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Del Castillo C, Verdugo F, Appiani F, Yáñez F, Bontá C, Torres-Herrera C, Garcia A, Blázquez-Bermejo Z, Castrodeza J, Requena D, Rodríguez A, Silvio A, Gatica A, Begazo A, Alfaro M. Echocardiogram by apical-subcostal protocol in prone position during invasive mechanical ventilation in cardiovascular intensive care unit. Cardiovasc Ultrasound 2024; 22:7. [PMID: 38858752 PMCID: PMC11163713 DOI: 10.1186/s12947-024-00326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024] Open
Abstract
AIMS To evaluate the feasibility of a transthoracic echocardiogram using an apical-subcostal protocol in invasive mechanical ventilation (IMV) and prone position. METHODS Prospective study of adults who required a prone position during IMV. A pillow was placed only under the left hemithorax in the prone position to elevate and ease the apical and subcostal windows. A critical care cardiologist (prone group) acquired and evaluated the images using the apical-subcostal protocol. Besides, we used ambulatory echocardiograms performed as a comparative group (supine group). RESULTS 86 patients were included, 43 in the prone and 43 in the supine. In the prone group, the indication to perform an echocardiogram was hemodynamic monitoring. All patients were ventilated with protective parameters, and the mean end-expiratory pressure was 10.6 cmH2O. The protocol was performed entirely in 42 of 43 patients in the prone group because one patient did not have any acoustic window. In the 43 patients in the prone group analyzed and compared to the supine group, global biventricular function was assessed in 97.7% (p = 1.0), severe heart valve disease in 88.4% (p = 0.055), ruled out of the presence of pulmonary hypertension in 76.7% (p = 0.80), pericardial effusion in 93% (p = 0.12), and volume status by inferior vena cava in 93% (p = 0.48). Comparing prone versus supine position, a statistical difference was found when evaluating the left ventricle apical 2-chamber view (65.1 versus 100%, p < 0.01) and its segmental function (53.4 versus 100%, p < 0.01). CONCLUSION The echocardiogram using an apical-subcostal protocol is feasible in patients in the IMV and prone position.
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Affiliation(s)
- César Del Castillo
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile.
- Postgraduate Department, Faculty of Medicine, Universidad Diego Portales, Santiago, Chile.
| | | | - Franco Appiani
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile
- Postgraduate Department, Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
| | - Francisca Yáñez
- Cardiovascular department, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | - Camila Bontá
- Cardiovascular department, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | - Carlos Torres-Herrera
- Postgraduate Department, Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
| | - Angela Garcia
- Intensive Care Unit, Hospital DIPRECA, Santiago, Chile
| | - Zorba Blázquez-Bermejo
- Cardiovascular department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Castrodeza
- Cardiovascular department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Daniel Requena
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile
| | | | - Arquimedes Silvio
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile
- Postgraduate Department, Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
| | - Agustín Gatica
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile
| | - Arnulfo Begazo
- Cardiovascular department, Hospital DIPRECA, Santiago, Chile
- Postgraduate Department, Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
| | - Mario Alfaro
- Cardiovascular department, Hospital Clínico San Borja Arriarán, Santiago, Chile
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You JY, Sato R, Chawla S, Kapoor A, Wang X, Collier P, Auzinger G, Duggal A, Dugar S. Hemodynamic profile of cirrhotic patients with sepsis and septic shock: A propensity score matched case-control study. J Crit Care 2024; 81:154532. [PMID: 38330737 DOI: 10.1016/j.jcrc.2024.154532] [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: 09/26/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Our understanding of hemodynamics in cirrhotic patients with sepsis remains limited. Our study aims to investigate differences in hemodynamic profiles using echocardiography between septic patients with and without cirrhosis. MATERIALS AND METHODS This is a single-center, retrospective study of septic patients with echocardiogram within 3 days of ICU admission. We compared baseline characteristics, echocardiographic markers of LV systolic function arterial load between patients with and without cirrhosis. A propensity score-matched case-control model was developed to describe the differences in those echocardiography derived parameters between the groups. RESULTS 3151 patients with sepsis were included of which 422 (13%) had cirrhosis. In the propensity score matched group with 828 patients, cirrhotic patients had significantly higher left ventricular ejection fraction (64 vs.56%, p < 0.001) and stroke volume (72 vs.48 ml, p < 0.001) along with lower arterial elastance (Ea) (1.35 1vs.20.3, p < 0.001) and systemic vascular resistance (SVR) (851 vs.1209 dynes/s/m-5, p = 0.001). The left ventricular elastance (Ees) (2.83 vs 2.45, p = 0.002) was higher and ventricular-arterial coupling (Ea/Ees) (0.48 vs. 0.86, p < 0.001) lower in cirrhotic compared to non-cirrhotic. CONCLUSIONS Septic patients with cirrhosis had higher LVEF with lower Ea and SVR with higher Ees and significantly lower Ea/Ees suggesting vasodilation as the principal driver of the hyperdynamic profile in cirrhosis.
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Affiliation(s)
- Jee Young You
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI, USA.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Georg Auzinger
- Department of Critical Care, Cleveland Clinic London, London, UK; Reader in Critical Care King's College London, London, UK; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
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Kumar A, Bharti AK, Hussain M, Kumar S, Kumar A. Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study. Indian J Crit Care Med 2024; 28:595-600. [PMID: 39130396 PMCID: PMC11310668 DOI: 10.5005/jp-journals-10071-24741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/06/2024] [Indexed: 08/13/2024] Open
Abstract
Background and aims Prompt assessments and quick replacement of intravascular fluid are critical steps to resuscitate hypovolemic patients. Intravascular volume assessment by direct central venous pressure (CVP) measurement is an invasive, time-consuming, and labor-intensive procedure. Nowadays, bedside ultrasound-guided volume assessment of the internal jugular vein (IJV) or inferior vena cava (IVC) is commonly employed as a proxy for direct CVP.Therefore, we examined the strength of association between CVP and collapsibility index (CI) of the IJV and IVC for evaluating the volume status of critically ill patients. Methods Bedside USG-guided A-P diameter and cross-sectional area of the right IJV and IVC were measured, and their corresponding collapsibility indices were deduced. The results of the IJV and IVC indices were correlated with CVP. Results About 60 out of 70 enrolled patients were analyzed. The baseline clinical parameters of patients are shown in Table 1. For CSA and AP diameter, the correlations between CVP and IJV-CI at 0° were r = -0.107 (p = 0.001) and r = -0.092 (p = 0.001). Correlations between CVP and IJV-CI at 30° for CSA and diameter, however, were (r = -0.109, p = 0.001) and (r = -0.117, p = 0.001), respectively. Table 2 depicts the correlation between CVP and IVC-CI r = -0.503, p = 0.001 for CSA and r = -0.452, p = 0.001 for diameter. Conclusion The IVC and IJV collapsibility indices can be used in place of invasive CVP monitoring to assess fluid status in critically ill patients. How to cite this article Kumar A, Bharti AK, Hussain M, Kumar S, Kumar A. Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study. Indian J Crit Care Med 2024;28(6):595-600.
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Affiliation(s)
- Anuj Kumar
- Department of Anesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Alok K Bharti
- Department of Anesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Mumtaz Hussain
- Department of Anesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Sanjeev Kumar
- Department of Anesthesiology and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Arvind Kumar
- Department of Anesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Bogaert J, Bekhuis Y, Rosseel T, Laveaux S, Dausin C, Voigt JU, Claessen G, Dresselaers T. Use of Real-Time Cine MRI to Assess the Respirophasic Variation of the Inferior Vena Cava-Proof-of-Concept and Validation Against Transthoracic Echocardiography. J Magn Reson Imaging 2024; 59:1809-1817. [PMID: 37427759 DOI: 10.1002/jmri.28863] [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: 03/06/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND In clinical practice, the right heart filling status is assessed using the respirophasic variation of the inferior vena cava (IVC) assessed by transthoracic echocardiography (TTE) showing moderate correlations with the catheter-based reference standard. PURPOSE To develop and validate a similar approach using MRI. STUDY TYPE Prospective. POPULATION 37 male elite cyclists (mean age 26 ± 4 years). FIELD STRENGTH/SEQUENCE Real-time balanced steady-state free-precession cine sequence at 1.5 Tesla. ASSESSMENT Respirophasic variation included assessment of expiratory size of the upper hepatic part of the IVC and degree of inspiratory collapse expressed as collapsibility index (CI). The IVC was studied either in long-axis direction (TTE) or using two transverse slices, separated by 30 mm (MRI) during operator-guided deep breathing. For MRI, in addition to the TTE-like diameter, IVC area and major and minor axis diameters were also assessed, together with the corresponding CIs. STATISTICAL TESTS Repeated measures ANOVA test with Bonferroni correction. Intraclass correlation coefficient (ICC) and Bland-Altman analysis for intrareader and inter-reader agreement. A P value <0.05 was considered statistically significant. RESULTS No significant differences in expiratory IVC diameter were found between TTE and MRI, i.e., 25 ± 4 mm vs. 25 ± 3 mm (P = 0.242), but MRI showed a higher CI, i.e., 76% ± 14% vs. 66% ± 14% (P < 0.05). As the IVC presented a noncircular shape, i.e., major and minor expiratory diameter of 28 ± 4 mm and 21 ± 4 mm, respectively, the CI varied according to the orientation, i.e., 63% ± 27% vs. 75% ± 16%, respectively. Alternatively, expiratory IVC area was 4.3 ± 1.1 cm2 and showed a significantly higher CI, i.e., 86% ± 14% than diameter-based CI (P < 0.05). All participants showed a CI >50% with MRI versus 35/37 (94%) with TTE. ICC values ranged 0.546-0.841 for MRI and 0.545-0.704 for TTE. CONCLUSION Assessment of the respirophasic IVC variation is feasible with MRI. Adding this biomarker may be of particular use in evaluating heart failure patients. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Jan Bogaert
- Department of Radiology, UZ Leuven, Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Youri Bekhuis
- Department of Cardiology, UZ Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | | | | | - Jens-Uwe Voigt
- Department of Cardiology, UZ Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, Hartcentrum, Jessa Ziekenhuis, Hasselt, Belgium
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Yampolsky S, Kwan A, Cheng S, Kedan I. Point of Care Ultrasound for Diagnosis and Management in Heart Failure: A Targeted Literature Review. POCUS JOURNAL 2024; 9:117-130. [PMID: 38681155 PMCID: PMC11044942 DOI: 10.24908/pocus.v9i1.16795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND Cardiac point of care ultrasound (POCUS) has shown increasing utility as a tool for diagnosing and managing heart failure (HF). Within cardiology, intravascular volume assessment leveraging visualization of the inferior vena cava (IVC) is a central aspect of care, as IVC size correlates with central venous pressure. This targeted literature review aimed to examine the existing literature assessing the use of POCUS in diagnosis and management of HF patients utilizing POCUS-based IVC measurement either alone or in combination with secondary methods. METHODS A targeted PubMed and Ovid database search up until August 28, 2023 using a keyword search was completed. Studies that did not include IVC assessment with POCUS in HF were excluded. RESULTS The initial search using both PubMed and Ovid resulted in 370 journal publications. After exclusion criteria were used 15 studies were included in the review. Studies were grouped into three categories: 1) how well POCUS was able to identify HF, 2) whether POCUS-based findings correlated with other measures evaluating HF and was able to predict the effect of diuretic administration, and 3) whether POCUS-based findings served as a good prognostic indicator. The 5 studies that evaluated HF identification with POCUS found that both diagnostic sensitivity and specificity may reach 90%-100% when IVC measurement was coupled with a lung ultrasound assessing the presence of B-lines or pleural effusion. Five studies assessing POCUS findings correlating with other HF measures and diuretic effect found that IVC diameter changed significantly with diuretic administration (p<0.05). All 6 studies assessing POCUS as a predictor of long-term mortality or hospital readmission found measures that achieved statistical significance with p<0.05. CONCLUSIONS Including POCUS as standard-of-care - both as a diagnostic tool in the emergency department and a management tool in in-patient and out-patient facilities - may improve the treatment of HF.
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Affiliation(s)
| | - Alan Kwan
- Smidt Heart Institute, Cedars Sinai HospitalLos Angeles, CAUSA
| | - Susan Cheng
- Smidt Heart Institute, Cedars Sinai HospitalLos Angeles, CAUSA
| | - Ilan Kedan
- Smidt Heart Institute, Cedars Sinai HospitalLos Angeles, CAUSA
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Ogawa M, Kuwajima K, Yamane T, Hasegawa H, Yagi N, Shiota T. Prognostic Implication of Right Ventricular Free Wall Longitudinal Strain and Right Atrial Pressure Estimated By Echocardiography in Patients With Severe Functional Tricuspid Regurgitation. J Am Heart Assoc 2024; 13:e033196. [PMID: 38609840 PMCID: PMC11262525 DOI: 10.1161/jaha.123.033196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND The interaction between right ventricular (RV) function and pulmonary hypertension is crucial for prognosis of patients with severe functional tricuspid regurgitation. RV free wall longitudinal strain (RVFWLS) has been reported to detect RV systolic dysfunction earlier than other conventional parameters. Although pulmonary artery systolic pressure measured by Doppler echocardiography is often underestimated in severe functional tricuspid regurgitation, right atrial pressure (RAP) estimated by echocardiography may be viewed as a prognostic factor. Impact of RAP and RVFWLS on outcome in patients with severe functional tricuspid regurgitation remains unclear. The aim of the present study was to investigate prognostic implication of RAP, RVFWLS, and their combination in this population. METHODS AND RESULTS We retrospectively examined 377 patients with severe functional tricuspid regurgitation. RAP, pulmonary artery systolic pressure, RV fractional area change, and RVFWLS were analyzed. RAP of 15 mm Hg was classified as elevated RAP. All-cause death at 2-year follow-up was defined as the primary end point. RVFWLS provided better prognostic information than RV fractional area change by receiver operating characteristic curve analysis. In the multivariable Cox regression analysis, elevated RAP and RVFWLS of ≤18% were independent predictors of clinical outcome. Patients with RVFWLS of ≤18% had higher risk of all-cause death than those without by Kaplan-Meier curve analysis. Furthermore, when patients were stratified into 4 groups by RAP and RVFWLS, the group with elevated RAP and RVFWLS of ≤18% had the worst outcome. CONCLUSIONS Elevated RAP and RVFWLS of ≤18% were independent predictors of all-cause death. The combination of elevated RAP and RVFWLS effectively stratified the all-cause death.
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Affiliation(s)
- Mana Ogawa
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
| | - Ken Kuwajima
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
| | - Takafumi Yamane
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
| | - Hiroko Hasegawa
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
| | - Nobuichiro Yagi
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
| | - Takahiro Shiota
- Cedars‐Sinai Medical CenterSmidt Heart InstituteLos AngelesCAUSA
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Hakim DDL, Meilyana F, Peryoga SU, Arniawati I, Wijaya EA, Martiano MR. Usefulness of Non-Invasive Parameters (Inferior Vena Cava Diameter, Inferior Vena Cava Collapsibility, Inferior Vena Cava-Aortic Ratio) for Hemodynamic Monitoring in Critically Ill Children: A Systematic Review. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2024; 17:123-133. [PMID: 38525306 PMCID: PMC10959115 DOI: 10.2147/mder.s454849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose Volume measurement in critically ill children can be conducted using invasive procedure such as Central Venous Pressure (CVP), or non-invasive procedure such as measurement of Inferior Vena Cava (IVC) indices using ultrasonography. However, their accuracy and efficacy are still under scrutiny. We aim to compare CVP and IVC indices as non-invasive parameters in assessing volume status in critically ill children. Methods We conducted a systematic review based on literature searching from four electronic databases which were PubMed, Cochrane, ScienceDirect, SpringerLink with keywords: "CENTRAL VENOUS PRESSURE", "INFERIOR VENA CAVA DIAMETER", "INFERIOR VENA CAVA COLLAPSIBILITY", "INFERIOR VENA CAVA AORTIC-RATIO", "VOLUME STATUS", "FLUID STATUS", "CRITICAL ILL", "CHILDREN", and "PEDIATRICS". We included relevant studies in English published from 2000 to 2023 on critically ill children aged 0-18 years. Comparison between CVP and IVC indices was resumed. Results Eight articles were included in this study. Majority of the studies showed a consistent correlation between CVP and IVC indices. IVC-CI was the most common parameter evaluated in the included studies. There was moderate to strong correlations using IVC-CI and IVC-DI, and moderate correlation using IVC-Ao ratio. Conclusion We found that non-invasive tools might have a potential role to measure volume in critically ill children equals to CVP. Further high-quality and longitudinal studies are needed to validate these findings and to establish a clear guideline for the non-invasive tool to be used in daily clinical practice.
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Affiliation(s)
- Dzulfikar Djalil Lukman Hakim
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Fina Meilyana
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Stanza Uga Peryoga
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Irma Arniawati
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Elrika Anastasia Wijaya
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Muhamad Rinaldhi Martiano
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
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Miranda WR, Egbe AC, Van De Bruaene A, Connolly HM, Burchill LJ, Jain CC. Peripheral Venous Pressure Accurately Reflects Invasively Measured Resting and Exercise Fontan Pressures. Am J Cardiol 2024; 215:62-64. [PMID: 38253306 DOI: 10.1016/j.amjcard.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States.
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, United States
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Longino A, Martin K, Leyba K, Siegel G, Thai TN, Riscinti M, Douglas IS, Gill E, Burke J. Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion. Chest 2024; 165:590-600. [PMID: 37813180 PMCID: PMC11317813 DOI: 10.1016/j.chest.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/24/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. RESEARCH QUESTION Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? STUDY DESIGN AND METHODS We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and < 7 mm Hg. RESULTS Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (β = 4.8; 95% CI, 2.6-7.1; P < .01) and 3 (β = 11; 95% CI, 8.9-14; P < .01) and RAP, VExUS grade of 2 (β = 6.8; 95% CI, 0.16-13; P = .045) and 3 (β = 15; 95% CI, 7.3-22; P < .01) and mean pulmonary artery pressure, and VExUS grade of 2 (β = 7.0; 95% CI, 3.9-10; P < .01) and 3 (β = 13; 95% CI, 9.5-17; P < .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10 mm Hg were 0.9 (95% CI, 0.83-0.97), 0.77 (95% CI, 0.68-0.88), and 0.65 (95% CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP < 7 mm Hg were 0.79 (95% CI, 0.70-0.87), 0.74 (95% CI, 0.64-0.84), and 0.62 (95% CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P = .025). INTERPRETATION Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO.
| | - Katie Martin
- University of Colorado School of Medicine, University of Colorado, Aurora, CO
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Theresa N Thai
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Matthew Riscinti
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO
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Chayapinun V, Koratala A, Assavapokee T. Seeing beneath the surface: Harnessing point-of-care ultrasound for internal jugular vein evaluation. World J Cardiol 2024; 16:73-79. [PMID: 38456073 PMCID: PMC10915892 DOI: 10.4330/wjc.v16.i2.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/16/2024] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
Point-of-care ultrasound (POCUS) of the internal jugular vein (IJV) offers a non-invasive means of estimating right atrial pressure (RAP), especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery. While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein, this method lacks sensitivity. The utilization of POCUS significantly enhances the visualization of the vein, leading to a more accurate identification. It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation. This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein, drawing upon existing data.
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Affiliation(s)
- Vichayut Chayapinun
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Wauwatosa, WI 53226, United States.
| | - Taweevat Assavapokee
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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Wrobel JR, Magin JC, Williams D, An X, Acton JD, Doyal AS, Jia S, Krakowski JC, Serrano R, Grant SA, Flynn DN, McLean DJ. Comparing preoperative fasting and ultrasound-measured intravascular volume status in elective surgery, enhanced recovery patients versus inpatient, urgent surgery patients and the ability of IVC collapsibility to predict post-induction hypotension. J Perioper Pract 2023:17504589231215932. [PMID: 38149485 DOI: 10.1177/17504589231215932] [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: 12/28/2023]
Abstract
Hypotension following induction of general anaesthesia has been shown to result in increased complications and mortality postoperatively. Patients admitted to the hospital undergoing urgent surgery are often fasted from fluids for significant periods compared to elective patients subject to Enhanced Recovery After Surgery protocols despite guidelines stating that a two-hour fast is sufficient. The aim of this prospective, observational study was to compare fasting times and intravascular volume status between elective surgery patients subject to enhanced recovery protocols and inpatient, urgent surgery patients and to assess differences in the incidence of post-induction hypotension. Fasting data was obtained by questionnaire in the preoperative area in addition to inferior vena cava collapsibility index, a non-invasive measure of intravascular volume. Blood pressure readings and drug administration for the ten minutes following induction were obtained from patients' charts. Inpatients undergoing urgent surgery were fasted significantly longer than enhanced recovery patients and had lower intravascular volume. However, no difference was found in the incidence of post-induction hypotension.
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Affiliation(s)
| | | | | | - Xinming An
- UNC School of Medicine, Chapel Hill, NC, USA
| | | | | | - Shawn Jia
- UNC School of Medicine, Chapel Hill, NC, USA
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12
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Lee JH, Denault AY, Beaubien-Souligny W, Kang P, Kim J, Kim HW, Ji SH, Jang YE, Kim EH, Kim HS, Kim JT. Higher portal venous pulsatility is associated with worse clinical outcomes following congenital heart surgery: a single-centre prospective cohort study. Can J Anaesth 2023; 70:1957-1969. [PMID: 37919629 DOI: 10.1007/s12630-023-02605-0] [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: 01/05/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE Increased portal venous flow pulsatility is associated with major complications after adult cardiac surgery. Nevertheless, no data are available for pediatric patients with congenital heart disease. We hypothesized that Doppler parameters including portal flow pulsatility could be associated with postoperative outcomes in children undergoing various cardiac surgeries. METHODS We conducted a prospective observational cohort study in children undergoing congenital cardiac surgery. We obtained postoperative portal, splenic, and hepatic venous Doppler data and perioperative clinical data including major postoperative complications. Portal and splenic venous flow pulsatility were calculated. We evaluated the association between venous Doppler parameters and adverse outcomes. The primary objective was to determine whether postoperative portal flow pulsatility could indicate major complications following congenital heart surgery. RESULTS In this study, we enrolled 389 children, 74 of whom experienced major postoperative complications. The mean (standard deviation) portal pulsatility (44 [30]% vs 25 [14]%; 95% confidence interval [CI] for mean difference, 12 to 26; P < 0.001] and splenic pulsatility indices (41 [30]% vs 26 [16]%; 95% CI, 7 to 23; P < 0.001) were significantly higher in children with postoperative complications than in those without complications. The portal pulsatility index was able to help identify postoperative complications in biventricular patients and univentricular patients receiving bidirectional cavopulmonary shunt whereas it did not in other univentricular patients. An increased postoperative portal pulsatility index was significantly associated with major complications after pediatric cardiac surgery (odds ratio, 1.40; 95% CI, 1.29 to 1.91; P < 0.001). CONCLUSIONS Higher portal venous pulsatility is associated with major postoperative complications in children undergoing cardiac surgery. Nevertheless, more data are needed to conclude the efficacy of portal venous pulsatility in patients with univentricular physiology. STUDY REGISTRATION ClinicalTrials.gov (NCT03990779); registered 19 June 2019.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - André Y Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - William Beaubien-Souligny
- Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jay Kim
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Hee-Won Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, # 101 Daehakno, Jongnogu, Seoul, 03080, South Korea.
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Hearon CM, Peters K, Dias KA, Macnamara JP, Marshall JET, Campain J, Martin D, Marshal‐Goebel K, Levine BD. Assessment of venous pressure by compression sonography of the internal jugular vein during 3 days of bed rest. Exp Physiol 2023; 108:1560-1568. [PMID: 37824038 PMCID: PMC10988448 DOI: 10.1113/ep091372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023]
Abstract
Compression sonography has been proposed as a method for non-invasive measurement of venous pressures during spaceflight, but initial reports of venous pressure measured by compression ultrasound conflict with prior reports of invasively measured central venous pressure (CVP). The aim of this study is to determine the agreement of compression sonography of the internal jugular vein (IJVP) with invasive measures of CVP over a range of pressures relevant to microgravity exposure. Ten healthy volunteers (18-55 years, five female) completed two 3-day sessions of supine bed rest to simulate microgravity. IJVP and CVP were measured in the seated position, and in the supine position throughout 3 days of bed rest. The range of CVP recorded was in line with previous reports of CVP during changes in posture on Earth and in microgravity. The correlation between IJVP and CVP was poor when measured during spontaneous breathing (r = 0.29; R2 = 0.09; P = 0.0002; standard error of the estimate (SEE) = 3.0 mmHg) or end-expiration CVP (CVPEE ; r = 0.19; R2 = 0.04; P = 0.121; SEE = 3.0 mmHg). There was a modest correlation between the change in CVP and the change in IJVP for both spontaneous ΔCVP (r = 0.49; R2 = 0.24; P < 0.0001) and ΔCVPEE (r = 0.58; R2 = 0.34; P < 0.0001). Bland-Altman analysis of IJVP revealed a large positive bias compared to spontaneous breathing CVP (3.6 mmHg; SD = 4.0; CV = 85%; P < 0.0001) and CVPEE (3.6 mmHg; SD = 4.2; CV = 84%; P < 0.0001). Assessment of absolute IJVP via compression sonography correlated poorly with direct measurements of CVP by invasive catheterization over a range of venous pressures that are physiologically relevant to spaceflight. However, compression sonography showed modest utility for tracking changes in venous pressure over time. NEW FINDINGS: What is the central question of this study? Compression sonography has been proposed as a novel method for non-invasive measurement of venous pressures during spaceflight. However, the accuracy has not yet been confirmed in the range of CVP experienced by astronauts during spaceflight. What is the main finding and its importance? Our data show that compression sonography of the internal jugular vein correlates poorly with direct measurement of central venous pressures in a range that is physiologically relevant to spaceflight. However, compression sonography showed modest utility for tracking changes in venous pressure over time.
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Affiliation(s)
- Christopher M. Hearon
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Kirsten Peters
- University Medical CenterRadboud UniversityNijmegenthe Netherlands
| | - Katrin A. Dias
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - James P. Macnamara
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - John E. T. Marshall
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Joseph Campain
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
| | | | | | - Benjamin D. Levine
- Institute for Exercise and Environmental MedicineTexas Health Presbyterian Hospital DallasDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
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14
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Alerhand S, Adrian RJ. What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension? Am J Emerg Med 2023; 72:72-84. [PMID: 37499553 DOI: 10.1016/j.ajem.2023.07.011] [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: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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15
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Tafciu E, Niro L, Iseppi M, Fanti D, Maffeis C, Bergamini C, Benfari G, Rossi A, Ribichini FL. Right Atrial Function Role in Tricuspid Regurgitation-Related Systemic Venous Congestion. Am J Cardiol 2023; 204:320-324. [PMID: 37567024 DOI: 10.1016/j.amjcard.2023.07.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023]
Abstract
Tricuspid regurgitation (TR) is a frequent valvular pathology and when significant, may cause systemic venous congestion (SC). The right atrium (RA) is an intermediate structure between the tricuspid valve and the venous system and its role in SC is not yet defined. A total of 116 patients with a measurable TR effective regurgitant orifice area (EROA) and regurgitant volume (RVol) were selected from 2020 to 2022. SC was estimated by echocardiography using inferior vena cava diameter and estimated right atrial pressure (eRAP) and by clinical congestive features. TR grade was mild in 23 patients (20%), moderate in 53 patients (46%), and severe in 40 patients (34%). There was a significant decrease in RA function measured by strain with increasing TR severity (p <0.001). There was a marked difference in RA strain between the groups with eRAP >10 and ≤10 mm Hg (25 ± 11% vs 11 ± 7%, p <0.0001). Variables independently associated with inferior vena cava diameter were RA strain (β -0.532, p <0.001), RA volume indexed (β 0.249, p = 0.002), RVol (β 0.229, p = 0.005) and EROA (β 0.185, p = 0.016), and independently associated with eRAP >10 mm Hg were EROA (odds ratio [OR] 1.024, 95% confidence interval [CI] 1.002 to 1.046), RVol (OR 1.039, 95% CI 1.007 to 1.072) and RA strain (OR 0.863, 95% CI 0.794 to 0.940). The addition of RA strain to models containing EROA or RVol significantly improved the power of the model. RA strain was independently associated with the presence of 3 or more congestive features. In conclusion, echocardiographic and clinical signs of SC are frequent in higher degrees of TR, and RA function seems to play a key role in modulating the downstream effect of TR.
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Affiliation(s)
- Elvin Tafciu
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
| | - Lorenzo Niro
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Manuela Iseppi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Diego Fanti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Caterina Maffeis
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Corinna Bergamini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Rossi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Flavio L Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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16
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Chun Chau T, Nik Muhamad NA. Internal jugular vein measurements: an alternative ultrasonic approach in estimating volume status of emergency department patients. Eur J Emerg Med 2023; 30:374-375. [PMID: 37650741 DOI: 10.1097/mej.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Tan Chun Chau
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) Jalan Yaacob Latif, Kuala Lumpur, Wilayah Persekutuan, Malaysia
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17
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McGill M, Raja KR, Evans M, Hiremath G, Ameduri R, Narasimhan S. Correlation between non-invasive to invasive right-heart data in paediatric heart transplant patients. Cardiol Young 2023; 33:2034-2040. [PMID: 36514992 DOI: 10.1017/s1047951122003900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Paediatric studies have shown serum N-terminal pro b-type natriuretic peptide levels to be a valuable tool in the surveillance of myocardial function and an early biomarker for rejection in transplant patients. The correlation between low mean right atrial pressure and increased inferior vena cava collapsibility index is well studied in adults. Our study aims to assess correlation between non-invasive measurements (serum N-terminal pro b-type natriuretic peptide, inferior vena cava dimensions collapsibility, tricuspid regurgitation, and left ventricular remodelling index to invasive mean right atrial pressure in paediatric heart transplant patients). METHODS A single centre, retrospective chart review of the paediatric transplant patients from 0 to 21 years of age was performed between 2015 and 2017. Thirty-nine patients had complete data which includes cardiac catheterisation, transthoracic echocardiogram, and serum N-terminal pro b-type natriuretic peptide levels done within a two weeks of interval. RESULTS A higher inferior vena cava collapsibility index correlated with a lower mean right atrial pressure (r = -0.21, p = 0.04) and a larger inferior vena cava diameter in expiration indexed to body surface area (IVCmax/BSA0.5) correlated with a higher mean right atrial pressure (r = 0.29, p = 0.01). There was a correlation between elevated N-terminal pro b-type natriuretic peptide and inferior vena cava collapsibility index (r = -0.38, p = 0.0001), IVCmax/BSA0.5 (r = 0.25, p = 0.0002), and mean right atrial pressure (r = 0.6, p = 0.0001). CONCLUSION Serum N-terminal pro b-type natriuretic peptide levels correlated to non-invasive measurements (inferior vena cava collapsibility index and IVCmax/BSA0.5) and to the invasive mean right atrial pressure. Non-invasive (IVC-CI IVCmax/BSA0.5) correlates with elevated mean right atrial pressure in this population. Together, these may serve as a reliable surveillance tool in assessing right heart filling pressures and cardiac function within the paediatric heart transplant patient.
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Affiliation(s)
- Mark McGill
- Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Kishore R Raja
- Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Michael Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | | | - Rebecca Ameduri
- Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
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18
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Sampath-Kumar R, Ben-Yehuda O. Inferior vena cava diameter and risk of acute decompensated heart failure rehospitalisations. Open Heart 2023; 10:e002331. [PMID: 37696618 PMCID: PMC10496688 DOI: 10.1136/openhrt-2023-002331] [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: 03/31/2023] [Accepted: 08/03/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVES Inferior vena cava (IVC) diameter may be a surrogate for volume status in acute decompensated heart failure (ADHF). The utility of IVC diameter measurement is under studied. The aim of this study was to assess the relationship between IVC diameter, clinical variables and ADHF rehospitalisations. METHODS Retrospective chart review of 200 patients admitted for ADHF from 2018 to 2019 with transthoracic echocardiogram during index hospitalisation. Charts were assessed for ADHF rehospitalisation within 1 year. RESULTS The median age was 64, 30.5% were female, and average left ventricular ejection fraction was 41%±20%. IVC diameter correlated to pulmonary arterial (PA) pressure (R=0.347, p<0.001) and body surface area (BSA) (R=0.424 p<0.001). IVC diameter corrected for BSA correlated to PA pressure (R=0.287, p<0.001) and log N-terminal B-type natriuretic peptide (NT-proBNP) (R=0.247, p≤0.01). Patients rehospitalised within 1 year had significantly greater mean IVC diameter compared with those not rehospitalised (p<0.001) while there was no difference in mean net weight lost during index hospitalisation or mean log NT-proBNP. Patients with IVC diameter greater than 2.07 cm had significantly increased ADHF rehospitalisation (85.6% vs 49.3%, log rank p<0.001) with HR 2.44 (95% CI 1.85 to 3.23, p<0.001). In multivariable Cox regression only IVC diameter (p<0.001), presence of tricuspid regurgitation (p=0.02) and NYHA class III/IV (p<0.001) independently predicted ADHF rehospitalisation within 1 year. CONCLUSIONS IVC diameter is predictive of rehospitalisation in patients with ADHF and may identify patients in need of greater monitoring and diuresis.
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Affiliation(s)
- Revathy Sampath-Kumar
- Cardiology, University of California San Diego Health Sciences, La Jolla, California, USA
| | - Ori Ben-Yehuda
- Cardiology, University of California San Diego Health Sciences, La Jolla, California, USA
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19
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Longino A, Martin K, Leyba K, Siegel G, Gill E, Douglas IS, Burke J. Correlation between the VExUS score and right atrial pressure: a pilot prospective observational study. Crit Care 2023; 27:205. [PMID: 37237315 PMCID: PMC10223840 DOI: 10.1186/s13054-023-04471-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Venous congestion is an under-recognized contributor to mortality in critically ill patients. Unfortunately, venous congestion is difficult to measure, and right heart catheterization (RHC) has been considered the most readily available means for measuring venous filling pressure. Recently, a novel "Venous Excess Ultrasound (VExUS)" score was developed to noninvasively quantify venous congestion using inferior vena cava (IVC) diameter and Doppler flow through the hepatic, portal, and renal veins. A preliminary retrospective study of post-cardiac surgery patients showed promising results, including a high positive-likelihood ratio of high VExUS grade for acute kidney injury. However, studies have not been reported in broader patient populations, and the relationship between VExUS and conventional measures of venous congestion is unknown. To address these gaps, we prospectively assessed the correlation of VExUS with right atrial pressure (RAP), with comparison to inferior vena cava (IVC) diameter. Patients undergoing RHC at Denver Health Medical Center underwent VExUS examination before their procedure. VExUS grades were assigned before RHC, blinding ultrasonographers to RHC outcomes. After controlling for age, sex, and common comorbidities, we observed a significant positive association between RAP and VExUS grade (P < 0.001, R2 = .68). VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC diameter (0.79, 95% CI 0.65-0.92). These results suggest a strong correlation between VExUS and RAP in a diverse patient population, and support future studies of VExUS as a tool to assess venous congestion and guide management in a spectrum of critical illnesses.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA.
| | - Katharine Martin
- School of Medicine, University of Colorado, University of Colorado, Aurora, CO, USA
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO, USA
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Nasu M, Sato R, Takahashi K, Nakaizumi T, Maruyama A, Ueda S. The Chronological Demographics of Ventricular-Arterial Decoupling in Patients with Sepsis and Septic Shock: A Prospective Observational Study. J Intensive Care Med 2023; 38:340-348. [PMID: 35957601 DOI: 10.1177/08850666221120219] [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: 11/17/2022]
Abstract
BACKGROUND Ventricular-arterial coupling (V-A coupling) recently gathers attention from clinicians to evaluate the interaction between afterload and left ventricular systolic function. We aimed to describe the chronological demographics of V-A decoupling in patients with sepsis and septic shock through the clinical course. METHOD We conducted a single-center prospective observational study comprising adult patients with sepsis and septic shock admitted to the tertiary care hospital between 04/2017 and 03/2019. Patients' characteristics, lab data on admission, and echocardiographic parameters including Ea and Ees on the day- 1, 2, 3, 7, and 14-28 were collected. V-A decoupling was defined as Ea/Ees ≥ 1.36. RESULTS Seventy-one patients with sepsis or septic shock were enrolled. The prevalence of V-A decoupling was as follows; day-1: 25.4%, day-2: 23.8%, day-3: 13.3%, day-7: 18.5%, day-14-28: 30.3%, respectively. Ea was higher in patients with V-A decoupling than those without throughout the clinical course (day1; 2.8 vs. 1.8, p < 0.01, day2; 2.7 vs. 1.9, p < 0.01, day3; 2.8 vs. 2.1, p = 0.06, day7; 2.7 vs. 1.9, p = 0.02, day14-28; 2.4 vs. 1.8, p = 0.08). This increase in Ea was mainly induced by reduced stroke volume (SV) as well as high systolic blood pressure (SBP) in the earlier course of sepsis but only by increased SBP in the later course of sepsis. Ees was lower in patients with V-A decoupling than those without throughout the clinical course (day1; 1.3 vs. 2.1, p < 0.01, day2; 1.5 vs. 2.3, p < 0.01, day3; 1.6 vs. 2.3, p = 0.02, day7; 1.8 vs. 2.3, p = 0.01, day14-28; 1.2 vs. 1.9, p = 0.07). CONCLUSION We reported that V-A decoupling was commonly seen in patients with sepsis and septic shock. In patients with V-A decoupling, both Ea and Ees were significantly altered, but the causes of these alterations appeared to be changing over the clinical course of sepsis.
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Affiliation(s)
- Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, HI, USA
| | - Kuniko Takahashi
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Takayuki Nakaizumi
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Akiyoshi Maruyama
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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21
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Inferior Vena Cava Ultrasonography for Volume Status Evaluation: An Intriguing Promise Never Fulfilled. J Clin Med 2023; 12:jcm12062217. [PMID: 36983218 PMCID: PMC10053997 DOI: 10.3390/jcm12062217] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
The correct determination of volume status is a fundamental component of clinical evaluation as both hypovolaemia (with hypoperfusion) and hypervolaemia (with fluid overload) increase morbidity and mortality in critically ill patients. As inferior vena cava (IVC) accounts for two-thirds of systemic venous return, it has been proposed as a marker of volaemic status by indirect assessment of central venous pressure or fluid responsiveness. Although ultrasonographic evaluation of IVC is relatively easy to perform, correct interpretation of the results may not be that simple and multiple pitfalls hamper its wider application in the clinical setting. In the present review, the basic elements of the pathophysiology of IVC behaviour, potential applications and limitations of its evaluation are discussed.
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Furuya T, Hirose N, Sato H, Niikura R, Kijima M, Suzuki T. Preanesthetic ultrasonography assessment of inferior vena cava diameter in the supine position, left lateral tilt position, and with the left uterine displacement maneuver in full-term pregnant women: A randomized cross-over design study. J Obstet Gynaecol Res 2023; 49:904-911. [PMID: 36513438 DOI: 10.1111/jog.15518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/31/2022] [Accepted: 11/26/2022] [Indexed: 12/15/2022]
Abstract
Preanesthetic ultrasonography assessment of inferior vena cava diameter (IVCD) in the supine position (SP), left lateral tilt position (LLT), and with the left uterine displacement maneuver (LUD) in full-term pregnant women: a randomized cross-over design study. AIM We pre-anesthetically measured IVCD using ultrasonography in the SP, LLT, and the LUD in full-term pregnant women, using a cross-over design, to evaluate the effectiveness of LLT and LUD on increasing IVCD, and the presence of inter-individual differences among patients in the effect of posture on IVCD. METHODS Twenty-two parturients scheduled for elective cesarean section under spinal anesthesia were recruited. All patients were sequentially placed in the SP, LLT, and with LUD before spinal anesthesia induction. Indices of IVCD, measured by subxiphoid ultrasonography, including maximum IVCD (IVCDmax), minimum IVCD (IVCDmin), and collapsibility index (CI) were recorded in each of the postures. Mean or median values of all measurements were compared among the postures. RESULTS The mean values of IVCDmax observed with both LLT and LUD were significantly larger than those in the SP, respectively (SP vs. LLT: p < 0.05, SP vs. LUD: p < 0.01), although there were no significant differences between IVCDmax with LLT and LUD. There were no significant differences in IVCDmin and CI between any of the postures. IVCDmax was highest with LUD in 11 patients (55%), in the LLT in seven patients (35%) and in the SP in two patients (10%). CONCLUSIONS LLT and LUD might be equally effective in enlarging the narrowed IVCD as compared to SP. However, both LLT and LUD might not necessarily be appropriate treatments to relieve IVC compression in some cases.
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Affiliation(s)
- Tomonori Furuya
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Noriya Hirose
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hanae Sato
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Risa Niikura
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Miho Kijima
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
| | - Takahiro Suzuki
- Department of Anesthesiology, Nihon University School of Medicine, Tokyo, Japan
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Elia J, Diwan M, Deshpande R, Brainard JC, Karamchandani K. Perioperative Fluid Management and Volume Assessment. Anesthesiol Clin 2023; 41:191-209. [PMID: 36871999 DOI: 10.1016/j.anclin.2022.10.010] [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: 03/07/2023]
Abstract
Fluid therapy is an integral component of perioperative care and helps maintain or restore effective circulating blood volume. The principal goal of fluid management is to optimize cardiac preload, maximize stroke volume, and maintain adequate organ perfusion. Accurate assessment of volume status and volume responsiveness is necessary for appropriate and judicious utilization of fluid therapy. To accomplish this, static and dynamic indicators of fluid responsiveness have been widely studied. This review discusses the overarching goals of perioperative fluid management, reviews the physiology and parameters used to assess fluid responsiveness, and provides evidence-based recommendations on intraoperative fluid management.
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Affiliation(s)
- Jennifer Elia
- Department of Anesthesiology, University of California, Irvine School of Medicine, 101 The City Drive South, Building 53-225, Orange, CA 92868, USA.
| | - Murtaza Diwan
- Department of Anesthesiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine, 333Cedars Street, TMP 3, New Haven, CT 06510, USA
| | - Jason C Brainard
- Department of Anesthesiology, University of Colorado, University of Colorado Hospital, 12401 East 17th Avenue, Mail Stop B113, Aurora, CO 80045, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Fan YC, Wang XQ, Zhu DY, Huai XR, Yu WF, Su DS, Pan ZY. Association of different central venous pressure levels with outcome of living-donor liver transplantation in children under 12 years. World J Pediatr 2023; 19:170-179. [PMID: 36399311 DOI: 10.1007/s12519-022-00632-3] [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: 06/14/2022] [Accepted: 10/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pediatric liver transplantation is an important modality for treating biliary atresia. The overall survival (OS) rate of pediatric liver transplantation has significantly improved compared with that of 20 years ago, but it is still unsatisfactory. The anesthesia strategy of maintaining low central venous pressure (CVP) has shown a positive effect on prognosis in adult liver transplantation. However, this relationship remains unclear in pediatric liver transplantation. Thus, this study was conducted to review the data of pediatric living-donor liver transplantation to analyze the associations of different CVP levels with the prognosis of recipients. METHODS This was a retrospective study and the patients were divided into two groups according to CVP levels after abdominal closure: low CVP (LCVP) (≤ 10 cmH2O, n = 470) and high CVP (HCVP) (> 10 cmH2O, n = 242). The primary outcome measured in the study was the overall survival rate. The secondary outcomes included the duration of mechanical ventilation in the intensive care unit (ICU), length of stay in the ICU, and postoperative stay in the hospital. Patient demographic and perioperative data were collected and compared between the two groups. Kaplan-Meier curves were constructed to determine the associations of different CVP levels with the survival rate. RESULTS In the study, 712 patients, including 470 in the LCVP group and 242 in the HCVP group, were enrolled. After propensity score matching, 212 pairs remained in the group. The LCVP group showed a higher overall survival rate than the HCVP group in the Kaplan-Meier curves and multivariate Cox regression analyses (P = 0.018), and the HCVP group had a hazard ratio of 2.445 (95% confidence interval, 1.163-5.140). CONCLUSION This study confirmed that a low-CVP level at the end of surgery is associated with improved overall survival and a shorter length of hospital stay.
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Affiliation(s)
- Yi-Chen Fan
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Xiao-Qiang Wang
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Dan-Yan Zhu
- Nursing Department, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Shanghai, China
| | - Xiao-Rong Huai
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Wei-Feng Yu
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Dian-San Su
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Zhi-Ying Pan
- Department of Anesthesiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, No. 160 Pujian Road, Pudong New District, Shanghai, 200127, China.
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Monhart Z. Point‑of‑Care Ultrasound in internal medicine. VNITRNI LEKARSTVI 2023; 69:214-221. [PMID: 37468287 DOI: 10.36290/vnl.2023.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Point-of-Care ultrasound (POCUS) is bedside ultrasound examination performed by a clinician. POCUS is a suitable tool for rapid diagnosis and monitoring of the condition of many patients examined by internists in emergency departments and inpatient departments. POCUS allows the examining physician to supplement the physical examination with additional information obtained in real time, and is a useful tool for differential diagnosis of a number of acute conditions (shock, shortness of breath, etc.). Chest POCUS includes an indicative assessment of cardiac function and evaluation of the lung parenchyma, including exclusion of pericardial effusion, pneumothorax or fluidothorax. One of the most common applications of POCUS is to assess the state of the venous filling by examining the inferior vena cava. When examining the abdomen, the internist should at least be able to diagnose fluid in the abdominal cavity and exclude congestion in the hollow system of the kidney. POCUS for internists also includes examination of main venous trunks to rule out proximal venous thrombosis. Even when performing conventional invasive procedures, we cannot do without ultrasound at the bedside, whether it is a puncture of ascites or pleural effusion, or cannulation of the central vein. The advantage of POCUS is the immediate availability of the examination and the possibility to repeat scans when needed for monitoring the patient's condition.
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Lombardi A, Gambardella M, Palermi S, Frecentese F, Serio A, Sperlongano S, Tavarozzi R, D'andrea A, De Luca M, Politi C. Liver and heart failure: an ultrasound relationship. J Basic Clin Physiol Pharmacol 2023; 34:11-20. [PMID: 36117247 DOI: 10.1515/jbcpp-2022-0211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/22/2022] [Indexed: 01/27/2023]
Abstract
Liver and heart are anatomically and patho-physiologically related. In heart failure (HF) the increased right atrial pressure and volume overload cause histological changes in hepatocytes, leading to a condition known as "congestive hepatopathy" (CH), with consequent variations in liver functioning and ultrasound (US) findings. CH has specifical US findings especially regarding venous vessels aspect, easily detecting by gray-scale study, but many others can be distinguished by Doppler analysis. Usually, hepatic veins look enlarged and hypocollassing, together with signs of portal hypertension (hepatomegaly, ascites, splenomegaly, porto-systemic collaterals). Typically, in CH Doppler findings regard alterations in venous vessel flow and arterial resistance (venous system hyperpulsatility, reduced velocity flow, high resistance index in hepatic arterial Doppler spectrum). Sometimes CH and other primary hepatopathy can coexist, and therefore some of the expected variations may not manifest: it allows suspecting an unknown underlying liver disease. At last, US technologies of more recent applications, even if not routinely used, allow investigating additional aspects such as elastography that detects changes in liver elasticity or contrastographic US, able to show differences in hepatic venous opacification. However, most of these US signs are not pathognomonic, and therefore a multidisciplinary clinical reasoning must not be lacking. The aim of the present review is to easily provide US signs of liver alterations in HF, in particular right heart failure with volume overload, suggesting including liver US in instrumental diagnosis and therapeutic monitoring of HF.
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Affiliation(s)
- Anna Lombardi
- Department of Internal Medicine, Veneziale Hospital, Isernia, Italy
| | - Michele Gambardella
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Stefano Palermi
- Public Health Department, University Federico II, Naples, Italy
| | - Francesca Frecentese
- Section of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Simona Sperlongano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rita Tavarozzi
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Antonello D'andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | | | - Cecilia Politi
- Department of Internal Medicine, Veneziale Hospital, Isernia, Italy
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Pastore MC, Ilardi F, Stefanini A, Mandoli GE, Palermi S, Bandera F, Benfari G, Esposito R, Lisi M, Pasquini A, Santoro C, Valente S, D’Andrea A, Cameli M. Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit. J Clin Med 2022; 11:jcm11247538. [PMID: 36556154 PMCID: PMC9785677 DOI: 10.3390/jcm11247538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.
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Affiliation(s)
- Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Mediterranea Cardiocentro, 80122 Naples, Italy
| | - Andrea Stefanini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy
| | - Francesco Bandera
- Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milano, 20122 Milan, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Roberta Esposito
- Department of Clinical Medicine and Surgery, Federico II University Hospital, 80131 Naples, Italy
| | - Matteo Lisi
- Department of Cardiovascular Disease—AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Annalisa Pasquini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Antonello D’Andrea
- Department of Cardiology, Umberto I Hospital, 84014 Nocera Inferiore, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
- Correspondence: (M.C.P.); (M.C.); Tel.: +39-057-758-5377 (M.C.P.)
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Elzeneini M, Gupta S, Li Y, Guo Y, Hamburger R. Estimation of Right Atrial Pressure Using a Portable Handheld Ultrasound Device. Am J Med 2022; 135:1378-1381. [PMID: 35636478 DOI: 10.1016/j.amjmed.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Handheld ultrasound devices are increasingly used by clinicians for their ease of use and portability. Their utility for estimating right atrial pressure (RAP) is poorly described. METHODS This prospective study enrolled 50 consecutive patients presenting for outpatient right heart catheterization (RHC). A handheld ultrasound device was used to measure inferior vena cava size and collapsibility and estimate RAP to be 3, 8, or 15 mmHg according to American Society of Echocardiography recommendations for cardiac chamber quantification. Invasive pressure measurements were then performed using RHC. Spearman's correlation and linear regression analysis were used to evaluate the association between estimated RAP using ultrasound and invasive RAP. RESULTS Fifty patients were enrolled (mean age 68 ± 8 years). Estimated RAP by ultrasound was significantly associated with invasive RAP (r 0.80; R2 0.63; 95% confidence interval, 0.61-0.96; P < .001). The correlation was stronger when RHC was indicated for evaluation of heart failure (r 0.88; P < .001) compared with other indications (r 0.69; P < .001). An estimated RAP of 3, 8, and 15 mmHg by ultrasound had a sensitivity and specificity of predicting an invasive RAP of 0-5, 6-10, and > 10 mmHg of 88% and 76%, 56% and 88%, and 81% and 97%, respectively, with overall accuracy of 80%, 76%, and 92%, respectively. Estimated RAP also correlated with invasive pulmonary capillary wedge pressure (r 0.64; R2 0.41; 95% confidence interval, 0.26-0.54; P < .001). CONCLUSIONS Handheld ultrasonography is a useful tool that can accurately estimate RAP at the bedside.
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Affiliation(s)
| | - Shishir Gupta
- Department of Internal Medicine, University of Florida, Gainesville
| | - Yujia Li
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville
| | - Yi Guo
- Department of Health Outcomes & Biomedical Informatics, University of Florida
| | - Robert Hamburger
- Division of Cardiovascular Medicine, University of Florida, Gainesville; Malcom Randall Veterans Administration Medical Center, Gainesville, Fla.
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Gottlieb M, Alerhand S. Managing Cardiac Arrest Using Ultrasound. Ann Emerg Med 2022; 81:532-542. [PMID: 36334956 DOI: 10.1016/j.annemergmed.2022.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 11/15/2022]
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Kramer T, Brinkkoetter P, Rosenkranz S. Right Heart Function in Cardiorenal Syndrome. Curr Heart Fail Rep 2022; 19:386-399. [PMID: 36166185 PMCID: PMC9653308 DOI: 10.1007/s11897-022-00574-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Since CRS is critically dependent on right heart function and involved in interorgan crosstalk, assessment and monitoring of both right heart and kidney function are of utmost importance for clinical outcomes. This systematic review aims to comprehensively report on novel diagnostic and therapeutic paradigms that are gaining importance for the clinical management of the growing heart failure population suffering from CRS. Recent Findings Cardiorenal syndrome (CRS) in patients with heart failure is associated with poor outcome. Although systemic venous congestion and elevated central venous pressure have been recognized as main contributors to CRS, they are often neglected in clinical practice. The delicate hemodynamic balance in CRS is particularly determined by the respective status of the right heart. Summary The consideration of hemodynamic and CRS profiles is advantageous in tailoring treatment for better preservation of renal function. Assessment and monitoring of right heart and renal function by known and emerging tools like renal Doppler ultrasonography or new biomarkers may have direct clinical implications.
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Affiliation(s)
- Tilmann Kramer
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany. .,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.
| | - Paul Brinkkoetter
- Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Klinik II Für Innere Medizin, Nephrologie, Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
| | - Stephan Rosenkranz
- Klinik III Für Innere Medizin, Herzzentrum Der Universität Zu Köln, Köln, Germany.,Cologne Cardiovascular Research Center (CCRC), Klinikum Der Universität Zu Köln, Köln, Germany.,Center for Molecular Medicine Cologne (CMMC), Universität Zu Köln, Köln, Germany
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You J, Li M, Fan W, Li T, Wang J. Effect of different position on inferior vena cava dimensions and its influence on hemodynamics during cesarean section under combined spinal-epidural anesthesia: A randomized controlled trial. J Obstet Gynaecol Res 2022; 48:3103-3110. [PMID: 36098384 PMCID: PMC10087638 DOI: 10.1111/jog.15420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of our study was to investigate the effect of the 15° left operating table tilt on the inferior vena cava (IVC) and the hemodynamics of full-term pregnant women, and to evaluate the efficacy of inferior vena cava collapse index (IVCCI) in predicting hypotension. METHODS All parturients planning to perform cesarean section (CS) were randomly divided into supine group and 15° group. Their parameters of IVC were measured by ultrasound and then calculated the IVCCI. Systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) in two positions were recorded from baseline to fetal delivery. RESULTS The IVCCI in the 15° group was significantly lower when compared with that in the supine group (20.40 [18.84-21.60] vs. 21.82 [20.16-22.79] %, p = 0.012). The incidence of hypotension was observed statistically lower in the 15° group than the supine group (27.5% vs. 50%, p = 0.039). Best cut-off value was 21.69% and area under the receiver operating characteristic (ROC) curve of IVCCI in supine position to predict hypotension was 0.93. Best cut-off value was 21.78% and area under the ROC curve of IVCCI in supine position to predict hypotension was 0.80. CONCLUSIONS The 15° left operating table tilt can relieve the extent of compression of IVC and reduce the incidence of hypotension. IVCCI can predict the occurrence of hypotension.
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Affiliation(s)
- Junli You
- Department of Postgraduate, Changzhi Medical College, Changzhi, Shanxi, China
| | - Murong Li
- Department of Anesthesiology, Jincheng General Hospital, Jincheng, Shanxi, China
| | - Wei Fan
- Department of Anesthesiology, Jincheng General Hospital, Jincheng, Shanxi, China
| | - Tao Li
- Department of Postgraduate, Changzhi Medical College, Changzhi, Shanxi, China
| | - Jinping Wang
- Department of Anesthesiology, Jincheng People's Hospital, Jincheng, Shanxi, China
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Cardiac response to changes in central venous sonomorphology: Mechanism of impaired heart relaxation in patients with varicose veins of lower extremities. Phlebology 2022; 37:644-650. [DOI: 10.1177/02683555221108879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim This study examines the interactions between central venous and cardiac sonomorphologies to explain the mechanism of impaired heart relaxation in patients with varicose veins of lower extremities. Material and Methods Part 1: We performed retrospective analysis of influences of inferior vena cava (IVC) diameters on tricuspid and mitral inflow and annular velocities in 64 patients with primary varicose veins. Part 2: We compared IVC diameters and IVC collapsibility index (IVC CI) in patients with varicose veins with normal values. Results We found a significant positive influence of an increase in maximal expiratory and minimal inspiratory IVC diameters on mitral and tricuspid early annular velocities or e′-waves ( p-values < .008), inflow velocities or E-waves ( p-values < .05) and early to late inflow E/A ratios ( p-values < .01). Less influenced by the changes in venous biometry ( p-values > .05) were late mitral and tricuspid inflow, annular and systolic velocities (A-, a′-, s-waves). Expiratory and inspiratory diameters in patients with varicose veins were significantly smaller ( p-values < .05 expiratory; < .0001 inspiratory), and IVC CI was significantly higher ( p-values < .0001) than the normal values. Conclusion Chronic venous disease impairs the function and the morphology of the entire inferior caval system and the heart. Impaired relaxation of the heart in patients with varicose veins is the result of two factors: (1) impaired venous return resulting in the low central venous pressure and the low early diastolic cardiac inflow; (2) structural changes in the heart resulting in the compensatory increased late diastolic cardiac inflow. Increase in central venous pressure (IVC diameters) and early diastolic cardiac inflow (E-waves), accompanied by unchanged myocardial response (e′-wave) can serve as marker for return to normal physiology.
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Piccioni A, Franza L, Rosa F, Manca F, Pignataro G, Salvatore L, Simeoni B, Candelli M, Covino M, Franceschi F. Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have? Diagnostics (Basel) 2022; 12:diagnostics12071620. [PMID: 35885525 PMCID: PMC9325275 DOI: 10.3390/diagnostics12071620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022] Open
Abstract
Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.
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Affiliation(s)
- Andrea Piccioni
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
- Correspondence:
| | - Laura Franza
- Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.F.); (F.R.); (F.M.)
| | - Federico Rosa
- Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.F.); (F.R.); (F.M.)
| | - Federica Manca
- Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.F.); (F.R.); (F.M.)
| | - Giulia Pignataro
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
| | - Lucia Salvatore
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
| | - Benedetta Simeoni
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
| | - Marcello Candelli
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
| | - Marcello Covino
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
- Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.F.); (F.R.); (F.M.)
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (L.S.); (B.S.); (M.C.); (M.C.); (F.F.)
- Facoltà di Medicina e Chirurgia, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (L.F.); (F.R.); (F.M.)
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Ultrasonographical Assessment of Caudal Vena Cava Size through Different Views in Healthy Calves: A Pilot Study. Vet Sci 2022; 9:vetsci9070308. [PMID: 35878325 PMCID: PMC9322146 DOI: 10.3390/vetsci9070308] [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: 04/21/2022] [Revised: 06/08/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Ultrasonographic measurements of the caudal vena cava (CVC) and aorta (Ao) are known as reliable tools to assess intravascular volume status in humans. The aim of this study was to evaluate the feasibility of obtaining ultrasonographical measurements of CVC and Ao in two different views, assess intra- and interobserver variability, and study the effect of sex, age, body weight, and breed on measurements in healthy calves. The diameter and area of CVC and Ao were measured by a single investigator in two anatomic sites (subxiphoid and paralumbar window) in 48 calves aged less than 60 days and then repeated 2.5 months after the first assessment. For intra- and interobserver variability assessment, CVC and Ao measurements were repeated by three observers on five randomly selected calves. CVC and Ao measurements were easily obtained in PV and more difficult to obtain in SV. CVC and Ao area in PV showed high repeatability and reproducibility. A positive correlation was highlighted between age and CVC and Ao measurements in both sites. In conclusion, CVC size assessment by point of care ultrasound can be easily performed at a paralumbar site in calves under 4 months of age and could be used to assess intravascular volume status.
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Giustiniano E, Palma S, Meco M, Ripani U, Nisi F. Echocardiography in Prone Positioned Critically Ill Patients: A Wealth of Information from a Single View. Diagnostics (Basel) 2022; 12:diagnostics12061460. [PMID: 35741270 PMCID: PMC9221662 DOI: 10.3390/diagnostics12061460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 02/05/2023] Open
Abstract
In critically ill patients, standard transthoracic echocardiography (TTE) generally does not facilitate good image quality during mechanical ventilation. We propose a prone-TTE in prone positioned patients, which allows clinicians to obtain a complete apical four-chamber (A-4-C) view. A basic cardiac assessment can be performed in order to evaluate right ventricle function and left ventricle performance, even measuring objective parameters, i.e., tricuspid annular plane systolic excursion (TAPSE); pulmonary artery systolic pressure (PAP), from the tricuspid regurgitation peak Doppler velocity; RV end-diastolic diameter and its ratio to left ventricular end-diastolic diameter; the S’ wave peak velocity with tissue Doppler imaging; the ejection fraction (EF); the mitral annular plane systolic excursion (MAPSE); diastolic function evaluation by the mitral valve; and annular Doppler velocities. Furthermore, by tilting the probe, we can obtain the apical-five-chamber (A-5-C) view, which facilitates the analysis of blood flow at the level of the output tract of the left ventricle (LVOT) and then the estimation of stroke volume. Useful applications of this technique are hemodynamic assessment, titration of fluids, vasoactive drugs therapy, and evaluation of the impact of prone positioning on right ventricle performance and right pulmonary resistances. We believe that considerable information can be drawn from a single view and hope this may be helpful to emergency and critical care clinicians whenever invasive hemodynamic monitoring tools are not available or are simply inconvenient due to clinical reasons.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
| | - Sergio Palma
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
| | - Massimo Meco
- Department of Anesthesia and Intensive Care, Humanitas Gavazzeni Clinics, Via Mauro Gavazzeni, 21, 24125 Bergamo, Italy;
| | - Umberto Ripani
- Division of Clinic Anaesthesia, Department of Emergency Hospital Riuniti, Conca Street 71, 60126 Ancona, Italy;
| | - Fulvio Nisi
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
- Correspondence: ; Tel.: +39-02-8224-4115; Fax: +39-02-8224-4190
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Albaeni A, Sharma M, Ahmad M, Khalife WI. Accurate Estimation of Right-Filling Pressure Using Handheld Ultrasound Score in Patients with Heart Failure. Am J Med 2022; 135:634-640. [PMID: 34979092 DOI: 10.1016/j.amjmed.2021.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This study aims to evaluate the accuracy of bedside assessment of inferior vena cava (IVC) and right internal jugular (RIJ) vein in predicting right atrial (RA) pressure in heart failure patients. METHODS We prospectively studied 124 heart failure patients who were referred to our catheterization laboratory for right heart catheterizations to assess hemodynamics and to guide heart failure management. Just prior to the procedure, a handheld ultrasound examination was performed in each patient. The volume status was assessed by estimating RA pressure using end-expiratory IVC dimension, IVC respiratory collapsibility, and RIJ respiratory collapsibility. Patients were divided into 2 groups based on invasive RA pressure value. Multiple logistic regression models were used to identify factors associated with RA ≥10 mm Hg; a 3-point simple score was then created. The performance of this score was assessed using the receiver operating characteristics curve. RESULTS In this study 124 heart failure patients were included; median age was 59 years (interquartile range 48-65), and 40% were female. RIJ respiratory collapsibility <50%, end-expiratory IVC dimension ≥21 mm, and respiratory collapsibility <50% were significantly associated with elevated RA pressure, and were used to build the score. The area under the receiver operating characteristics curve (AUC) for the 3-point score was 0.84 (0.77-0.92), and it performed better than 2-point score using IVC characteristics alone (AUC 0.84 [0.77-0.92] vs 0.75 [0.67-0.83]; P = .003). Of 124 patients, 90 patients (72.5%) had concordant RA pressure and pulmonary capillary wedge pressure. CONCLUSION Concomitant ultrasound assessment of RIJ and IVC correlated better with RA pressure than IVC alone. A simple 3-point score can provide a useful and easily accessible tool to estimate volume status, and further guide management of heart failure patients.
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Affiliation(s)
- Aiham Albaeni
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston
| | - Mohit Sharma
- Division of Cardiology, Mather Hospital Northwell Health, Port Jefferson, NY
| | - Masood Ahmad
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston
| | - Wissam I Khalife
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston.
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Ruge M, Marhefka GD. IVC measurement for the noninvasive evaluation of central venous pressure. J Echocardiogr 2022; 20:133-143. [PMID: 35362870 DOI: 10.1007/s12574-022-00569-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/07/2022] [Accepted: 03/16/2022] [Indexed: 01/19/2023]
Abstract
Central venous pressure (CVP) is one of only a handful of variables that can be used to assess a patient's volume status to attempt to optimize stroke volume. The gold standard method for assessing CVP is though pulmonary artery catheterization, which is invasive and risks severe complications such as pneumothorax and cardiac conduction abnormalities. Current noninvasive methods for estimating CVP such as jugular venous pressure assessment are imperfect with wide inter-examiner variability. The inferior vena cava (IVC) is a highly compliant vessel that uniquely does not constrict in response to hypovolemia, making it an ideal, noninvasive surrogate for the estimation of CVP. A range of IVC indices including minimum and maximum IVC diameter and fraction of IVC collapse with inspiration (known as collapsibility index) have been studied with highly variable results that range from excellent to poor correlation between these values and CVP. Despite this inconsistency in findings, multiple schemes have been proposed to attempt to estimate CVP from IVC measurements, but when prospectively tested, none has been shown to be accurate. Since the most recent 2015 American Society of Echocardiography guidelines, multiple studies have identified unique ways of improving the accuracy of IVC measurement, which could translate into better CVP estimation. The goal of this review is to summarize the many, often conflicting studies that exist in this area, and provide recommendations for future studies based on our findings.
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Affiliation(s)
- Max Ruge
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregary D Marhefka
- Division of Cardiology, Thomas Jefferson University Hospital, Jefferson Heart Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA.
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Parker LP, Svensson Marcial A, Brismar TB, Broman LM, Prahl Wittberg L. Impact of Altered Vena Cava Flow Rates on Right Atrium Flow Characteristics. J Appl Physiol (1985) 2022; 132:1167-1178. [PMID: 35271411 PMCID: PMC9054263 DOI: 10.1152/japplphysiol.00649.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The right atrium (RA) combines the superior (SVC) and inferior vena cava (IVC) flows. Treatments like extracorporeal membrane oxygenation (ECMO) and hemodialysis by catheter alter IVC/SVC flows. Here we assess how altered IVC/SVC flow contributions impact RA flow. Four healthy volunteers were imaged with CT, reconstructed and combined into a patient-averaged model. Large Eddy Simulations (LES) were performed for a range of IVC/SVC flow contributions (30-70% each, increments of 5%) and common flow metrics were recorded. Model sensitivity to reconstruction domain extent, constant/pulsatile inlets and hematocrit was also assessed. Consistent with literature, a single vortex occupied the central RA across all flowrates with a smaller counter-rotating vortex, not previously reported, in the auricle. Vena cava flow was highly helical. RA turbulent kinetic energy (TKE) (P=0.027) and time-averaged wall shear stress (WSS) (P<0.001) increased with SVC flow. WSS was lower in the auricle (2 Pa, P<0.001). WSS in the vena cava were equal at IVC/SVC =65/35%. The model was highly sensitive to the reconstruction domain with cropped geometries lacking helicity in the vena cavae, altering RA flow. RA flow was not significantly affected by constant inlets or hematocrit. The rotational flow conventionally described in the RA is confirmed however a new, smaller vortex was also recorded in the auricle. When IVC flow dominates, as is normal, TKE in the RA is reduced and WSS in the vena cavae equalize. Significant helicity exists in the vena cava, a result of distal geometry and this geometry appears crucial to accurately simulating RA flow.
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Affiliation(s)
- Louis P Parker
- FLOW and BioMEx, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Stockholm, Sweden
| | - Anders Svensson Marcial
- Department of Clinical Science, Intervention and Technology at Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital in Huddinge, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Clinical Science, Intervention and Technology at Karolinska Institute, Division of Medical Imaging and Technology, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital in Huddinge, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Prahl Wittberg
- FLOW and BioMEx, Department of Engineering Mechanics, Royal Institute of Technology, KTH, Stockholm, Sweden
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Giraud L, Rodrigues NF, Lekane M, Farnir F, Kennedy C, Gommeren K, Merveille AC. Caudal vena cava point-of-care ultrasound in dogs with degenerative mitral valve disease without clinically important right heart disease. J Vet Cardiol 2022; 41:18-29. [DOI: 10.1016/j.jvc.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/25/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
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Kirillova VV, Smorgon AV, Garganeeva AA, Batalov RE, Meshchaninov VN, Sokolova LA, Blagodareva MS, Khlynin MS, Popov SV. Ultrasound Diagnosis Of Pulmonary Edema And Systemic Circulation Congestion In Patients With Atrial Fibrillation And Chronic Heart Failure. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Rationale — Fluid retention is among the most common causes of heart failure decompensation. The goal of our study was to evaluate the sensitivity and specificity of the ultrasound method for evaluating congestive phenomena in both systemic and pulmonary circulatory systems in patients with atrial fibrillation (AF) and chronic heart failure (CHF). Material and Methods — The study included 28 patients with paroxysmal AF, with or without CHF, who were scheduled for radiofrequency pulmonary vein isolation. The maximum and minimum diameters of the right superior pulmonary vein (RSPV) and inferior vena cava (IVC) were measured via echocardiography on expiration. Mean blood pressure in both right and left atria was measured intraoperatively. We calculated the correlations between maximum and minimum diameters of the RSPV and a mean pressure in the left atrium, as well as between IVC on expiration and a mean pressure in the right atrium, and evaluated the sensitivity and specificity of ultrasound diagnostics for evaluating congestive phenomena in both systemic and pulmonary circulation. Results — We established positive correlation between the minimum diameter of RSPV and invasively measured mean left atrial pressure (R=0.65, P<0.05), and between invasively measured mean right atrial pressure and IVC diameter on expiration (R=0.49, P<0.05). The proposed method sensitivity for detecting pulmonary venous hypertension (PVH) on the basis of the maximum RSPV diameter ≥21.7 mm was 75%, and the specificity was 86%. The sensitivity and specificity for detecting PVH on the basis of the minimum RSPV diameter ≥10.5 mm constituted 85% and 86%, respectively. When using the IVC diameter on expiration ≥18.5 mm as an indicator, the sensitivity and specificity for detecting PVH were evaluated at the levels of 100% and 92%, correspondingly. Conclusion — The proposed ultrasound method of diagnosing congestion in pulmonary circulation via maximum and/or minimum diameter of the RSPV can be effectively employed in clinical practice in the same way as conventional technique of congestion diagnostics in systemic circulation via the diameter of IVC in patients with atrial fibrillation and chronic heart failure.
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Affiliation(s)
- Venera V. Kirillova
- Ural State Medical University, Ekaterinburg, Russia; Institute for Medical Cell Technology, Ekaterinburg, Russia; Uralskaya Clinic LLC, Ekaterinburg, Russia
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Yang F, Cao Z, Wang X, Cui Z, Cheng D, Li Z, Lv B, Zhang H, Guo P, Feng Y, Liu W. A multi-parameter study of the etiological diagnosis of hyponatremia after hypothalamic tumor surgery. Clin Neurol Neurosurg 2021; 210:106963. [PMID: 34715556 DOI: 10.1016/j.clineuro.2021.106963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/21/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to analyze the difference between cerebral salt-wasting syndrome (CSWS) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in patients with hyponatremia after hypothalamic tumor surgery, and to explore a convenient and effective way to identify CSWS and SIADH. METHODS Patients undergoing craniotomy of hypothalamic tumor admitted to the Department of The Affiliated Hospital of Qingdao University from December 2018 to May 2020 were enrolled in this study. Plasma brain natriuretic peptide (BNP), 24-h urine sodium, 24-h urine volume, and the diameter of the inferior vena cava (IVCD) were measured daily before operation and 1-7 days after operation, to analyze differences in plasma BNP, 24-h urinary sodium excretion, 24-h urine volume, and IVCD between the CSWS and SIADH. RESULTS The medical data of 31 patients with hypothalamic tumors were collected. Fifteen of these patients (48%) had postoperative hyponatremia, nine patients (29%) had CSWS, and six patients (19%) had SIADH. Plasma BNP, 24-h urinary sodium excretion, and 24-h urine volume in the CSWS group were significantly higher than those in the SIADH group. IVCD decreased in the CSWS group and increased in the SIADH group. CONCLUSIONS When hyponatremia occurs after hypothalamic tumor surgery, plasma BNP, 24-h urinary sodium excretion, 24-h urine volume, and IVCD are of great help in identifying CSWS and SIADH.
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Affiliation(s)
- Fengyu Yang
- Department of Neurosurgery, Chengyang District People's Hospital, Qingdao 266071, China
| | - Zhigang Cao
- Department of Neurosurgery, Chengyang District People's Hospital, Qingdao 266071, China
| | - Xiaoyu Wang
- Department of Operating Room, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Zhenwen Cui
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Dekui Cheng
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Ziji Li
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Bingke Lv
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Hongliang Zhang
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Pin Guo
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Yugong Feng
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Wei Liu
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, China.
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Ma Z, Gai J, Sun Y, Bai Y, Cai H, Wu L, Sun L, Liu J, Xue L, Liu B. Measuring the ratio of femoral vein diameter to femoral artery diameter by ultrasound to estimate volume status. BMC Cardiovasc Disord 2021; 21:506. [PMID: 34670503 PMCID: PMC8527729 DOI: 10.1186/s12872-021-02309-7] [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: 05/07/2021] [Accepted: 10/05/2021] [Indexed: 12/26/2022] Open
Abstract
Background Currently, the accepted effective method for assessing blood volume status, such as measuring central venous pressure (CVP) and mean pulmonary artery pressure (mPAP), is invasive. The purpose of this study was to explore the feasibility and validity of the ratio of the femoral vein diameter (FVD) to the femoral artery diameter (FAD) for predicting CVP and mPAP and to calculate the cut-off value for the FVD/FAD ratio to help judge a patient’s fluid volume status. Methods In this study, 130 patients were divided into two groups: in group A, the FVD, FAD, and CVP were measured, and in group B, the FVD, FAD, and mPAP were measured. We measured the FVD and FAD by ultrasound. We monitored CVP by a central venous catheter and mPAP by a Swan-Ganz floating catheter. Pearson correlation coefficients were calculated. The best cut-off value for the FVD/FAD ratio for predicting CVP and mPAP was obtained according to the receiver operating characteristic (ROC) curve. Results The FVD/FAD ratio was strongly correlated with CVP (R = 0.87, P < 0.0000) and mPAP (R = 0.73, P < 0.0000). According to the ROC curve, an FVD/FAD ratio ≥ 1.495 had the best test characteristics to predict a CVP ≥ 12 cmH2O, and an FVD/FAD ratio ≤ 1.467 had the best test characteristics to predict a CVP ≤ 10 cmH2O. An FVD/FAD ratio ≥ 2.03 had the best test characteristics to predict an mPAP ≥ 25 mmHg. According to the simple linear regression curve of the FVD/FAD ratio and CVP, when the predicted CVP ≤ 5 cmH2O, the FVD/FAD ratio was ≤ 0.854. Conclusion In this study, the measurement of the FVD/FAD ratio obtained via ultrasound was strongly correlated with CVP and mPAP, providing a non-invasive method for quickly and reliably assessing blood volume status and providing good clinical support.
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Affiliation(s)
- Zhihang Ma
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Jiaxin Gai
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yinghan Sun
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yunpeng Bai
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Hongyi Cai
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Lei Wu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Lixiu Sun
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Junyan Liu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Li Xue
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Bingchen Liu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
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Rupp T, Maufrais C, Walther G, Esteve F, Macdonald JH, Bouzat P, Verges S. MEDEX 2015: Prophylactic Effects of Positive Expiratory Pressure in Trekkers at Very High Altitude. Front Physiol 2021; 12:710622. [PMID: 34621182 PMCID: PMC8490760 DOI: 10.3389/fphys.2021.710622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Positive expiratory pressure (PEP) breathing has been shown to increase arterial oxygenation during acute hypoxic exposure but the underlying mechanisms and consequences on symptoms during prolonged high-altitude exposure remain to be elucidated. Methods: Twenty-four males (41 ± 16 years) were investigated, at sea level and at 5,085 m after 18 days of trekking from 570 m. Participants breathed through a face-mask with PEP = 0 cmH2O (PEP0, 0-45th min) and with PEP = 10 cmH2O (PEP10, 46-90th min). Arterial (SpO2), quadriceps and prefrontal (near infrared spectroscopy) oxygenation was measured continuously. Middle cerebral artery blood velocity (MCAv, transcranial Doppler), cardiac function (2D-echocardiography), extravascular lung water accumulation (UsLC, thoracic ultrasound lung comets) and acute mountain sickness (Lake Louise score, LLS) were assessed during PEP0 and PEP10. Results: At 5,085 m with PEP0, SpO2 was 78 ± 4%, UsLC was 8 ± 5 (a.u.) and the LLS was 2.3 ± 1.7 (all P < 0.05 versus sea level). At 5,085 m, PEP10 increased significantly SpO2 (+9 ± 5%), quadriceps (+2 ± 2%) and prefrontal cortex (+2 ± 2%) oxygenation (P < 0.05), and decreased significantly MCAv (-16 ± 14 cm.s-1) and cardiac output (-0.7 ± 1.2 L.min-1) together with a reduced stroke volume (-9 ± 15 mL, all P < 0.05) and no systemic hypotension. PEP10 decreased slightly the number of UsLC (-1.4 ± 2.7, P = 0.04) while the incidence of acute mountain sickness (LLS ≥ 3) fell from 42% with PEP0 to 25% after PEP10 (P = 0.043). Conclusion: PEP10 breathing improved arterial and tissue oxygenation and symptoms of acute mountain sickness after trekking to very high altitude, despite reduced cerebral perfusion and cardiac output. Further studies are required to establish whether PEP-breathing prophylactic mechanisms also occur in participants with more severe acute mountain sickness.
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Affiliation(s)
- Thomas Rupp
- Inter-University Laboratory of Human Movement Science (LIBM), University Savoie Mont Blanc, Chambéry, France
| | - Claire Maufrais
- Laboratoire de Pharm-Ecologie Cardiorespiratoire (LAPEC EA4278), Avignon University, Avignon, France.,HP2 Laboratory, INSERM, Grenoble Alpes University, Grenoble, France
| | - Guillaume Walther
- Laboratoire de Pharm-Ecologie Cardiorespiratoire (LAPEC EA4278), Avignon University, Avignon, France
| | - François Esteve
- RSRM EA7442, ID17-ESRF, Grenoble Alpes University, Grenoble, France
| | - Jamie Hugo Macdonald
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Bangor, United Kingdom
| | - Pierre Bouzat
- Pôle Anesthésie Réanimation, Grenoble Alpes University Hospital, Grenoble, France
| | - Samuel Verges
- HP2 Laboratory, INSERM, Grenoble Alpes University, Grenoble, France
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Lee KF, Lo EYJ, Wong KKC, Fung AKY, Chong CCN, Wong J, Ng KKC, Lai PBS. Acute kidney injury following hepatectomy and its impact on long-term survival for patients with hepatocellular carcinoma. BJS Open 2021; 5:6380640. [PMID: 34601569 PMCID: PMC8487667 DOI: 10.1093/bjsopen/zrab077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/19/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is increasingly being recognized after hepatectomy. This study aimed to identify factors predicting its occurrence and its impact on long-term outcome among patients with hepatocellular carcinoma (HCC). Methods This was a retrospective analysis of the incidence of AKI, factors predicting its occurrence, and its impact on patients undergoing hepatectomy between September 2007 and December 2018. A subgroup analysis included patients with histologically proven HCC. Results The incidence of AKI was 9.2 per cent in 930 patients. AKI was associated with increased mortality, morbidity, posthepatectomy liver failure (PHLF), and a longer hospital stay. On multivariable analysis, study period December 2013 to December 2018, diabetes mellitus, mean intraoperative BP below 72.1 mmHg, operative blood loss exceeding 377ml, high Model for End-Stage Liver Disease (MELD) score, and PHLF were predictive factors for AKI. Among 560 patients with HCC, hypertension, BP below 76.9 mmHg, blood loss greater than 378ml, MELD score, and PHLF were predictive factors. The 1-, 3-, and 5-year overall survival rates were 74.1, 59.2, and 51.6 per cent respectively for patients with AKI, and 91.8, 77.9, and 67.3 per cent for those without AKI. Corresponding 1-, 3-, and 5-year disease-free survival rates were 56.9, 42.3, and 35.4 per cent respectively in the AKI group, and 71.7, 54.5, and 46.2 per cent in the no-AKI group. AKI was an independent predictor of survival in multivariable analysis. Conclusion AKI is associated with longer hospital stay, and higher morbidity and mortality rates. It is also associated with shorter long-term survival among patients with HCC. To avoid AKI, control of blood loss and maintaining a reasonable BP (72–77 mmHg) during hepatectomy is important.
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Affiliation(s)
- K F Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - E Y J Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - K K C Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - A K Y Fung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - C C N Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - J Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - K K C Ng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - P B S Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
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Can Inferior Vena Cava Diameter and Collapsibility Index Be a Predictor in Detecting Preoperative Intravascular Volume Change in Pediatric Patients? JOURNAL OF CARDIOVASCULAR EMERGENCIES 2021. [DOI: 10.2478/jce-2021-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: Inferior vena cava (IVC) ultrasound measurement is a reliable indicator used in the assessment of intravascular volume status. The aim of this study was to evaluate intravascular volume changes in pediatric patients by measuring the IVC diameter and collapsibility index (CI) in children whose oral feeding was restricted preoperatively. Material and Methods: From May 2018 to October 2018, a total of 55 pediatric patients who were scheduled for surgery were included in this prospective, observational, cohort study. Fasting and satiety IVC diameters and CIs of patients were determined by ultrasonographic evaluation twice: in the preoperative preliminary evaluation, when the patients were satiated, and before surgery, during a fasting period of 6–8 hours. Ultra-sonographic data were recorded and compared between fasting and satiety periods. Results: In the grey scale (B-mode), mean IVC diameter was significantly higher when the patients were satiated, compared to the measurements made just before surgery during the fasting period. In the M-mode, the mean IVC diameter was significantly higher only during the inspiratory phase when the patients were satiated, while during the expiratory phase it was detected to be statistically similar. Mean CI was significantly higher in the immediate preoperative period, compared to the assessment made when satiated. Conclusion: Preoperative ultrasound IVC diameter and CI measurement can be a practical and useful method for evaluating preoperative intravascular volume in children.
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Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients. Infection 2021; 50:65-82. [PMID: 34110570 PMCID: PMC8803774 DOI: 10.1007/s15010-021-01637-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/31/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Fluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients. METHODS To assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon. RESULTS IVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO2 ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls. CONCLUSION In malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.
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Safadi S, Murthi S, Kashani KB. Use of Ultrasound to Assess Hemodynamics in Acutely Ill Patients. KIDNEY360 2021; 2:1349-1359. [PMID: 35369668 PMCID: PMC8676393 DOI: 10.34067/kid.0002322021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/01/2021] [Indexed: 02/04/2023]
Abstract
Early diagnosis of AKI and preventive measures can likely decrease the severity of the injury and improve patient outcomes. Current hemodynamic monitoring variables, including BP, heart and respiratory rates, temperature, and oxygenation status, have been used to identify patients at high risk for AKI. Despite the widespread use of such variables, their ability to accurately and timely detect patients who are high risk has been questioned. Therefore, there is a critical need to develop and validate tools that can measure new and more kidney-specific hemodynamic and laboratory variables, potentially assisting with AKI risk stratification, implementing appropriate and timely preventive measures, and hopefully improved outcomes. The new ultrasonography techniques provide novel insights into kidney hemodynamics and potential management and/or therapeutic targets. Contrast-enhanced ultrasonography; Doppler flow patterns of hepatic veins, portal vein, and intrakidney veins; and ultrasound elastography are among approaches that may provide such information, particularly related to vascular changes in AKI, venous volume excess or congestion, and fluid tolerance. This review summarizes the current state of these techniques and their relevance to kidney hemodynamic management.
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Affiliation(s)
- Sami Safadi
- Division of Critical Care Medicine, Alteon Health, Carroll Hospital, Westminster, Maryland
| | - Sarah Murthi
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Del Prete C, Freccero F, Lanci A, Hallowell GD, Bullone C, Castagnetti C, Pasolini MP. Transabdominal ultrasonographic measurement of caudal vena cava to aorta derived ratios in clinically healthy neonatal foals. Vet Med Sci 2021; 7:1451-1459. [PMID: 33939323 PMCID: PMC8464261 DOI: 10.1002/vms3.506] [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: 11/10/2020] [Accepted: 04/07/2021] [Indexed: 01/24/2023] Open
Abstract
Background Ultrasonographic measurement of the vena cava and aorta (Ao) diameters and their ratios have been suggested to be a reliable way of quantifying hypovolemia. Objective To evaluate the feasibility and reliability of an ultrasonographic technique for measurement of Ao and caudal vena cava (CVC) and derived ratios using three different acoustic windows in a population of healthy neonatal foals. Correlation between Ao and CVC measurements and ratios and foals' age or bodyweight were also investigated. Methods In 14 healthy foals aged less than 7 days, the diameters of the Ao and of the CVC in long and short axis were measured by two observers from images obtained using three different ultrasonographic imaging planes (left dorsal, left ventral and right views). The Ao and CVC cross‐sectional area and the CVC/Ao diameter and area ratios were calculated. Image quality was subjectively assessed. Intraobserver and interobserver reliabilities for image quality scores and measurements were evaluated between the two observers. Simple linear regression models were used to identify correlations between the CVC/Ao measurements and ratios and the age and bodyweight of the foals. Results The left ventral view showed the highest reliability. A correlation between bodyweight and the short axis measurement of the CVC was found (R2 = 0.385; p = 0.018). Age was positively correlated with the long axis of measurement of the CVC (R2 = 0.426; p = 0.011) and CVC/Ao diameter ratio (R2 = 0.625; p = 0.001). Conclusions The left ventral view allows the Ao and CVC cross sections to be easily visualized and measured in neonatal foals in right lateral recumbency.
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Affiliation(s)
- Chiara Del Prete
- Department of Veterinary Medicine and Animal Production, University of Naples Federico II, Naples, Italy
| | - Francesca Freccero
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Aliai Lanci
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Gayle D Hallowell
- School of Veterinary Medicine and Science, Sutton Bonington Campus, University of Nottingham, Leicestershire, UK
| | | | - Carolina Castagnetti
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy.,Health Science and Technologies Interdepartmental Center for Industrial Research (HST-ICIR), University of Bologna, Bologna, Italy
| | - Maria Pia Pasolini
- Department of Veterinary Medicine and Animal Production, University of Naples Federico II, Naples, Italy
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Hockstein MA, Haycock K, Wiepking M, Lentz S, Dugar S, Siuba M. Transthoracic Right Heart Echocardiography for the Intensivist. J Intensive Care Med 2021; 36:1098-1109. [PMID: 33853435 DOI: 10.1177/08850666211003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. MAIN RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. CONCLUSION The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
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Affiliation(s)
- Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Korbin Haycock
- Department of Emergency Medicine, 4608Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Matthew Wiepking
- Department of Emergency Medicine and Surgery, 12223University of Southern California-Keck School of Medicine, Los Angeles, CA, USA
| | - Skyler Lentz
- Division of Emergency Medicine and Pulmonary Disease & Critical Care Medicine, Department of Surgery and Medicine, Larner College of 12352Medicine-University of Vermont, Burlington, VT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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Hacıalioğulları F, Yılmaz F, Yılmaz A, Sönmez BM, Demir TA, Karadaş MA, Duyan M, Ayaz G, Özdemir M. Role of Point-of-Care Lung and Inferior Vena Cava Ultrasound in Clinical Decisions for Patients Presenting to the Emergency Department With Symptoms of Acute Decompensated Heart Failure. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:751-761. [PMID: 32865243 DOI: 10.1002/jum.15447] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This prospective study was performed to evaluate the diagnostic role of point-of-care lung ultrasound (LUS) and inferior vena cava (IVC) ultrasound in patients with acute decompensated heart failure (ADHF). METHODS A prospective cohort study was conducted between January 2018 and November 2018 on patients with a diagnosis of ADHF in the emergency department (ED). On admission, LUS findings, inspiratory and expiratory IVC diameters, and the inferior vena cava collapsibility index (IVCCI) were obtained. After therapeutic interventions, third-hour changes in LUS and the IVC index and the treatment response were assessed. RESULTS Eighty patients were enrolled. Forty-six (58%) patients had an ejection fraction (EF) greater than 40%, and 34 (42%) had an EF of less than 40%. Significant differences were detected between the admission and third-hour inspiratory IVC diameter, expiratory IVC diameter, and IVCCI (P = .001). There was no correlation between the EF and inspiratory IVC diameter (r = -0.03; P = .976), expiratory IVC diameter (r = -109; P = .336), or IVCCI (r = -0.72; P = .523) and between the B-type natriuretic peptide level and inspiratory IVC diameter (r = -0.58; P = .610), expiratory IVC diameter (r = -0.33; P = .774), or IVCCI (r = -0.78; P = .493) either. A comparison of admission and third-hour numbers of B-lines on LUS imaging showed a significant decrease in the number of B-lines in all zones at the end of 3 hours (P = .001). A significant difference existed between the hospitalized and discharged patients with respect to IVC diameters and number of B-lines. CONCLUSIONS In the ED setting, an assessment of B-lines and measurement of IVC diameters are better markers than the B-type natriuretic peptide level, EF, or chest x-ray for diagnosis of ADHF and can be used to make decisions for hospitalization or discharge from the ED.
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Affiliation(s)
| | - Fevzi Yılmaz
- Department of Emergency Medicine, Health Sciences University, Antalya Education and Research Hospital, Antalya, Turkey
| | - Aykut Yılmaz
- Department of Cardiology, Siirt State Hospital, Siirt, Turkey
| | - Bedriye Müge Sönmez
- Department of Emergency Medicine, Health Sciences University, Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Tayfun Anıl Demir
- Department of Emergency Medicine, Başkent University, Alanya Medical and Research Center, Alanya, Turkey
| | - Mehmet Akif Karadaş
- Alanya Medical and Research Center, Başkent University Hospital, Alanya, Turkey
| | | | - Gizem Ayaz
- Department of Emergency Medicine, Health Sciences University, Antalya Education and Research Hospital, Antalya, Turkey
| | - Metin Özdemir
- Department of Emergency Medicine, Istanbul Esenyurt Necmi Kadıoğlu State Hospital, Istanbul, Turkey
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