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Zhao J, Sun Y, Tang J, Guo K, Zhuge J, Fang H. Predictive value of trendelenburg position and carotid ultrasound for fluid responsiveness in patients on VV-ECMO with acute respiratory distress syndrome in the prone position. Sci Rep 2024; 14:31808. [PMID: 39738306 DOI: 10.1038/s41598-024-83038-7] [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: 08/01/2024] [Accepted: 12/11/2024] [Indexed: 01/01/2025] Open
Abstract
Fluid administration is widely used to treat hypotension in patients undergoing veno-venous extracorporeal membrane oxygenation (VV-ECMO). However, excessive fluid administration may lead to fluid overload can aggravate acute respiratory distress syndrome (ARDS) and increase patient mortality, predicting fluid responsiveness is of great significance for VV-ECMO patients. This prospective single-center study was conducted in a medical intensive care unit (ICU) and finally included 51 VV-ECMO patients with ARDS in the prone position (PP). Stroke volume index variation (ΔSVI), pulse pressure variation (PPV), stroke volume variation (SVV), baseline carotid corrected flow time (FTcBaseline), and respirophasic variation in carotid artery blood flow peak velocity (ΔVpeakCA) were taken before and after the Trendelenburg position or volume expansion. Fluid responsiveness was defined as a 15% or more increase in stroke volume index as assessed by transthoracic echocardiography after the volume expansion (VE). In our study, 33 patients (64.7%) were identified as fluid responders. Stroke volume index variation induced by the Trendelenburg position (ΔSVITrend), FTcBaseline, and ΔVpeakCA demonstrated superior predictive performance of fluid responsiveness. ΔSVITrend had an AUC of 0.89 (95% CI, 0.80-0.98) with an optimal threshold of 14.5% (95% CI, 12.5-21.5%), with the sensitivity and specificity were 82% (95% CI, 66-91%) and 83% (95% CI, 61-94%). FTcBaseline had an AUC of 0.87 (95% CI, 0.76-0.98) with an optimal threshold of 332ms (95% CI, 318-335ms), the sensitivity and specificity were 85% (95% CI, 69-93%) and 83% (95% CI, 61-94%), respectively. ΔVpeakCA showed an AUC of 0.83 (95% CI, 72-95), with a 10% optimal threshold (95% CI, 9-13%), sensitivity was 82% (95% CI, 66-91%) and specificity 78% (95% CI, 55-91%). ΔSVITrend, FTcBaseline and ΔVpeakCA could effectively predict fluid responsiveness in VV-ECMO patients with ARDS in the PP. Compared to ΔSVITrend and ΔVpeakCA, FTcBaseline is easier and more direct to acquire, and it does not require Trendelenburg position or VE, making it a more accessible and efficient option for assessing fluid responsiveness.
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Affiliation(s)
- Junjie Zhao
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Yong Sun
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Jing Tang
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Kai Guo
- Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Jiancheng Zhuge
- Quzhou Hospital of Traditional Chinese Medicine, Quzhou, 324000, Zhejiang, China.
| | - Honglong Fang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China.
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Solak S, Erkoç SK, Bermede OA, Bayar MK. Comparison of subclavian vein and inferior vena cava collapsibility index in the intensive care unit. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20240786. [PMID: 39630720 PMCID: PMC11639514 DOI: 10.1590/1806-9282.20240786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 09/13/2024] [Indexed: 12/07/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the correlation between changes in the inferior vena cava collapsibility index and subclavian vein collapsibility index in patients undergoing passive leg raising tests in the intensive care unit, considering that respiratory changes affecting the inferior vena cava may similarly affect the subclavian vein. METHODS This single-center observational study was conducted on patients aged between 18 and 85 years who underwent passive leg raising in the intensive care unit. When the patient was 45° above the bed, the inferior vena cava and subclavian vein were displayed using ultrasonography; subclavian vein collapsibility index and inferior vena cava collapsibility index values were calculated. After the initial values were recorded, passive leg raising was performed, and the initial measurements were repeated. The CI values measured after passive leg raising were subtracted from those calculated before passive leg raising to determine the changes (Δ) in inferior vena cava and subclavian vein collapsibility indices. RESULTS The study was conducted with a total of 64 patients. The mean±standard deviation values for ΔIVC-CI% and ΔSCV-CI% variables were found as 8.97±8.89 and 10.31±10.81, respectively. There were no statistically significant differences in values of ΔIVC-CI% and ΔSCV-CI% (p=0.297). In the Bland-Altman plot, because there were only two values exceeding the +1.96 SD and -1.96 SD limits, it can be said that the agreement between ΔIVC-CI% and ΔSCV-CI% was adequate. CONCLUSION ΔSCV-CI% values are compatible and correlated with ΔIVC-CI% values. Inferior vena cava and subclavian vein responded similarly to fluid changes during passive leg raising.
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Affiliation(s)
- Serkan Solak
- Ankara University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Ankara, Turkey
| | - Suheyla Karadag Erkoç
- Ankara University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Ankara, Turkey
| | - Onat Ahmet Bermede
- Ankara University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Ankara, Turkey
| | - Mustafa Kemal Bayar
- Ankara University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Ankara, Turkey
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Dai S, Wang C, Tao X, Shen J, Xu L. Predicting fluid responsiveness in spontaneously breathing parturients undergoing caesarean section via carotid artery blood flow and velocity time integral measured by carotid ultrasound: a prospective cohort study. BMC Pregnancy Childbirth 2024; 24:60. [PMID: 38216901 PMCID: PMC10785346 DOI: 10.1186/s12884-024-06246-z] [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: 06/05/2023] [Accepted: 01/01/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Present evidence suggests that the Doppler ultrasonographic indices, such as carotid artery blood flow (CABF) and velocity time integral (VTI), had the ability to predict fluid responsiveness in non-obstetric patients. The purpose of this study was to assess their capacity to predict fluid responsiveness in spontaneous breathing parturients undergoing caesarean section and to determine the effect of detecting and management of hypovolemia (fluid responsiveness) on the incidence of hypotension after anaesthesia. METHODS A total of 72 full term singleton parturients undergoing elective caesarean section were enrolled in this study. CABF, VTI, and hemodynamic parameters were recorded before and after fluid challenge and assessed by carotid artery ultrasonography. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. RESULTS Thirty-one (43%) patients were fluid responders. The area under the ROC curve to predict fluid responsiveness for CABF and VTI were 0.803 (95% CI, 0.701-0.905) and 0.821 (95% CI, 0.720-0.922). The optimal cut-off values of CABF and VTI for fluid responsiveness was 175.9 ml/min (sensitivity of 74.0%; specificity of 78.0%) and 8.7 cm/s (sensitivity of 67.0%; specificity of 90.0%). The grey zone for CABF and VTI were 114.2-175.9 ml/min and 6.8-8.7 cm/s. The incidence of hypotension after the combined spinal-epidural anaesthesia (CSEA) was significantly higher in the Responders group 25.8% (8/31) than in the Non-Responders group 17.1(7/41) (P < 0.001). The total incidence of hypotension after CSEA of the two groups was 20.8% (15/72). CONCLUSIONS Ultrasound evaluation of CABF and VTI seem to be the feasible parameters to predict fluid responsiveness in parturients undergoing elective caesarean section and detecting and management of hypovolemia (fluid responsiveness) could significantly decrease incidence of hypotension after anaesthesia. TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org ), registration number was ChiCTR1900022327 (The website link: https://www.chictr.org.cn/showproj.html?proj=37271 ) and the date of trial registration was in April 5, 2019. This study was performed in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Women's Hospital, Zhejiang University School of Medicine (20,180,120).
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Affiliation(s)
- Shaobing Dai
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chun Wang
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xia Tao
- Department of Ultrasound, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jianjun Shen
- Department of Anaesthesiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Lili Xu
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, Zhejiang Province, China.
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Suriani I, van Houte J, de Boer EC, van Knippenberg L, Manzari S, Mischi M, Bouwman RA. Carotid Doppler ultrasound for non-invasive haemodynamic monitoring: a narrative review. Physiol Meas 2023; 43. [PMID: 36179705 DOI: 10.1088/1361-6579/ac96cb] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
Objective.Accurate haemodynamic monitoring is the cornerstone in the management of critically ill patients. It guides the optimization of tissue and organ perfusion in order to prevent multiple organ failure. In the past decades, carotid Doppler ultrasound (CDU) has been explored as a non-invasive alternative for long-established invasive haemodynamic monitoring techniques. Considering the large heterogeneity in reported studies, we conducted a review of the literature to clarify the current status of CDU as a haemodynamic monitoring tool.Approach.In this article, firstly an overview is given of the equipment and workflow required to perform a CDU exam in clinical practice, the limitations and technical challenges potentially faced by the CDU sonographer, and the cerebrovascular mechanisms that may influence CDU measurement outcomes. The following chapter describes alternative techniques for non-invasive haemodynamic monitoring, detailing advantages and limitations compared to CDU. Next, a comprehensive review of the literature regarding the use of CDU for haemodynamic monitoring is presented. Furthermore, feasibility aspects, training requirements and technical developments of CDU are addressed.Main results.Based on the outcomes of these studies, we assess the applicability of CDU-derived parameters within three clinical domains (cardiac output, volume status, and fluid responsiveness), and amongst different patient groups. Finally, recommendations are provided to improve the quality and standardization of future research and clinical practice in this field.Significance.Although CDU is not yet interchangeable with invasive 'gold standard' cardiac output monitoring, the present work shows that certain CDU-derived parameters prove promising in the context of functional haemodynamic monitoring.
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Affiliation(s)
- Irene Suriani
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Joris van Houte
- Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Esmée C de Boer
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Luuk van Knippenberg
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Sabina Manzari
- Philips Research High Tech Campus 34, 5656 AE Eindhoven, The Netherlands
| | - Massimo Mischi
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands.,Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
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Khan S, Mishra SK, Parida S, Jha AK, Nagabhushanam Padala SRA. Carotid doppler indices do not predict fluid responsiveness in mechanically ventilated patients undergoing coronary artery bypass grafting surgery. J Card Surg 2022; 37:4418-4424. [PMID: 36251251 DOI: 10.1111/jocs.17035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY This study aimed to determine the predictive value of carotid artery blood flow (CABF), corrected carotid flow time (CFT), and respiratory variation in carotid peak systolic velocity (DVPeakCA) for fluid responsiveness in mechanically ventilated patients undergoing coronary artery bypass grafting (CABG) surgery. It also aimed to correlate each of these indices with changes in stroke volume index (SVI) after a fluid bolus. METHODS This prospective, interventional, before-after study recruited 45 adult patients undergoing CABG. Following induction of anesthesia, a fluid challenge of 6 ml/kg of a crystalloid solution was delivered over 10 min. Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), CABF, CFT, and DVPeakCA were recorded before and following the intervention. Patients with an increase in SVI of >15% from baseline were considered responders. RESULTS We had 22 responders and 23 nonresponders. Areas under the receiver operating characteristic (AUROC) curves for the studied indices (CABF, 0.516, CFT, 0.502, and DVPeakCA, 0.671) did not suggest any strong predictive value to detect fluid responsiveness. Similarly, the r values for correlation of these carotid doppler-derived indices, both baseline and as % change from baseline with the % alteration of SVI were all <0.2, which demonstrates a very weak correlation between these variables. CONCLUSIONS Carotid doppler indices are unreliable to assess fluid responsiveness, and cannot replace invasive methods of analyzing preload optimization. There was no significant correlation between carotid doppler-derived indices and alterations in SVI before and after the fluid bolus.
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Affiliation(s)
- Saba Khan
- Department of Anaesthesiology, Universal College of Medical Sciences, Bhairahawa, Nepal
| | | | - Satyen Parida
- Department of Anaesthesiology& Critical Care, JIPMER, Pondicherry, India
| | - Ajay Kumar Jha
- Department of Anaesthesiology& Critical Care, JIPMER, Pondicherry, India
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Grau-Mercier L, Coisy F, Markarian T, Muller L, Roger C, Lefrant JY, Claret PG, Bobbia X. Can blood loss be assessed by echocardiography? An experimental study on a controlled hemorrhagic shock model in piglets. J Trauma Acute Care Surg 2022; 92:924-930. [PMID: 34991127 DOI: 10.1097/ta.0000000000003518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment of the volemic loss is a major challenge during the management of hemorrhagic shock. Echocardiography is an increasingly used noninvasive tool for hemodynamic assessment. In mechanically ventilated patients, some studies suggest that respiratory variations of mean subaortic time-velocity integral (∆VTI) would be predictive of fluid filling response. An experimental model of controlled hemorrhagic shock provides a precise approach to study correlation between blood volume and cardiac ultrasonographic parameters. OBJECTIVES The main objective was to analyze the ∆VTI changes during hemorrhage in an anesthetized-piglet model of controlled hemorrhagic shock. The secondary objective was to evaluate ∆VTI during the resuscitation process after hemorrhage and other echocardiographic parameters changes during the whole protocol. METHODS Twenty-four anesthetized and ventilated piglets were bled until mean arterial pressure reached 40 mm Hg. Controlled hemorrhage was maintained for 30 minutes before randomizing the piglets to two resuscitation groups: fluid filling group resuscitated with saline solution and noradrenaline group resuscitated with saline solution and noradrenaline. Echocardiography and hemodynamic measures, including pulsed pressure variations (PPV), were performed at different stages of the protocol. RESULTS The correlation coefficient between ΔVTI and PPV with the volume of bleeding during the hemorrhagic phase were respectively 0.24 (95% confidence interval, 0.08-0.39; p < 0.01) and 0.57 (95% CI, 0.44-0.67; p < 0.01). Two parameters had a moderate correlation coefficient with hemorrhage volume (over 0.5): mean subaortic time-velocity index (VTI) and mitral annulus diastolic tissular velocity (E'). CONCLUSION In this hemorrhagic shock model, ΔVTI had a low correlation with the volume of bleeding, but VTI and E' had a correlation with blood volume comparable to that of PPV.
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Affiliation(s)
- Laura Grau-Mercier
- From the Division of Anesthesiology, Critical Care, Pain and Emergency Medicine (L.G.-M., F.C., L.M., C.R., J.-Y.L., P.-G.C.), Nîmes University Hospital, Prévention et prise en charge de la défaillance circulatoire des patients en état de choc (IMAGINE), University of Montpellier, Nîmes; Department of Emergency Medicine (T.M.), Timone University Hospital, Marseille; and Department of Emergency Medicine (X.B.), Montpellier University Hospital Université de Montpellier, Prévention et prise en charge de la défaillance circulatoire des patients en état de choc (IMAGINE), University of Montpellier, Montpellier, France
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Elbadry AA, El dabe A, Abu Sabaa MA. Pre-operative Ultrasonographic Evaluation of the Internal Jugular Vein Collapsibility Index and Inferior Vena Cava Collapsibility Index to Predict Post Spinal Hypotension in Pregnant Women Undergoing Caesarean Section. Anesth Pain Med 2022; 12:e121648. [PMID: 35433379 PMCID: PMC8995868 DOI: 10.5812/aapm.121648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Post spinal anesthesia hypotension (PSAH) is frequently encountered in anesthetic practice, especially during cesarean section. Ultrasound is a safe and easy technique for hemodynamic monitoring. Objectives: This study was conducted to assess the efficacy of pre-operative inferior vena cava collapsibility index (IVCCI) and internal jugular vein collapsibility index (IJVCI) in predicting PSAH. Methods: This cross-sectional blinded study included 55 pregnant females prepared for elective cesarean section. They were divided into two groups based on the incidence of PSAH: (1) cases with PSAH (26 cases); and (2) cases without PSAH (29 cases). All the cases underwent ultrasound-guided measurement of IVCCI and IJVCI. The efficacy of these parameters was assessed in predicting PSAH. Results: Cases in both groups expressed non-significant differences regarding demographic data. However, IVCCI had mean values of 38.27 and 23.97%, while IJVCCI had mean values of 46.50 and 33.41%, respectively, in cases with and without PSAH. For IVCCI, using a cut-off point of 33% had sensitivity and specificity (84.6 and 93.1%, respectively) for predicting PSAH, with a diagnostic accuracy of 89.1%. IJVCI had sensitivity and specificity of 84.6 and 82.8%, respectively, for predicting the same complication using a cut-off value of 38.5%. Conclusion: IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.
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Affiliation(s)
- Amr Arafa Elbadry
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
- Corresponding Author: Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Ahmed El dabe
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Motaz Amr Abu Sabaa
- Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
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Beier L, Davis J, Esener D, Grant C, Fields JM. Carotid Ultrasound to Predict Fluid Responsiveness: A Systematic Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1965-1976. [PMID: 32314817 DOI: 10.1002/jum.15301] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To perform a systematic review of the accuracy of carotid ultrasound measures in determining volume responsiveness in adults. METHODS We conducted a systematic review of Ovid MEDLINE and Scopus from conception until January 1, 2019. Two independent reviewers used an iterative process to identify relevant articles and abstract information from them. The quality and risk of bias were assessed with the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. RESULTS We identified 17 relevant articles with 956 patients. The 2 most frequently cited carotid measures of fluid responsiveness were corrected flow time and peak velocity or change in peak velocity with respiration (ΔCDPV). Accordingly, the diagnostic characteristics of corrected flow time in these studies varied widely, with sensitivities from 60% to 73%, specificities from 82% to 92%, and areas under the receiver operating characteristic curves from 0.75 to 0.88. Optimal cutoff values for ΔCDPV ranged from 9.1% to 14%, with areas under the receiver operating characteristic curves from 0.81 to 0.91, sensitivities from 73% to 86%, and specificities from 78% to 86%. Other measures, such as carotid blood flow and carotid diameter, had limited data to support their use. Heterogeneity of the studies prohibited a meta-analysis. Most studies had a moderate risk of bias and high applicability. CONCLUSIONS Preliminary research suggests that carotid ultrasound measures may be useful adjunct measures of fluid status; however, they should not be interpreted as absolute and should be placed in a clinical context. The most well-defined and supported measure currently is ΔCDPV, with cutoffs from 9% to 14%. Corrected flow time shows promise, because of heterogeneity of how this value is measured, an optimal cutoff has not been established.
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Affiliation(s)
- Lance Beier
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Joshua Davis
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Charles Grant
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - J Matthew Fields
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Patel AK, Mistry K, Breslin K, Shokoohi H, Thomas-Mohtat R. Carotid Artery Flow Time Measured by Point-of-Care Ultrasound Correlates with Volume Changes in Pediatric Hemodialysis Patients. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1670-1676. [PMID: 32387153 DOI: 10.1016/j.ultrasmedbio.2020.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
Carotid artery flow time corrected for heart rate (CFTc) correlates with intravascular volume changes in adults but has not been studied adequately in the pediatric population. We studied how fluid status changes correlate with CFTc in pediatric patients undergoing hemodialysis. This prospective observational study involved pediatric patients aged 5-18 y undergoing chronic hemodialysis at a tertiary care children's hospital in the United States. We measured CFTc by point-of-care ultrasound before and after each hemodialysis session, including passive leg raise. One hundred sixty-eight CFTc measurements were obtained from a total of 21 patient encounters. Post-dialysis CFTc decreased by 21.7 ms (95% confidence interval: 12.3-31.0) (p < 0.001). Pre- and post-dialysis ∆CFTc measurements were proportionally correlated with volume removed in dialysis adjusted for weight (mL/kg) (R2 = 0.224, p = 0.03). There was no significant change in mean CFTc with passive leg raise before or after hemodialysis. In children on hemodialysis, changes in CFTc were moderately correlated with decrease in intravascular volume after hemodialysis.
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Affiliation(s)
- Amit K Patel
- Division of Pediatric Emergency Medicine and Trauma Services, Children's National Health System, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Kirtida Mistry
- Division of Pediatric Nephrology, Children's National Health System, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Kristen Breslin
- Division of Pediatric Emergency Medicine and Trauma Services, Children's National Health System, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rosemary Thomas-Mohtat
- Division of Pediatric Emergency Medicine and Trauma Services, Children's National Health System, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.
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Parenti N, Bastiani L, Palazzi C, Urrea K, Silingardi M. Could Duplex carotid ultrasound be useful in the assessment of volume status and fluid responsiveness? Eur J Intern Med 2020; 76:110-114. [PMID: 32089423 DOI: 10.1016/j.ejim.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Nicola Parenti
- Department of Internal Medicine of Maggiore Hospital, Bologna, Italy.
| | - Luca Bastiani
- Department of Biostatistics, Istituto Fisiologia Clinica CNR, Pisa, Italy
| | | | | | - Mauro Silingardi
- Department of Internal Medicine, Maggiore Hospital, Bologna, Italy
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Osgood R, Mohan S, John L, Stirling E, Stirling S. In training emergency physicians the carotid artery Doppler with passive leg raise, does previous sonographic experience influence scan time and competency? Australas J Ultrasound Med 2020; 24:20-26. [PMID: 34760607 DOI: 10.1002/ajum.12204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/09/2022] Open
Abstract
Background Determination of fluid responsiveness (FR) associated with intravascular fluid resuscitation in hypotensive patients poses a challenge, with current best evidence methods fraught with poor retest reliability and difficulty in image acquisition (Osman, Crit Care Med 2007; 35: 64; Marik, Crit Care Med 2009; 37: 2642). Doppler carotid blood flow with passive leg raise (PLR) is a recent modality for determining FR (Marik, Chest 2013; 143: 364). Purpose This study aimed to determine whether emergency physicians with limited ultrasound experience can reliably acquire this skill. Method This prospective study recruited 60 emergency physicians with varying experience, who underwent a 3-step learning programme. Participants performed carotid velocity time integral (VTi) Doppler on healthy subjects, followed by repeat measurements in the PLR position. A 16-point checklist and time recorded were assessed for each sonographer, with each participant completing a post-study questionnaire to evaluate perceived competence and ease of skill acquisition. Results Of the 60 emergency physicians recruited, 37 (61.6%) were inexperienced and 23 (38.4%) were experienced. Against the 16-point assessment, 61% completed assessment without any errors. Fifty-six out of 60 (94.3%) completed the assessment to acceptable standard with errors recognised and corrected, and four participants (6.7%) made critical errors without correction (Figure 1). Average (±SEM) total scan time was 4:52 ± 0:19, with no significant difference found between inexperienced and experienced groups. Conclusions This study demonstrated feasibility to train emergency physicians, demonstrating that average FR assessment was obtained within 5 min, with no difference between prior experience in scan quality/time taken. 94% completed the scan to acceptable standards, demonstrating ease of carotid Doppler flow with PLR to provide critical information in management of the hypotensive patient.
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Affiliation(s)
- Robert Osgood
- Emergency Department Metro South Health Logan Hospital Meadowbrook Queensland Australia.,Emergency Centre Ramsay Health Greenslopes Hospital Greenslopes Queensland Australia
| | - Sangeeth Mohan
- Emergency Department Metro South Health Logan Hospital Meadowbrook Queensland Australia.,Emergency Department Launceston General Hospital Launceston Tasmania Australia
| | - Lisa John
- Emergency Department Metro South Health Logan Hospital Meadowbrook Queensland Australia.,The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Erin Stirling
- Emergency Department Metro South Health Logan Hospital Meadowbrook Queensland Australia
| | - Scott Stirling
- Emergency Department Metro South Health Logan Hospital Meadowbrook Queensland Australia
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McGregor D, Sharma S, Gupta S, Ahmed S, Harris T. Emergency department non-invasive cardiac output study (EDNICO): an accuracy study. Scand J Trauma Resusc Emerg Med 2020; 28:8. [PMID: 32005274 PMCID: PMC6995135 DOI: 10.1186/s13049-020-0704-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/19/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assess here the accuracy of five non-invasive methods in detecting fluid responsiveness in the ED: (1) common carotid artery blood flow, (2) suprasternal aortic Doppler, (3) bioreactance, (4) plethysmography with digital vascular unloading method, and (5) inferior vena cava collapsibility index. Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients. METHODS This is a prospective observational study of non-invasive methods for assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Sensitivity and specificity of each method in determining the fluid responsiveness status of participants is determined in comparison to the reference standard. RESULTS Thirty-three patient data sets were included for analysis. The specificity and sensitivity to detect fluid responders was 46.2 and 45% for common carotid artery blood flow (CCABF), 61.5 and 63.2% for suprasternal artery Doppler (SSAD), 46.2 and 50% for bioreactance, 50 and 41.2% for plethysmography vascular unloading technique (PVUT), and 63.6 and 47.4% for inferior vena cava collapsibility index (IVCCI), respectively. Analysis of agreement with Cohen's Kappa - 0.08 for CCABF, 0.24 for SSAD, - 0.04 for bioreactance, - 0.08 for PVUT, and 0.1 for IVCCI. CONCLUSION In this study, non-invasive methods were not found to reliably identify fluid responders. Non-invasive methods of identifying fluid responders are likely to play a key role in improving patient outcome in the ED in fluid depleted states such as sepsis. These results have implications for future studies assessing the accuracy of such methods.
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Affiliation(s)
- David McGregor
- Queen Mary University London and Barts Health NHS Trust, London, UK.
| | - Shrey Sharma
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - Saksham Gupta
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - Shanaz Ahmed
- Emergency Department Research Group, Royal London Hospital, London, UK
| | - Tim Harris
- Queen Mary University London and Barts Health NHS Trust, London, UK
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Chacon MM, Markin NW. Part of the Great Fluid Debate—Are Fasting Patients Hypovolemic? J Cardiothorac Vasc Anesth 2019; 33:2428-2430. [DOI: 10.1053/j.jvca.2019.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 11/11/2022]
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Singh Y, Anand RK, Gupta S, Chowdhury SR, Maitra S, Baidya DK, Singh AK. Role of IVC collapsibility index to predict post spinal hypotension in pregnant women undergoing caesarean section. An observational trial. Saudi J Anaesth 2019; 13:312-317. [PMID: 31572075 PMCID: PMC6753747 DOI: 10.4103/sja.sja_27_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Postspinal anesthesia hypotension (PSH) in pregnant women is common and may lead to poor maternal and fetal outcome. Fluid loading in pregnant women before spinal anesthesia to prevent hypotension is of limited ability. We hypothesized that those women who are hypovolemic before spinal anesthesia may be at risk of PSH and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients. Methods: In this prospective observational study, n = 45 women undergoing elective lower segment cesarean section with singleton pregnancy were recruited and IVCCI in left lateral tilt (with wedge) and supine position (without wedge) were noted by M-mode ultrasound (USG) before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted till 15 min after spinal anesthesia. Results: USG measurements were obtained in 40 patients and 23 of 40 patients (57.5%) had at least one episode of hypotension. Area under the ROC curve of IVCCI with wedge to predict PSH was 0.46 (95% CI 0.27, 0.64) and best cut-of value was 25.64 with a sensitivity and specificity of 60.9% and 35.5%, respectively. Area under the ROC curve of IVCCI without wedge to predict PSH was 0.38 (95% CI 0.19, 0.56) and best cut-of value was 20.4 with a sensitivity and specificity of 69.6% and 23.5%, respectively. Conclusion: We conclude that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section.
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Affiliation(s)
- Yudhyavir Singh
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Rahul K Anand
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Stuti Gupta
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Sumit Roy Chowdhury
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Akhil K Singh
- Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India
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Girotto V, Teboul JL, Beurton A, Galarza L, Guedj T, Richard C, Monnet X. Carotid and femoral Doppler do not allow the assessment of passive leg raising effects. Ann Intensive Care 2018; 8:67. [PMID: 29845417 PMCID: PMC5975047 DOI: 10.1186/s13613-018-0413-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 05/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The hemodynamic effects of the passive leg raising (PLR) test must be assessed through a direct measurement of cardiac index (CI). We tested whether changes in Doppler common carotid blood flow (CBF) and common femoral artery blood flow (FBF) could detect a positive PLR test (increase in CI ≥ 10%). We also tested whether CBF and FBF changes could track simultaneous changes in CI during PLR and volume expansion. In 51 cases, we measured CI (PiCCO2), CBF and FBF before and during a PLR test (one performed for CBF and another for FBF measurements) and before and after volume expansion, which was performed if PLR was positive. RESULTS Due to poor echogenicity or insufficient Doppler signal quality, CBF could be measured in 39 cases and FBF in only 14 cases. A positive PLR response could not be detected by changes in CBF, FBF, carotid nor by femoral peak systolic velocities (areas under the receiver operating characteristic curves: 0.58 ± 0.10, 0.57 ± 0.16, 0.56 ± 0.09 and 0.64 ± 10, respectively, all not different from 0.50). The correlations between simultaneous changes in CI and CBF and in CI and FBF during PLR and volume expansion were not significant (p = 0.41 and p = 0.27, respectively). CONCLUSION Doppler measurements of CBF and of FBF, as well as measurements of their peak velocities, are not reliable to assess cardiac output and its changes.
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Affiliation(s)
- Valentina Girotto
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Alexandra Beurton
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Laura Galarza
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thierry Guedj
- Service de Radiologie, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Christian Richard
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Insert UMR_999, Université Paris-Sud, Assistance Publique - Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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Elwan MH, Roshdy A, Reynolds JA, Elsharkawy EM, Eltahan SM, Coats TJ. What is the normal haemodynamic response to passive leg raise? A study of healthy volunteers. Emerg Med J 2018; 35:544-549. [PMID: 29728410 DOI: 10.1136/emermed-2017-206836] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/13/2017] [Accepted: 04/27/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Passive leg raise (PLR) is used as self-fluid challenge to optimise fluid therapy by predicting preload responsiveness. However, there remains uncertainty around the normal haemodynamic response to PLR with resulting difficulties in application and interpretation in emergency care. We aim to define the haemodynamic responses to PLR in spontaneously breathing volunteers using a non-invasive cardiac output monitor, thoracic electrical bioimpedance, TEB (PLR-TEB). METHODS We recruited healthy volunteers aged 18 or above. Subjects were monitored using TEB in a semirecumbent position, followed by PLR for 3 min. The procedure was repeated after 6 min at the starting position. Correlation between the two PLRs was assessed using Spearman's r (rs). Agreement between the two PLRs was evaluated using Cohen Kappa with responsiveness defined as ≥10% increase in stroke volume. Parametric and non-parametric tests were used as appropriate to evaluate statistical significance of baseline variables between responders and non-responders. RESULTS We enrolled 50 volunteers, all haemodynamically stable at baseline, of whom 49 completed the study procedure. About half of our subjects were preload responsive. The ∆SV in the two PLRs was correlated (rs=0.68, 95% CI 0.49 to 0.8) with 85% positive concordance. Good agreement was observed with Cohen Kappa of 0.67 (95% CI 0.45 to 0.88). Responders were older and had significantly lower baseline stroke volume and cardiac output. CONCLUSION Our results suggest that the PLR-TEB is a feasible method in spontaneously breathing volunteers with reasonable reproducibility. The age and baseline stroke volume effect suggests a more complex underlying physiology than commonly appreciated. The fact that half of the volunteers had a positive preload response, against the 10% threshold, leads to questions about how this measurement should be used in emergency care and will help shape future patient studies.
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Affiliation(s)
- Mohammed H Elwan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt.,Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ashraf Roshdy
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt.,General Intensive Care Unit, Queen Elizabeth, Lewisham and Greenwich NHS Trust, London, UK
| | - Joseph A Reynolds
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Salah M Eltahan
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Timothy J Coats
- Emergency Medicine Academic Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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