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Sipmann FS, Giralt JAS, Tusman G. Monitoring CO2 kinetics as a marker of cardiopulmonary efficiency. Curr Opin Crit Care 2024; 30:251-259. [PMID: 38690954 DOI: 10.1097/mcc.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW To describe current and near future developments and applications of CO2 kinetics in clinical respiratory and cardiovascular monitoring. RECENT FINDINGS In the last years, we have witnessed a renewed interest in CO2 kinetics in relation with a better understanding of volumetric capnography and its derived parameters. This together with technological advances and improved measurement systems have expanded the monitoring potential of CO2 kinetics including breath by breath continuous end-expiratory lung volume and continuous noninvasive cardiac output. Dead space has slowly been gaining relevance in clinical monitoring and prognostic evaluation. Easy to measure dead space surrogates such as the ventilatory ratio have demonstrated a strong prognostic value in patients with acute respiratory failure. SUMMARY The kinetics of carbon dioxide describe many relevant physiological processes. The clinical introduction of new ways of assessing respiratory and circulatory efficiency based on advanced analysis of CO2 kinetics are paving the road to a long-desired goal in clinical monitoring of critically ill patients: the integration of respiratory and circulatory monitoring during mechanical ventilation.
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Affiliation(s)
- Fernando Suarez Sipmann
- Department of Intensive Care Medicine, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid
- Ciber de enfermedades respiratorias, Instituto Carlos III, Madrid, Spain
| | - Juan Antonio Sanchez Giralt
- Department of Intensive Care Medicine, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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Chun EH, Chung MH, Kim JE, Lee HS, Jo Y, Jun JH. Use of stepwise lung recruitment maneuver to predict fluid responsiveness under lung protective ventilation in the operating room. Sci Rep 2024; 14:11649. [PMID: 38773192 PMCID: PMC11109109 DOI: 10.1038/s41598-024-62355-x] [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: 10/06/2023] [Accepted: 05/16/2024] [Indexed: 05/23/2024] Open
Abstract
Recent research has revealed that hemodynamic changes caused by lung recruitment maneuvers (LRM) with continuous positive airway pressure can be used to identify fluid responders. We investigated the usefulness of stepwise LRM with increasing positive end-expiratory pressure and constant driving pressure for predicting fluid responsiveness in patients under lung protective ventilation (LPV). Forty-one patients under LPV were enrolled when PPV values were in a priori considered gray zone (4% to 17%). The FloTrac-Vigileo device measured stroke volume variation (SVV) and stroke volume (SV), while the patient monitor measured pulse pressure variation (PPV) before and at the end of stepwise LRM and before and 5 min after fluid challenge (6 ml/kg). Fluid responsiveness was defined as a ≥ 15% increase in the SV or SV index. Seventeen were fluid responders. The areas under the curve for the augmented values of PPV and SVV, as well as the decrease in SV by stepwise LRM to identify fluid responders, were 0.76 (95% confidence interval, 0.61-0.88), 0.78 (0.62-0.89), and 0.69 (0.53-0.82), respectively. The optimal cut-offs for the augmented values of PPV and SVV were > 18% and > 13%, respectively. Stepwise LRM -generated augmented PPV and SVV predicted fluid responsiveness under LPV.
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Affiliation(s)
- Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngbum Jo
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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Messina A, Caporale M, Calabrò L, Lionetti G, Bono D, Matronola GM, Brunati A, Frassanito L, Morenghi E, Antonelli M, Chew MS, Cecconi M. Reliability of pulse pressure and stroke volume variation in assessing fluid responsiveness in the operating room: a metanalysis and a metaregression. Crit Care 2023; 27:431. [PMID: 37940953 PMCID: PMC10631038 DOI: 10.1186/s13054-023-04706-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pulse pressure and stroke volume variation (PPV and SVV) have been widely used in surgical patients as predictors of fluid challenge (FC) response. Several factors may affect the reliability of these indices in predicting fluid responsiveness, such as the position of the patient, the use of laparoscopy and the opening of the abdomen or the chest, combined FC characteristics, the tidal volume (Vt) and the type of anesthesia. METHODS Systematic review and metanalysis of PPV and SVV use in surgical adult patients. The QUADAS-2 scale was used to assess the risk of bias of included studies. We adopted a metanalysis pooling of aggregate data from 5 subgroups of studies with random effects models using the common-effect inverse variance model. The area under the curve (AUC) of pooled receiving operating characteristics (ROC) curves was reported. A metaregression was performed using FC type, volume, and rate as independent variables. RESULTS We selected 59 studies enrolling 2,947 patients, with a median of fluid responders of 55% (46-63). The pooled AUC for the PPV was 0.77 (0.73-0.80), with a mean threshold of 10.8 (10.6-11.0). The pooled AUC for the SVV was 0.76 (0.72-0.80), with a mean threshold of 12.1 (11.6-12.7); 19 studies (32.2%) reported the grey zone of PPV or SVV, with a median of 56% (40-62) and 57% (46-83) of patients included, respectively. In the different subgroups, the AUC and the best thresholds ranged from 0.69 and 0.81 and from 6.9 to 11.5% for the PPV, and from 0.73 to 0.79 and 9.9 to 10.8% for the SVV. A high Vt and the choice of colloids positively impacted on PPV performance, especially among patients with closed chest and abdomen, or in prone position. CONCLUSION The overall performance of PPV and SVV in operating room in predicting fluid responsiveness is moderate, ranging close to an AUC of 0.80 only some subgroups of surgical patients. The grey zone of these dynamic indices is wide and should be carefully considered during the assessment of fluid responsiveness. A high Vt and the choice of colloids for the FC are factors potentially influencing PPV reliability. TRIAL REGISTRATION PROSPERO (CRD42022379120), December 2022. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=379120.
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Affiliation(s)
- Antonio Messina
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
| | - Mariagiovanna Caporale
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lorenzo Calabrò
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Giulia Lionetti
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Daniele Bono
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Guia Margherita Matronola
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Andrea Brunati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Luciano Frassanito
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Emanuela Morenghi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Capnography for Monitoring of the Critically Ill Patient. Clin Chest Med 2022; 43:393-400. [PMID: 36116809 DOI: 10.1016/j.ccm.2022.04.002] [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: 11/21/2022]
Abstract
Capnography has been widely adopted in multiple clinical areas. The capnogram and end-tidal carbon dioxide offer a wealth of information, in the right clinical setting, and when properly interpreted. In this article, the authors aim to review the most common clinical scenarios during which capnography has been shown to be of benefit. This includes the areas of fluid responsiveness, cardiopulmonary resuscitation, and conscious sedation. They review the published literature, highlighting its pitfalls and identifying its limitations.
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Ability of short-time low peep challenge to predict fluid responsiveness in mechanically ventilated patients in the intensive care. J Clin Monit Comput 2021; 36:1165-1172. [PMID: 34476670 PMCID: PMC8412862 DOI: 10.1007/s10877-021-00752-7] [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: 02/23/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022]
Abstract
Short-time low PEEP challenge (SLPC, application of additional 5 cmH2O PEEP to patients for 30 s) is a novel functional hemodynamic test presented in the literature. We hypothesized that SLPC could predict fluid responsiveness better than stroke volume variation (SVV) in mechanically ventilated intensive care patients. Heart rate, mean arterial pressure, stroke volume index (SVI) and SVV were recorded before SLPC, during SLPC and before and after 500 mL fluid loading. Patients whose SVI increased more than 15% after the fluid loading were defined as fluid responders. Reciever operating characteristics (ROC) curves were generated to evaluate the abilities of the methods to predict fluid responsiveness. Fifty-five patients completed the study. Twenty-five (46%) of them were responders. Decrease percentage in SVI during SLPC (SVIΔ%–SLPC) was 11.6 ± 5.2% and 4.3 ± 2.2% in responders and non-responders, respectively (p < 0.001). A good correlation was found between SVIΔ%–SLPC and percentage change in SVI after fluid loading (r = 0.728, P < 0.001). Areas under the ROC curves (ROC–AUC) of SVIΔ%–SLPC and SVV were 0.951 (95% CI 0.857–0.991) and 0.747 (95% CI 0.611–0.854), respectively. The ROC–AUC of SVIΔ%–SLPC was significantly higher than that of SVV (p = 0.0045). The best cut-off value of SVIΔ%–SLPC was 7.5% with 90% sensitivity and 96% specificity. The percentage change in SVI during SLPC predicts fluid responsiveness in intensive care patients who are ventilated with low tidal volumes; the sensitivity and specificity values are higher than those of SVV.
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Belliato M, Cremascoli L, Epis F, Ferrari F, Quattrone MG, Malfertheiner MV, Broman LM, Aliberti A, Taccone FS, Iotti GA, Lorusso R. Carbon Dioxide Elimination During Veno-Venous Extracorporeal Membrane Oxygenation Weaning: A Pilot Study. ASAIO J 2021; 67:700-708. [PMID: 33074866 DOI: 10.1097/mat.0000000000001282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) represents a component of the treatment strategy for severe respiratory failure. Clinical evidence on the management of the lung during V-V ECMO are limited just as the consensus regarding timing of weaning. The monitoring of the carbon dioxide (CO2) removal (V'CO2TOT) is subdivided into two components: the membrane lung (ML) and the native lung (NL) are both taken into consideration to evaluate the improvement of the function of the lung and to predict the time to wean off ECMO. We enrolled patients with acute respiratory distress syndrome (ARDS). The V'CO2NL ratio (V'CO2NL/V'CO2TOT) value was calculated based on the distribution of CO2 between the NL and the ML. Of 18 patients, 15 were successfully weaned off of V-V ECMO. In this subgroup, we observed a significant increase in the V'CO2NL ratio comparing the median values of the first and last quartiles (0.32 vs. 0.53, p = 0.0045), without observing any modifications in the ventilation parameters. An increase in the V'CO2NL ratio, independently from any change in ventilation could, despite the limitations of the study, indicate an improvement in pulmonary function and may be used as a weaning index for ECMO.
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Affiliation(s)
- Mirko Belliato
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fiorenza Ferrari
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria G Quattrone
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Maximilian V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Medical Center Regensburg, Regensburg, Germany
| | - Lars M Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Aliberti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Bruxelles (CUB) Erasme, Brussels, Belgium
| | - Giorgio A Iotti
- From the UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, The Netherlands
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Schiewe R, Bein B. [Monitoring of Fluid Therapy]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:246-260. [PMID: 33890257 DOI: 10.1055/a-1118-7474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fluid and volume therapy is of paramount importance in anaesthesia and intensive care medicine. Fluid replacement as well as volume therapy can cause hypervolemia with deleterious consequences. Therefore, a prerequisite for an adequate volume therapy is the assessment of fluid responsiveness. Several monitoring techniques for evaluation of volume status and of volume responsiveness are currently used. However, there are several limitations of the different monitoring techniques that the user should be aware of. An algorithm can be helpful for a structured approach in monitoring volume therapy.
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de Courson H, Chauvet J, Le Gall L, Georges D, Boyer P, Verchère E, Nouette-Gaulain K, Biais M. Utility of changes in end-tidal carbon dioxide after volume expansion to assess fluid responsiveness in the operating room: a prospective observational study. Br J Anaesth 2020; 125:672-679. [DOI: 10.1016/j.bja.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 12/12/2022] Open
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Abstract
Volume capnography provides a noninvasive, continuous display of the fractional concentration or partial pressure of carbon dioxide (Pco2) versus exhaled volume. Derived measurements and calculations are influenced by changes in both ventilation and perfusion and are therefore useful for assessing both respiratory and cardiovascular function. This article provides an evidence-based review of several potential uses of volume capnography in the intensive care unit: 1) monitoring the effectiveness of ventilation by using end-tidal Pco2 as a surrogate for arterial Pco2, 2) assessing volume responsiveness, 3) measuring cardiac output, 4) determining prognosis in patients with the acute respiratory distress syndrome, 5) optimizing alveolar recruitment, and 6) excluding pulmonary embolism. Studies performed during the past few decades have clearly shown that volume capnography can provide important prognostic information in patients with acute respiratory distress syndrome and that end-tidal Pco2 should not be used to estimate or even to monitor the direction of change in the arterial Pco2 in mechanically ventilated intensive care unit patients. Unfortunately, few conclusions can be made from studies evaluating other potential applications. Of these, the most promising are the noninvasive measurement of cardiac output and optimization of alveolar recruitment in patients with acute respiratory distress syndrome and in mechanically ventilated, morbidly obese patients.
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Bachmann KF, Haenggi M, Jakob SM, Takala J, Gattinoni L, Berger D. Gas exchange calculation may estimate changes in pulmonary blood flow during veno-arterial extracorporeal membrane oxygenation in a porcine model. Am J Physiol Lung Cell Mol Physiol 2020; 318:L1211-L1221. [PMID: 32294391 PMCID: PMC7276983 DOI: 10.1152/ajplung.00167.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used as rescue therapy for severe cardiopulmonary failure. We tested whether the ratio of CO2 elimination at the lung and the V-A ECMO (V̇co2ECMO/V̇co2Lung) would reflect the ratio of respective blood flows and could be used to estimate changes in pulmonary blood flow (Q̇Lung), i.e., native cardiac output. Four healthy pigs were centrally cannulated for V-A ECMO. We measured blood flows with an ultrasonic flow probe. V̇co2ECMO and V̇co2Lung were calculated from sidestream capnographs under constant pulmonary ventilation during V-A ECMO weaning with changing sweep gas and/or V-A ECMO blood flow. If ventilation-to-perfusion ratio (V̇/Q̇) of V-A ECMO was not 1, the V̇co2ECMO was normalized to V̇/Q̇ = 1 (V̇co2ECMONorm). Changes in pulmonary blood flow were calculated using the relationship between changes in CO2 elimination and V-A ECMO blood flow (Q̇ECMO). Q̇ECMO correlated strongly with V̇co2ECMONorm (r2 0.95–0.99). Q̇Lung correlated well with V̇co2Lung (r2 0.65–0.89, P < = 0.002). Absolute Q̇Lung could not be calculated in a nonsteady state. Calculated pulmonary blood flow changes had a bias of 76 (−266 to 418) mL/min and correlated with measured Q̇Lung (r2 0.974–1.000, P = 0.1 to 0.006) for cumulative ECMO flow reductions. In conclusion, V̇co2 of the lung correlated strongly with pulmonary blood flow. Our model could predict pulmonary blood flow changes within clinically acceptable margins of error. The prediction is made possible with normalization to a V̇/Q̇ of 1 for ECMO. This approach depends on measurements readily available and may allow immediate assessment of the cardiac output response.
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Affiliation(s)
- Kaspar F Bachmann
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Sander M, Schneck E, Habicher M. Management of perioperative volume therapy - monitoring and pitfalls. Korean J Anesthesiol 2020; 73:103-113. [PMID: 32106641 PMCID: PMC7113166 DOI: 10.4097/kja.20022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022] Open
Abstract
Over 300 million surgical procedures are performed every year worldwide. Anesthesiologists play an important role in the perioperative process by assessing the overall risk of surgery and aim to reduce the risk of complications. Perioperative hemodynamic and volume management can help to improve outcomes in perioperative patients. There has been ongoing discussion about goal-directed therapy. However, there is a consensus that fluid overload and severe fluid depletion in the perioperative period are harmful and can lead to adverse outcomes. This article provides an overview of how to evaluate the fluid responsiveness of patients, details which parameters could be used, and what limitations should be noted.
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Affiliation(s)
- Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
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Ali A, Aygun E, Abdullah T, Bolsoy-Deveci S, Orhan-Sungur M, Canbaz M, Ozkan Akinci I. A challenge with 5 cmH2O of positive end-expiratory pressure predicts fluid responsiveness in neurosurgery patients with protective ventilation: an observational study. Minerva Anestesiol 2019; 85:1184-1192. [DOI: 10.23736/s0375-9393.19.13721-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Volumetric and End-Tidal Capnography for the Detection of Cardiac Output Changes in Mechanically Ventilated Patients Early after Open Heart Surgery. Crit Care Res Pract 2019; 2019:6393649. [PMID: 31281675 PMCID: PMC6589280 DOI: 10.1155/2019/6393649] [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: 12/24/2018] [Revised: 04/13/2019] [Accepted: 05/03/2019] [Indexed: 11/17/2022] Open
Abstract
Background Exhaled carbon dioxide (CO2) reflects cardiac output (CO) provided stable ventilation and metabolism. Detecting CO changes may help distinguish hypovolemia or cardiac dysfunction from other causes of haemodynamic instability. We investigated whether CO2 measured as end-tidal concentration (EtCO2) and eliminated volume per breath (VtCO2) reflect sudden changes in cardiac output (CO). Methods We measured changes in CO, VtCO2, and EtCO2 during right ventricular pacing and passive leg raise in 33 ventilated patients after open heart surgery. CO was measured with oesophageal Doppler. Results During right ventricular pacing, CO was reduced by 21% (CI 18–24; p < 0.001), VtCO2 by 11% (CI 7.9–13; p < 0.001), and EtCO2 by 4.9% (CI 3.6–6.1; p < 0.001). During passive leg raise, CO increased by 21% (CI 17–24; p < 0.001), VtCO2 by 10% (CI 7.8–12; p < 0.001), and EtCO2 by 4.2% (CI 3.2–5.1; p < 0.001). Changes in VtCO2 were significantly larger than changes in EtCO2 (ventricular pacing: 11% vs. 4.9% (p < 0.001); passive leg raise: 10% vs. 4.2% (p < 0.001)). Relative changes in CO correlated with changes in VtCO2 (ρ=0.53; p=0.002) and EtCO2 (ρ=0.47; p=0.006) only during reductions in CO. When dichotomising CO changes at 15%, only EtCO2 detected a CO change as judged by area under the receiver operating characteristic curve. Conclusion VtCO2 and EtCO2 reflected reductions in cardiac output, although correlations were modest. The changes in VtCO2 were larger than the changes in EtCO2, but only EtCO2 detected CO reduction as judged by receiver operating characteristic curves. The predictive ability of EtCO2 in this setting was fair. This trial is registered with NCT02070861.
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Messina A, Pelaia C, Bruni A, Garofalo E, Bonicolini E, Longhini F, Dellara E, Saderi L, Romagnoli S, Sotgiu G, Cecconi M, Navalesi P. Fluid Challenge During Anesthesia. Anesth Analg 2018; 127:1353-1364. [DOI: 10.1213/ane.0000000000003834] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Al-Subu A, Jooste E, Hornik CP, Fleming GA, Cheifetz IM, Ofori-Amanfo G. Correlation between minute carbon dioxide elimination and pulmonary blood flow in single-ventricle patients after stage 1 palliation and 2-ventricle patients with intracardiac shunts: A pilot study. Paediatr Anaesth 2018; 28:618-624. [PMID: 30133920 PMCID: PMC6485938 DOI: 10.1111/pan.13423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Assessment of pulmonary blood flow and cardiac output is critical in the postoperative management of patients with single-ventricle physiology or 2-ventricle physiology with intracardiac shunting. Currently, such hemodynamic data are only obtainable by invasive procedures, such as cardiac catheterization or the use of a pulmonary artery catheter. Ready availability of such information, especially if attainable noninvasively, could be a valuable addition to postoperative management. AIMS The aim of this study was to assess the correlation between volume of CO2 elimination obtained by volumetric capnography and pulmonary blood flow in pediatric patients with single-ventricle physiology after stage 1 palliation as well as in patients with other cardiac lesions associated with intracardiac shunting. METHODS This prospective cohort study included children with congenital or acquired heart disease who underwent cardiac catheterization as part of clinical care. Cardiac output, pulmonary blood flow, and volume of CO2 elimination were simultaneously collected. Spearman's rank correlation coefficients were used to assess correlation between measurements after controlling for minute ventilation. RESULTS Thirty-five patients were enrolled and divided into 3 groups. Group 1 (n = 8) included single-ventricle patients after stage 1 palliation. Group 2 (n = 10) patients had structural heart disease with 2 ventricles and intracardiac shunting. Group 3 (n = 17) had structurally normal hearts. Among Group 1 patients, the correlation coefficients (R2 ) between volume of CO2 elimination and pulmonary blood flow and volume of CO2 elimination and cardiac output were 0.60 (P = .02) 95% CI [0.01-0.79] and 0.29 (P = .74) 95% CI [-0.91 - 0.86], respectively. In patients with 2 ventricles associated with intracardiac shunts (Group 2), the correlation coefficients between volume of CO2 elimination and pulmonary blood flow and volume of CO2 elimination and cardiac output were 0.86 (P = .001) 95% CI [0.53 - 0.97] and 0.73 (P = .001) 95% CI [0.29 - 0.95], respectively. Among Group 3 patients, the correlation coefficient between volume of CO2 elimination and pulmonary blood flow was 0.66 (P = .038) 95% CI [0.29 - 0.87]. CONCLUSION Volume of CO2 elimination may be a surrogate marker of pulmonary blood flow in single-ventricle patients and patients with biventricular physiology with intracardiac shunting. Also, among patients with normal cardiac anatomy, volume of CO2 elimination may be a marker of cardiac output.
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Affiliation(s)
- Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Edmund Jooste
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Christoph P. Hornik
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA,Duke Clinical Research Institute, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Gregory A. Fleming
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Ira M. Cheifetz
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - George Ofori-Amanfo
- Division of Pediatric Critical Care, Department of Pediatrics, Kravis Children’s Hospital at Mount Sinai, New York, NY, USA
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Tusman G, Suarez-Sipmann F. In Response. Anesth Analg 2018; 123:1332-1333. [PMID: 27644055 DOI: 10.1213/ane.0000000000001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gerardo Tusman
- Department of Anesthesia, Hospital Privado de Comunidad, Mar del Plata, Buenos Aires, Argentina, Department of Surgical Sciences section of Anesthesiology and Critical Care, Hedenstierna Laboratory, University Hospital, Uppsala, Sweden, CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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18
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Drummond G. Confusion Between Integration and Receiver Operator Curves? Anesth Analg 2018; 123:1332. [PMID: 27644063 DOI: 10.1213/ane.0000000000001497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gordon Drummond
- Department of Anaesthesia Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, United Kingdom,
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20
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017. [DOI: https://doi.org/10.1177/0885066617709434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia
- Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017; 33:227-240. [PMID: 28506136 DOI: 10.1177/0885066617709434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- 1 Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia.,2 Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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22
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Meng L, Heerdt P. Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution. Br J Anaesth 2016; 117:iii3-iii17. [DOI: 10.1093/bja/aew363] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care 2016; 6:111. [PMID: 27858374 PMCID: PMC5114218 DOI: 10.1186/s13613-016-0216-7] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/08/2016] [Indexed: 12/17/2022] Open
Abstract
In patients with acute circulatory failure, the decision to give fluids or not should not be taken lightly. The risk of overzealous fluid administration has been clearly established. Moreover, volume expansion does not always increase cardiac output as one expects. Thus, after the very initial phase and/or if fluid losses are not obvious, predicting fluid responsiveness should be the first step of fluid strategy. For this purpose, the central venous pressure as well as other “static” markers of preload has been used for decades, but they are not reliable. Robust evidence suggests that this traditional use should be abandoned. Over the last 15 years, a number of dynamic tests have been developed. These tests are based on the principle of inducing short-term changes in cardiac preload, using heart–lung interactions, the passive leg raise or by the infusion of small volumes of fluid, and to observe the resulting effect on cardiac output. Pulse pressure and stroke volume variations were first developed, but they are reliable only under strict conditions. The variations in vena caval diameters share many limitations of pulse pressure variations. The passive leg-raising test is now supported by solid evidence and is more frequently used. More recently, the end-expiratory occlusion test has been described, which is easily performed in ventilated patients. Unlike the traditional fluid challenge, these dynamic tests do not lead to fluid overload. The dynamic tests are complementary, and clinicians should choose between them based on the status of the patient and the cardiac output monitoring technique. Several methods and tests are currently available to identify preload responsiveness. All have some limitations, but they are frequently complementary. Along with elements indicating the risk of fluid administration, they should help clinicians to take the decision to administer fluids or not in a reasoned way.
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Affiliation(s)
- Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Inserm UMR_S999, Paris-Sud University, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France.
| | - Paul E Marik
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Inserm UMR_S999, Paris-Sud University, 78, rue du Général Leclerc, 94 270, Le Kremlin-Bicêtre, France
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Verscheure S, Massion PB, Verschuren F, Damas P, Magder S. Volumetric capnography: lessons from the past and current clinical applications. Crit Care 2016; 20:184. [PMID: 27334879 PMCID: PMC4918076 DOI: 10.1186/s13054-016-1377-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dead space is an important component of ventilation–perfusion abnormalities. Measurement of dead space has diagnostic, prognostic and therapeutic applications. In the intensive care unit (ICU) dead space measurement can be used to guide therapy for patients with acute respiratory distress syndrome (ARDS); in the emergency department it can guide thrombolytic therapy for pulmonary embolism; in peri-operative patients it can indicate the success of recruitment maneuvers. A newly available technique called volumetric capnography (Vcap) allows measurement of physiological and alveolar dead space on a regular basis at the bedside. We discuss the components of dead space, explain important differences between the Bohr and Enghoff approaches, discuss the clinical significance of arterial to end-tidal CO2 gradient and finally summarize potential clinical indications for Vcap measurements in the emergency room, operating room and ICU.
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Affiliation(s)
- Sara Verscheure
- Department of Critical Care Medicine, University of McGill, Montreal, Quebec, Canada.,Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Paul B Massion
- Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Franck Verschuren
- Department of Emergency Medicine, Cliniques universitaire Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Sheldon Magder
- Department of Critical Care Medicine, University of McGill, Montreal, Quebec, Canada.
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25
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Lefrant JY, Muller L. Assessing Fluid Responsiveness in Clinical Practice. Anesth Analg 2016; 122:1256-7. [DOI: 10.1213/ane.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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