www.chictr.org.cn (ChiCTR2100051912).
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Affiliation(s)
| | - Di Chen
- The Second Affiliated Hospital of Hainan Medical University, Hai Kou, China
| | - Zhi-Xin Xu
- The Second Affiliated Hospital of Hainan Medical University, Hai Kou, China
| | - Huan-Liang Wang
- The Second Affiliated Hospital of Hainan Medical University, Hai Kou, China
| | - Hu Sun
- The Second Affiliated Hospital of Hainan Medical University, Hai Kou, China.
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Abdelhamid BM, Matta M, Rady A, Adel G, Gamal M. Conventional fluid management versus plethysmographic variability index-based goal directed fluid management in patients undergoing spine surgery in the prone position - a randomised control trial. Anaesthesiol Intensive Ther 2023; 55:186-195. [PMID: 37728446 PMCID: PMC10496101 DOI: 10.5114/ait.2023.130792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/08/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION The plethysmographic variability index (PVI) is a dynamic approach for assessing volume status. This study aims to compare conventional fluid management and PVI based goal-directed fluid management (GDFM) during elective spine surgery in the prone position. MATERIAL AND METHODS Sixty-six adult patients, ASA I-II, scheduled for elective lumbar spine procedures under general anaesthesia in the prone position were included. Patients were randomly divided into either the Conventional Group with the conventional fluid management protocol or the PVI Group with the PVI-based GDFM protocol. The total amount of intraoperative crystalloid administered was set as a primary outcome. Intraoperative PVI and perfusion index (PI), mean arterial pressure (MAP), heart rate (HR), the incidence of hypotension after prone positioning in both groups and data from arterial blood gas samples (immediately after induction of anaesthesia [T1] and immediately postoperatively [T2]) were set as secondary outcomes. RESULTS The total amount of intraoperative crystalloids, blood transfusion, urine output, and fluid balance were similar in the two groups ( P -values 0.443, 0.317 and 0.273, respectively). The perioperative MAP and HR values showed no significant differences between the two groups at all time points of measurements. The values of pH, PaO 2 , PaCO 2 , HCO 3 , lactate and haemoglobin showed no statistically significant difference between the two groups. The blood lactate value at T2 was significantly increased when compared to T1 values in the two groups. CONCLUSIONS PVI dependent goal-directed fluid management (GDFM) therapy did not reduce the intraoperative total crystalloid administration or requirements for blood transfusion when compared to conventional fluid management using a fixed fluid rate in patients undergoing spine surgery in a prone position. Clinical trial registration: The study was registered at clinicaltrials.gov (NCT05239286).
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Affiliation(s)
- Bassant Mohamed Abdelhamid
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
- Department of Anaesthesiology, Armed Forces College of Medicine, Egypt
| | - Marina Matta
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - Ashraf Rady
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - George Adel
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
| | - Medhat Gamal
- Department of Anaesthesiology, Surgical ICU and Pain Management, Kasr-Alainy Faculty of Medicine, Cairo University, Egypt
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Morakul S, Prachanpanich N, Permsakmesub P, Pinsem P, Mongkolpun W, Trongtrakul K. Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery. Front Med (Lausanne) 2022; 9:881267. [PMID: 35783653 PMCID: PMC9247540 DOI: 10.3389/fmed.2022.881267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionExcessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period.MethodsPatients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM—PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR.ResultsOf 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66–0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%).ConclusionsΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.
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Ozyurt E. Pleth variability index measured in the sitting position before anesthesia can predict spinal anesthesia-induced hypotension in cesarean section: An observational study. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_97_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Orhon Ergun M, Zengin SU, Umuroglu T. Goal-Directed Fluid Management Using Plethysmographic Variability Index in Patients Undergoing Laparoscopic Bariatric Surgery. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2021.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Meliha Orhon Ergun
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Seniyye Ulgen Zengin
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Tumay Umuroglu
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
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11
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Coutrot M, Dudoignon E, Joachim J, Gayat E, Vallée F, Dépret F. Perfusion index: Physical principles, physiological meanings and clinical implications in anaesthesia and critical care. Anaesth Crit Care Pain Med 2021; 40:100964. [PMID: 34687923 DOI: 10.1016/j.accpm.2021.100964] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
Photoplethysmography (PPG) has been extensively used for pulse oximetry monitoring in anaesthesia, perioperative and intensive care. However, some components of PPG signal have been employed for other purposes, such as non-invasive haemodynamic monitoring. Perfusion index (PI) is derived from PPG signal and represents the ratio of pulsatile on non-pulsatile light absorbance or reflectance of the PPG signal. PI determinants are complex and interlinked, involving and reflecting the interaction between peripheral and central haemodynamic characteristics, such as vascular tone and stroke volume. Recently, several studies have shed light on the interesting performances of this variable, especially assessing regional or neuraxial block success, and haemodynamic monitoring in anaesthesia, perioperative and intensive care. Nevertheless, no review has yet been published concerning the interest of PI in these fields. In this narrative review will be exposed first the physiological and pathophysiological determinants of PI, and then the mean to measure this value as well as its potential limitations. In the second part, the existing data concerning usefulness of PI in different clinical settings such as operating theatres, intensive care units and emergency departments will be presented and discussed. Finally, the perspectives concerning the use of PI and mentioned aspects that should be explored regarding this tool will be underlined.
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Affiliation(s)
- Maxime Coutrot
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; FHU PROMICE, Paris, France.
| | - Emmanuel Dudoignon
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France.
| | - Jona Joachim
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France
| | - Etienne Gayat
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France
| | - Fabrice Vallée
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France; Inria, France; LMS, Ecole Polytechnique, CNRS, Institut Polytechnique de Paris, France
| | - François Dépret
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France; F-CRIN INICRCT network, Paris, France
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12
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刘 雅, 宋 琳, 邢 茂, 蔡 立, 王 东. [Comparison of pulse pressure variation, stroke volume variation, and plethysmographic variability index in pediatric patients undergoing craniotomy]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:946-951. [PMID: 34650300 PMCID: PMC8517666 DOI: 10.19723/j.issn.1671-167x.2021.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To compare well-known preload dynamic parameters intraoperatively including stroke volume variation (SVV), pulse pressure variation (PPV), and plethysmographic variability index (PVI) in children who underwent craniotomy for epileptogenic lesion excision. METHODS A total of 30 children aged 0 to 14 years undergoing craniotomy for intracranial epileptogenic lesion excision were enrolled. During surgery, we measured PPV, SVV (measured by the Flotrac/Vigileo device), and PVI (measured by the Masimo Radical-7 monitor) simultaneously and continuously. Preload dynamic parameter measurements were collected at predefined steps: after induction of anesthesia, during opening the skull, intraoperative electroencephalogram monitoring, excision of epileptogenic lesion, skull closure, at the end of the operation. After exclusion of outliers, agreement among SVV, PPV, and PVI was assessed using repeated measures of Bland-Altman approach. The 4-quadrant and polar plot techniques were used to assess the trending ability among the changes in the three parameters. RESULTS The mean SVV, PPV, and PVI were 8%±2%, 10%±3%, and 15%±7%, respectively during surgery. We analyzed a total of 834 paired measurements (3 to 8 data sets for each phase per patient). Repeated measures Bland-Altman analysis identified a bias of -2.3 and 95% confidence intervals between -1.9 and -2.7 (95% limits of agreement between -6.0 and 1.5) between PPV and SVV, showing significant correlation at all periods. The bias between PPV and PVI was -5.0 with 95% limits of agreement between -20.5 and 10.5, and that between SVV and PVI was -7.5 with 95% limits of agreement between -22.7 and 7.8, both not showing significant correlation. Reflected by 4-quadrant plots, the con-cordance rates showing the trending ability between the changes in PPV and SVV, PPV and PVI, SVV and PVI were 88.6%, 50.4%, and 50.1%, respectively. The concordance rate between PPV and SVV was higher (92.7%) in children aged less than 3 years compared with those aged 3 and more than 3 years. The mean angular bias, radial limits of agreement, and angular concordance rate in the polar analysis were not clinically acceptable in the changes between arterial pressure waveform-based parameters and volume-based PVI (PPV vs. PVI: angular mean bias 8.4°, angular concordance rate 29.9%; SVV vs. PVI: angular mean bias 2.4°, angular concordance rate 29.1%). There was a high concordance between the two arterial pressure waveform-based parameters reflected by the polar plot (angular mean bias -0.22°, angular concordance rate 86.6%). CONCLUSION PPV can be viewed as a surrogate for SVV, especially in children aged less than 3 years. The agreement between arterial pressure waveform-based preload parameters (PPV and SVV) and PVI is poor and these two should not be considered interchangeable. Attempt to combine PVI and PPV for improving the anesthesiologist's ability to monitor cardiac preload in major pediatric surgery is warranted.
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Affiliation(s)
- 雅菲 刘
- 北京大学第一医院麻醉科, 北京 100034Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - 琳琳 宋
- 北京大学第一医院麻醉科, 北京 100034Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - 茂炜 邢
- 北京大学第一医院麻醉科, 北京 100034Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
| | - 立新 蔡
- 京大学第一医院儿童癫痫中心, 北京 100034Pediatric Epilepsy Center, Peking University First Hospital, Beijing 100034, China
| | - 东信 王
- 北京大学第一医院麻醉科, 北京 100034Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
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13
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Tomo A, Pekdemir M, Ozturan IU, Dogan NO, Yaka E, Yilmaz S. Use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing volunteers. Clin Exp Emerg Med 2021; 8:9-15. [PMID: 33845517 PMCID: PMC8041582 DOI: 10.15441/ceem.20.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/12/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The use of noninvasive volume assessment methods to predict acute blood loss in spontaneously breathing patients remains unclear. We aimed to investigate changes in the pleth variability index (PVI), vena cava collapsibility index (VCCI), end-tidal carbon dioxide (EtCO2), pulse pressure (PP), and mean arterial pressure (MAP) in spontaneously breathing volunteers after acute loss of 450 mL blood and passive leg raise (PLR). METHODS This prospective observational study enrolled healthy volunteers in the blood donation center of an academic hospital. We measured the PVI, EtCO2, VCCI, MAP, and PP before blood donation; at the 0th and 10th minute of blood donation; and after PLR. The primary outcome was the changes in PVI, EtCO2, VCCI, MAP, and PP. RESULTS We enrolled thirty volunteers. There were significant differences among the four obtained measurements of the PVI, EtCO2, and MAP (P<0.001, P<0.001, P<0.001, respectively). Compared to the predonation values, post-hoc analysis revealed an increase in the PVI at the 0th min postdonation (mean difference [MD], 5.4±5.9; 95% confidence interval [CI], -7.6 to -3.1; P<0.001); a decrease in the EtCO2 and MAP at the 0th and 10th minute postdonation, respectively (MD, 2.4±4.6; 95% CI, 0.019 to 4.84; P=0.008 and MD, 6.4±6.4; 95% CI, 3 to 9.7; P<0.001, respectively). Compared with EtCO2 at the 10th minute, the value increased after PLR (MD, 1.8±3.2; 95% CI, 0.074 to 4.44; P=0.006). CONCLUSION The PVI and EtCO2 could detect early hemodynamic changes after acute blood loss. However, it remains unclear whether they can determine volume status in spontaneously breathing patients.
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Affiliation(s)
- Asim Tomo
- Department of Emergency Medicine, Kadikoy Medicana Hospital, Istanbul, Turkey
| | - Murat Pekdemir
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | | | - Nurettin Ozgur Dogan
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Elif Yaka
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Serkan Yilmaz
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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Enev R, Krastev P, Abedinov F. Prediction of fluid responsiveness: a review. BIOTECHNOL BIOTEC EQ 2021. [DOI: 10.1080/13102818.2021.1960190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Rostislav Enev
- Department of Anesthesiology and Intensive Care, University Hospital “Sveta Ekaterina”, Medical University of Sofia, Sofia, Bulgaria
| | - Plamen Krastev
- Department of Cardiology, University Hospital “Sveta Ekaterina”, Medical University of Sofia, Sofia, Bulgaria
| | - Filip Abedinov
- Department of Anesthesiology and Intensive Care, University Hospital “Sveta Ekaterina”, Medical University of Sofia, Sofia, Bulgaria
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Abstract
Disorders of perfusion in newborn infants are frequently observed in neonatal intensive care units. The current assessment practices are primarily based on clinical signs. Significant technologic advances have opened new avenues for continuous assessment at the bedside. Combining these devices with functional echocardiography provides an in-depth understanding of perfusion and allows targeting therapy to the pathophysiology rather than monitoring and targeting blood pressure. This change in approach is guided by the fact that perfusion disorders can result from a number of causes and a single management approach might do more harm than good. This approach has the potential to improve long term outcomes but needs to be tested in well-designed trials.
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Affiliation(s)
- Samir Gupta
- School of Medical Physics & Engineering, Durham University, United Kingdom; Division of Neonatology, Sidra Medicine, Doha, Qatar.
| | - Steven M Donn
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
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Fischer MO, Lemoine S, Tavernier B, Bouchakour CE, Colas V, Houard M, Greub W, Daccache G, Hulet C, Compère V, Taing D, Lorne E, Parienti JJ, Hanouz JL. Individualized Fluid Management Using the Pleth Variability Index: A Randomized Clinical Trial. Anesthesiology 2020; 133:31-40. [PMID: 32205547 DOI: 10.1097/aln.0000000000003260] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery. METHODS This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient. RESULTS In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, -0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 μg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively. CONCLUSIONS Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.
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Affiliation(s)
- Marc-Olivier Fischer
- From the Anesthesiology and Critical Care Medicine Department (M.-O.F., S.L., W.G., G.D., J.-L.H.) the INSERM COMETE 1075 Unit, Orthopedic Department, (C.H.) the Biostatistics Department (J.-J.P.), Normandy University, Caen University Hospital, Caen, France Anesthesiology and Critical Care Medicine Department, Lille University Hospital, Lille, France (B.T., M.H.) Anesthesiology and Intensive Care Medicine Department, Hospital of Catholic Institute of Lille, Saint Philibert Hospital, Lomme, France (C.-E.B., V.C.) Anesthesiology and Critical Care Medicine Department, Rouen University Hospital, Charles Nicolle Hospital, Rouen, France (V.C.) Anesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France (D.T., E.L.) Research Unit on Simplified Care of Complex Surgical Patients, Jules Verne University of Picardy, Amiens, France (E.L.). Caen University Hospital, Caen, France Caen University Hospital, Caen, France Amiens Picardie University Hospital, Amiens, France Amiens Picardie University Hospital, Amiens, France Lille University Hospital, Lille, France Lille University Hospital, Lille, France Hospital of Catholic Institute of Lille, Lomme, France Clinical Research Department, Caen University Hospital Clinical Research Department, Caen University Hospital Clinical Research Department, Caen University Hospital Clinical Research Department, Hospital of Catholic Institute of Lille Clinical Research Department, Lille University Hospital Clinical Research Department, Lille University Hospital Clinical Research Department, Amiens Picardie University Hospital
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Rozental O, Thalappillil R, White RS, Tam CW. To Swan or Not to Swan: Indications, Alternatives, and Future Directions. J Cardiothorac Vasc Anesth 2020; 35:600-615. [PMID: 32859489 DOI: 10.1053/j.jvca.2020.07.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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