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Koratala A. Point-of-care ultrasonography in cirrhosis-related acute kidney injury: How I do it. World J Crit Care Med 2024; 13:93812. [PMID: 38855271 PMCID: PMC11155506 DOI: 10.5492/wjccm.v13.i2.93812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/24/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024] Open
Abstract
Discerning the etiology of acute kidney injury (AKI) in cirrhotic patients remains a formidable challenge due to diverse and overlapping causes. The conventional approach of empiric albumin administration for suspected volume depletion may inadvertently lead to fluid overload. In the recent past, point-of-care ultrasonography (POCUS) has emerged as a valuable adjunct to clinical assessment, offering advantages in terms of diagnostic accuracy, rapidity, cost-effectiveness, and patient satisfaction. This review provides insights into the strategic use of POCUS in evaluating cirrhotic patients with AKI. The review distinguishes basic and advanced POCUS, emphasizing a 5-point basic POCUS protocol for efficient assessment. This protocol includes evaluations of the kidneys and urinary bladder for obstructive nephropathy, lung ultrasound for detecting extravascular lung water, inferior vena cava (IVC) ultrasound for estimating right atrial pressure, internal jugular vein ultrasound as an alternative to IVC assessment, and focused cardiac ultrasound for assessing left ventricular (LV) systolic function and identifying potential causes of a plethoric IVC. Advanced POCUS delves into additional Doppler parameters, including stroke volume and cardiac output, LV filling pressures and venous congestion assessment to diagnose or prevent iatrogenic fluid overload. POCUS, when employed judiciously, enhances the diagnostic precision in evaluating AKI in cirrhotic patients, guiding appropriate therapeutic interventions, and minimizing the risk of fluid-related complications.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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Ayar MS, Baydın A, Ustaoglu M, Caliskan F, Erenler AK. Inferior vena cava collapsibility index and stroke volume as predictors of blood transfusion in upper gastrointestinal bleeding in the emergency department. J Gastroenterol Hepatol 2024; 39:1040-1047. [PMID: 38334062 DOI: 10.1111/jgh.16500] [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: 09/07/2023] [Revised: 12/02/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND AIM This study investigates the effectiveness of bedside ultrasonography in predicting blood transfusion requirements in patients with upper gastrointestinal bleeding (UGIB). It focuses on evaluating the inferior vena cava (IVC) diameter, IVC collapsibility index (CI), and stroke volume (SV) as ultrasonographic measures. METHODS A hundred adult patients enrolled in this prospective clinical study. The patients were divided into two groups (group 1: only saline administered group, group 2: saline and blood administered group). IVC diameter, IVC CI, and SV were measured at the time of admission and after treatment. RESULTS At the initial admission, group 1 exhibited an IVC CI of 20.4% and an SV of 65.0 mL, whereas group 2 displayed an IVC CI of 26.6% and an SV of 58.0 mL. Upon analyzing the relationship between the Glasgow-Blatchford score (GBS) and SV, we identified a significant negative correlation (r = -0.7350; P < 0.001). Similarly, a weak negative correlation was observed between the Rockall score (RS) and SV (r = -0.4718; P < 0.001). It is worth noting that patients with UGIB require blood transfusion if their SV falls below 62.5 mL, with an area under the curve (AUC) of 89.1% and a 95% confidence interval (CI) ranging from 82.8% to 95.4%. CONCLUSION IVC CI and SV can be used as parameters to predict the need for blood transfusion in the ED in patients with UGIB.
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Affiliation(s)
- Mustafa Selçuk Ayar
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ahmet Baydın
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Müge Ustaoglu
- Department of Gastroenterology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Fatih Caliskan
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ali Kemal Erenler
- Department of Emergency Medicine, Faculty of Medicine, Hitit University, Çorum, Turkey
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Zhou L, Wiley BM. Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:15-35. [PMID: 37973351 DOI: 10.1016/j.ccc.2023.06.001] [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] [Indexed: 11/19/2023]
Abstract
The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA
| | - Brandon M Wiley
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA.
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Grotberg JC, McDonald RK, Co IN. Point-of-Care Echocardiography in the Difficult-to-Image Patient in the ICU: A Narrative Review. Crit Care Explor 2024; 6:e1035. [PMID: 38222871 PMCID: PMC10786596 DOI: 10.1097/cce.0000000000001035] [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] [Indexed: 01/16/2024] Open
Abstract
OBJECTIVES The objective of this narrative review was to address common obstacles encountered in the ICU to acquiring quality and interpretable images using point-of-care echocardiography. DATA SOURCES Detailed searches were performed using PubMed and Ovid Medline using medical subject headings and keywords on topics related to patient positioning, IV echo contrast, alternative subcostal views, right ventricular outflow tract (RVOT) hemodynamics, and point-of-care transesophageal echocardiography. Articles known to the authors were also selected based on expert opinion. STUDY SELECTION Articles specific to patient positioning, IV echo contrast, alternative subcostal views, RVOT hemodynamics, and point-of-care transesophageal echocardiography were considered. DATA EXTRACTION One author screened titles and extracted relevant data while two separate authors independently reviewed selected articles. DATA SYNTHESIS Impediments to acquiring quality and interpretable images in critically ill patients are common. Notably, body habitus, intra-abdominal hypertension, dressings or drainage tubes, postoperative sternotomies, invasive mechanical ventilation, and the presence of subcutaneous emphysema or lung hyperinflation are commonly encountered obstacles in transthoracic image acquisition in the ICU. Despite these obstacles, the bedside clinician may use obstacle-specific maneuvers to enhance image acquisition. These may include altering patient positioning, respiratory cycle timing, expanding the subcostal window to include multilevel short-axis views for use in the assessment of RV systolic function and hemodynamics, coronal transhepatic view of the inferior vena cava, and finally point-of-care transesophageal echocardiography. CONCLUSIONS Despite common obstacles to point-of-care echocardiography in critically ill patients, the beside sonographer may take an obstacle-specific stepwise approach to enhance image acquisition in difficult-to-image patients.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Rachel K McDonald
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Ivan N Co
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
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May LE, McDonald S, Stewart C, Newton E, Isler C, Steed D, Sarno LA, Kelley GA, Chasan-Taber L, Kuehn D, Allman-Tucker BR, Strom C, Claiborne A, Fang X. Influence of Supervised Maternal Aerobic Exercise during Pregnancy on 1-Month-Old Neonatal Cardiac Function and Outflow: A Pilot Study. Med Sci Sports Exerc 2023; 55:1977-1984. [PMID: 37259255 PMCID: PMC10592655 DOI: 10.1249/mss.0000000000003227] [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] [Indexed: 06/02/2023]
Abstract
PURPOSE The objective of this study is to assess the effects of supervised, recommended levels of prenatal aerobic exercise on 1-month-old infant cardiac function. METHODS Eligible pregnant women were randomly assigned to either an aerobic exercise group that participated in 150 min of supervised, moderate-intensity (40% to 59% V̇O 2peak , 12 to 14 on Borg rating of perceived exertion) aerobic exercise per week for 24 wk or more or a nonexercising group that consisted of 150 min·wk -1 of relaxation techniques. One-month-old infant echocardiogram was performed to assess infant cardiac function , including heart rate (HR), left-ventricular stroke volume, cardiac output, cardiac index, ejection fraction, fractional shortening, and velocity time integral at the aortic valve. Pearson correlation analyses and linear regression models were performed. RESULTS Prenatal aerobic exercise was negatively correlated with infant resting HR ( r = -0.311, P = 0.02). Similarly, when controlling for infant sex and activity state, exercise level/volume ( β = -0.316; 95% CI, -0.029 to -0.002; P = 0.02) predicted resting infant HR ( R2 = 0.18, P = 0.02). In infants of overweight/obese women, infants of aerobic exercisers had increased fractional shortening ( P = 0.03). In addition, infant ventricular ejection fraction was correlated with maternal exercise attendance ( r = 0.418, P = 0.03) as well as a trend for exercise level ( r = 0.351, P = 0.08). Similarly, the only significant regression model for infants of overweight/obese women controls infant activity state ( β = -0.444; 95% CI, -0.05 to -0.01; P = 0.006) and maternal exercise level ( β = 0.492; 95% CI, 5.46-28.74; P = 0.01) predicting infant resting HR ( F = 5.79, R2 = 0.40, P = 0.003). CONCLUSIONS The findings of this study demonstrate that women participating in exercise in the second and third trimesters of their pregnancy may have infants with increased cardiac function at 1 month of age. Importantly, the cardiac function effects were further augmented for infants born to overweight/obese women.
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Affiliation(s)
| | - Samantha McDonald
- School of Kinesiology and Recreation, Illinois State University, Normal, IL
| | - Courtney Stewart
- College of Osteopathic Medicine, Liberty University, Lynchburg, VA
| | - Edward Newton
- Department of Obstetrics and Gynecology, East Carolina University, Greenville, NC
| | - Christy Isler
- Department of Obstetrics and Gynecology, East Carolina University, Greenville, NC
| | - Dennis Steed
- Department of Pediatrics, Division of Pediatric Cardiology, East Carolina University, Greenville, NC
| | - Lauren A Sarno
- Department of Pediatrics, Division of Pediatric Cardiology, East Carolina University, Greenville, NC
| | - George A Kelley
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, WV
| | - Lisa Chasan-Taber
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA
| | | | | | - Cody Strom
- Department of Kinesiology and Sport, University of Southern Indiana, Evansville, IN
| | - Alex Claiborne
- Department of Kinesiology, East Carolina University, Greenville, NC
| | - Xiangming Fang
- Department of Biostatistics, East Carolina University, Greenville, NC
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Selvam V, Shende D, Anand RK, Kashyap L, Ray BR. End-expiratory Occlusion Test and Mini-fluid Challenge Test for Predicting Fluid Responsiveness in Acute Circulatory Failure. J Emerg Trauma Shock 2023; 16:109-115. [PMID: 38025504 PMCID: PMC10661572 DOI: 10.4103/jets.jets_44_23] [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: 05/10/2023] [Revised: 06/05/2023] [Accepted: 06/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Predicting which patients with acute circulatory failure will respond to the fluid by an increase in cardiac output is a daily challenge. End-expiratory occlusion test (EEOT) and mini-fluid challenge (MFC) can be used for assessing fluid responsiveness in patients with spontaneous breathing activity, cardiac arrhythmias, low-tidal volume and/or low lung compliance. Methods The objective of the study is to evaluate the value of EEOT and MFC-induced rise in left ventricular outflow tract (LVOT) velocity time integral (VTI) in predicting fluid responsiveness in acute circulatory failure in comparison to the passive leg-raising (PLR) test. Hundred critically ill ventilated and sedated patients with acute circulatory failure were studied. LVOT VTI was measured by transthoracic echocardiography before and after EEOT (interrupting the ventilator at end-expiration over 15 s), and before and after MFC (100 ml of Ringer lactate was infused over 1 min). The variation of LVOT VTI after EEOT and the MFC was calculated from the baseline. Sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) curve of LVOT VTI after EEOT and MFC to predict fluid responsiveness were determined. Results After PLR, stroke volume (SV) increased by ≥12% in 49 patients, who were defined as responders and 34 patients in whom the increase in SV <12% were defined as nonresponders. A cutoff of 9.1% Change in VTI after MFC (ΔVTIMFC) predicted fluid responsiveness with an AUROC of 0.96 (P < 0.001) with sensitivity and specificity of 91.5% and 88.9%, respectively. Change in VTI after EEOT (ΔVTIEEOT) >4.3% predicted fluid responsiveness with sensitivity and specificity 89.4% and 88.9%, respectively, with an AUROC of 0.97 (P < 0.001), but in 17 patients, EEOT was not possible because triggering of the ventilator by the patient's inspiratory effort. Conclusion In conclusion, in mechanically ventilated patients with acute circulatory failure Δ VTIMFC and Δ VTI EEOT accurately predicts fluid responsiveness.
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Affiliation(s)
- Velmurugan Selvam
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
- Department of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Dilip Shende
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar Anand
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Lokesh Kashyap
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bikash Ranjan Ray
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Pérez-Manjarrez A, García-Cruz E, Gopar-Nieto R, Jiménez-Rodríguez GM, Lazcano-Díaz E, Rojas-Velasco G, Manzur-Sandoval D. Usefulness of the velocity-time integral of the left ventricular outflow tract variability index to predict fluid responsiveness in patients undergoing cardiac surgery. Echo Res Pract 2023; 10:9. [PMID: 37381028 DOI: 10.1186/s44156-023-00022-z] [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: 02/27/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Haemodynamic monitoring of patients after cardiac surgery using echocardiographic evaluation of fluid responsiveness is both challenging and increasingly popular. We evaluated fluid responsiveness in the first hours after surgery by determining the variability of the velocity-time integral of the left ventricular outflow tract (VTI-LVOT). METHODS We conducted a cross-sectional study of 50 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain VTI-LVOT measurements. We then determined the variability and correlations with our pulse pressure variation (PPV) measurements to predict fluid responsiveness. RESULTS A strong positive correlation was seen between the VTI-LVOT variability index absolute values and PPV for predicting fluid responsiveness in the first hours after cardiac surgery. We also found that the VTI-LVOT variability index has high specificity and a high positive likelihood ratio compared with the gold standard using a cut-off point of ≥ 12%. CONCLUSIONS The VTI-LVOT variability index is a valuable tool for determining fluid responsiveness during the first 6 postoperative hours in patients undergoing cardiac surgery.
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Affiliation(s)
- Aldo Pérez-Manjarrez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Edgar García-Cruz
- Adult Congenital Heart Disease Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Rodrigo Gopar-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Gian Manuel Jiménez-Rodríguez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Emmanuel Lazcano-Díaz
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Gustavo Rojas-Velasco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico
| | - Daniel Manzur-Sandoval
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Belisario Domínguez, Sección XVI, Tlalpan, P.O. Box 14080, Mexico City, Mexico.
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Polyzogopoulou E, Bezati S, Karamasis G, Boultadakis A, Parissis J. Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done. J Clin Med 2023; 12:2643. [PMID: 37048727 PMCID: PMC10095596 DOI: 10.3390/jcm12072643] [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: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sofia Bezati
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Grigoris Karamasis
- Second Department of Cardiology, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
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Fortenbacher S, John S. [Fluid Management in Intensive Care Patients - New Strategies and optimal target?]. Dtsch Med Wochenschr 2023; 148:318-324. [PMID: 36878231 DOI: 10.1055/a-1938-2381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Adequate therapy with intravenous fluids is crucial in the initial treatment of critically ill patients. Both hypovolemia and hypervolemia are associated with organ dysfunction and adverse outcomes. A recent international randomized trial investigated a restrictive volume management in comparison with a standard volume regimen. 90-day-mortality was not significantly reduced in the group with restrictive fluid administration. Instead of using a fixed fluid strategy - either restrictive or liberal - fluid therapy should be individualised: Adequate fluid application optimizes cardiac preload and tissue perfusion and avoids the harms of abundant volume therapy. Early use of vasopressors may facilitate the achievement of mean arterial pressure targets and minimize the risk of volume overload. Appropriate volume management requires evaluation of fluid status, knowledge of hemodynamic parameters and accurate testing of fluid responsiveness. Regarding the absence of evidence-based criterias and treatment goals for volume management in shock patients, an individualised approach resorting to diverse monitoring tools should be considered. UItrasound-based assessment of IVC diameter and echocardiography are excellent non-invasive tools to evaluate volume status. Passive leg raising (PLR) test represents a valid method for the assessment of volume responsiveness.
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Affiliation(s)
- Silke Fortenbacher
- Klinik für Innere Medizin 8, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Klinikum Nürnberg Süd, Nürnberg
| | - Stefan John
- Klinik für Innere Medizin 8, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Klinikum Nürnberg Süd, Nürnberg
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Devangam S, Sigakis M, Palmer LJ, Goeddel L, Fiza B. Point-of-Care Ultrasound: A Moving Picture Is Worth a Thousand Tests. Anesthesiol Clin 2023; 41:231-248. [PMID: 36872001 DOI: 10.1016/j.anclin.2022.10.005] [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
The effective utilization of point-of-care ultrasound may decrease the utilization of conventional diagnostic modalities. This review describes the various pathologies that can be effectively and rapidly identified with point-of-care cardiac, lung, abdominal, vascular airway, and ocular ultrasonography.
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Affiliation(s)
- Suhas Devangam
- Department of Anesthesiology, Division of Critical Care, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Matthew Sigakis
- Department of Anesthesiology, Division of Critical Care, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Louisa J Palmer
- Department of Anesthesiology, Division of Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02115, USA
| | - Lee Goeddel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Bloomberg 6320, 1800 Orleans Street, Baltimore, MD, USA 21287
| | - Babar Fiza
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA.
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11
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [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: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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12
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Manzur-Sandoval D, Arteaga-Cárdenas G, Gopar-Nieto R, Lazcano-Díaz E, Rojas-Velasco G. Correlation between transhepatic and subcostal inferior vena cava ultrasonographic images for evaluating fluid responsiveness after cardiac surgery. J Card Surg 2022; 37:2586-2591. [PMID: 35735244 DOI: 10.1111/jocs.16696] [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: 04/04/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Echocardiographic monitoring during the postoperative period following cardiac surgery is essential because patients often develop hemodynamic instability from hypovolemia and other causes. Therefore, predicting fluid responsiveness by measuring respirophasic variation in the inferior vena cava (IVC) is essential in this population. Yet it is not always possible to evaluate using the traditional subcostal view. METHODS This cross-sectional study of 36 consecutive adult patients who underwent cardiac surgery included those in whom it was possible to adequately visualize the IVC in both the subcostal and transhepatic views. The maximum and minimum diameters and respirophasic variation were measured in each view. These views were then correlated and the capacity of the transhepatic view to predict fluid responsiveness was evaluated. RESULTS There was a strong positive correlation between IVC maximum and minimum diameters and respirophasic variation according to subcostal and transhepatic views. Evaluation of IVC respirophasic variation indices using the transhepatic view also showed high sensitivity for predicting fluid responsiveness. CONCLUSION There is a correlation between the transhepatic and subcostal views for determining maximum and minimum IVC diameters, and distensibility and variability indices for predicting fluid responsiveness in postoperative cardiac surgery patients.
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Affiliation(s)
- Daniel Manzur-Sandoval
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Gerardo Arteaga-Cárdenas
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Rodrigo Gopar-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Emmanuel Lazcano-Díaz
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Gustavo Rojas-Velasco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Spiliotaki E, Saranteas T, Moschovaki N, Panagouli K, Pistioli E, Kitsinelis V, Briasoulis P, Papadimos T. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: A critical analysis review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:733-744. [PMID: 35302241 DOI: 10.1002/jcu.23194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
Rapid evaluation of intravascular volume status is vital; either excessive or limited fluid administration may result in adverse patient outcomes. In this narrative review, critical analysis of pertinent diagnostic accuracy studies is developed to delineate the role of inferior vena cava ultrasound measurements in the assessment of both intravascular volume status and fluid responsiveness in the emergency department and intensive care unit. In addition, limitations, and technical considerations of inferior vena cava ultrasound measurements as well as directions for future research are thoroughly discussed.
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Affiliation(s)
- Eleni Spiliotaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nefeli Moschovaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Panagouli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathia Pistioli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Kitsinelis
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Briasoulis
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Papadimos
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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14
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Greatorex B, Colebourn C, Ormerod O. Echocardiographic assessment and critical care management of peri-partum women with unexpected left ventricular failure. J Intensive Care Soc 2022; 23:210-221. [PMID: 35615233 PMCID: PMC9125437 DOI: 10.1177/1751143720978862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION Cardiac disease remains the largest single cause of maternal death. Whilst uncommon, left ventricular failure during pregnancy and delivery can be devastating to both mother and child. Echocardiography can play a significant role in rapidly establishing a diagnosis, guiding initial therapy and then monitoring response. CLINICAL VIGNETTES The history, presentation and management of three cases of peri-partum left ventricular failure is examined: stress cardiomyopathy in a 34 year old with twins, left ventricular dysfunction secondary to pre-eclampsia in a 22 year old with a singleton pregnancy and a true peri-partum cardiomyopathy in a 42 year old with IVF twins. The defining risk factors, presenting characteristics and echocardiographical findings for each pathology are highlighted. CONCLUSION Echocardiography is playing an increasingly important role in the immediate assessment and management of left ventricular failure. This is especially true in the peri-partum woman, where establishing the correct therapy is both challenging and crucial due to the significant cardiovascular changes that occur around the time of delivery. To this end we believe that echocardiography should be rapidly available to guide the management of these patients by a multidisciplinary team made up of obstetricians, cardiologists, anaesthetists and intensive care physicians.
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Affiliation(s)
- Ben Greatorex
- Department of Anaesthesia and
Intensive Care, Raigmore Hospital, NHS Highlands, Inverness, UK
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15
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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16
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Mcnally RJ, Farukh B, Chowienczyk PJ, Faconti L. Sensitivity and Reproducibility of Inferior Vena Cava Diameter and Superior Vena Cava Flow Velocity Measurements to Changes in Cardiac Preload in Subjects with Hypertension. J Cardiovasc Echogr 2022; 32:6-11. [PMID: 35669130 PMCID: PMC9164919 DOI: 10.4103/jcecho.jcecho_56_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/14/2021] [Accepted: 01/08/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives We investigated the sensitivity and reproducibility of inferior vena cava (IVC) diameters and superior vena cava (SVC) flow velocities in detecting changes in cardiac preload in clinically euvolemic subjects with hypertension. Methods Measurements were obtained during passive leg raising (PLR) and lower limb venous occlusion (LVO), interventions which respectively transiently increase and decrease cardiac preload. Measurements were made in 36 subjects and repeated on two separate occasions to examine reproducibility. Results During PLR, there was no significant change in IVC diameters, but peak flow velocity of the SVC S wave increased by 6.5 (95% confidence interval 1.6-11.3) cm/s (P = 0.01). During LVO, IVC diameter in expiration decreased by 3.2 (1.7-4.7) mm and the SVC S wave decreased by 9.7 (4.4-14.7) cm/s (P < 0.001). Venae cavae-derived indices can be used to assess changes in preload within the physiological range in euvolemia. Conclusions Despite suboptimal reproducibility of baseline measurements, high agreeability between the changes in IVC diameter and SVC flow after LVO suggests that these indices can be used to monitor changes in cardiac preload.
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Affiliation(s)
| | - Bushra Farukh
- British Heart Foundation Centre, King's College London, London, UK
| | | | - Luca Faconti
- British Heart Foundation Centre, King's College London, London, UK
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17
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Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consult: How Point of Care Ultrasound Helps Guide Medical Decision Making. Int J Gen Med 2021; 14:9789-9806. [PMID: 34938102 PMCID: PMC8685447 DOI: 10.2147/ijgm.s339476] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jake A Rice
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Brewer
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tyler Speaks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Choi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Lahsaei
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Correspondence: Bryan T Romito Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9068, USATel +1 214 648 7674Fax +1 214 648 5461 Email
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18
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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19
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Qasem F, Hegazy AF, Fuller JG, Lavi R, Singh SI. Inferior vena cava assessment in term pregnant women using ultrasound: A comparison of the subcostal and right upper quadrant views. Anaesth Intensive Care 2021; 49:389-394. [PMID: 34514866 DOI: 10.1177/0310057x211034181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Point-of-care ultrasound can be used at the bedside to assess the haemodynamic status and fluid responsiveness of a pregnant woman. Previous studies demonstrated that views from the apical and parasternal windows are readily obtainable in labouring women. However, using the subcostal window to assess the inferior vena cava can be challenging because of the gravid uterus. A potential alternative is the right upper quadrant transhepatic window. We sought to compare visualisation of the inferior vena cava via the subcostal and right upper quadrant windows, in full-term pregnant women. This was a prospective pilot study carried out in a tertiary academic obstetric centre. Thirty pregnant non-labouring women at full term were recruited. In each patient, the inferior vena cava was visualised through both the subcostal and the right upper quadrant windows. Time to acquire each image, acquisition success rates and ease of obtaining images were compared for both approaches. Image quality was then reviewed and rated by two independent expert reviewers. There was a significant difference in the time required to obtain each view; subcostal median (interquartile range): 52 (35-59) seconds, right upper quadrant median (interquartile range): 23 (11-55) seconds (P=0.0045). Operator-defined successful image acquisition was 100% for the right upper quadrant window compared to 80% for the subcostal window. Ease of obtaining the view, as rated by the operator, was significantly easier in the right upper quadrant window compared to the subcostal window (P <0.0001). Both reviewers independently rated image adequacy to be significantly greater in the right upper quadrant window (73% and 57%) compared to the subcostal window (40% and 10%) (P=0.0213 and P=0.0005, respectively). Inter-rater agreement ranged between good (Cohen's kappa coefficient 0.64) for right upper quadrant windows to fair (Cohen's kappa coefficient 0.29) for subcostal windows. Inferior vena cava visualisation in term pregnant patients may take less time, be easier and provide better quality images when the right upper quadrant window is used compared to the subcostal window.
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Affiliation(s)
- Fatemah Qasem
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ahmed F Hegazy
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - John G Fuller
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Ronit Lavi
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Sudha I Singh
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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20
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Ladzinski AT, Thind GS, Siuba MT. Rational Fluid Resuscitation in Sepsis for the Hospitalist: A Narrative Review. Mayo Clin Proc 2021; 96:2464-2473. [PMID: 34366137 DOI: 10.1016/j.mayocp.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/24/2021] [Accepted: 05/20/2021] [Indexed: 12/11/2022]
Abstract
Administration of fluid is a cornerstone of supportive care for sepsis. Current guidelines suggest a protocolized approach to fluid resuscitation in sepsis despite a lack of strong physiological or clinical evidence to support it. Both initial and ongoing fluid resuscitation requires careful consideration, as fluid overload has been shown to be associated with increased risk for mortality. Initial fluid resuscitation should favor balanced crystalloids over isotonic saline, as the former is associated with decreased risk of renal dysfunction. Traditionally selected resuscitation targets, such as lactate elevation, are fraught with limitations. For developing or established septic shock, a focused hemodynamic assessment is needed to determine if fluid is likely to be beneficial. When initial fluid therapy is unable to achieve the blood pressure goal, initiation of early vasopressors and admission to intensive care should be favored over repetitive administration of fluid.
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Affiliation(s)
- Adam Timothy Ladzinski
- Department of Internal Medicine, Adolescent and Internal Medicine, Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Guramrinder Singh Thind
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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21
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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [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: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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22
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Point of care cardiac ultrasound in the management of hyponatremia: an enhancement to physical examination. CEN Case Rep 2021; 11:6-10. [PMID: 34227056 DOI: 10.1007/s13730-021-00623-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022] Open
Abstract
Accurate assessment of fluid status is vital to appropriate management of hyponatremia. However, conventional parameters such as physical examination, vital signs, and laboratory markers such as natriuretic peptides suffer from limitations in this regard. Point of care ultrasonography (POCUS) is a noninvasive bedside diagnostic tool that is emerging as an adjunct to physical examination in internal medicine and subspecialties including nephrology. In this manuscript, we describe a complex case of hyponatremia, where stroke volume assessment using Doppler echocardiography has helped to objectively assess fluid status and guided therapy. A 73-year-old woman was seen for worsening serum sodium. Her urine sodium was high and there was no hypotension suggestive of euvolemia. However, POCUS demonstrated low stroke volume in the presence of normal left ventricular ejection fraction, indicative of hypovolemia. She was treated with intravenous fluids based on these findings and response was evident by normalization of the stroke volume. Clinicians should adopt a multi-parametric approach integrating all the pieces of hemodynamic puzzle when evaluating complex fluid and electrolyte disorders.
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23
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Boysen SR, Gommeren K. Assessment of Volume Status and Fluid Responsiveness in Small Animals. Front Vet Sci 2021; 8:630643. [PMID: 34124213 PMCID: PMC8193042 DOI: 10.3389/fvets.2021.630643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/29/2021] [Indexed: 12/30/2022] Open
Abstract
Intravenous fluids are an essential component of shock management in human and veterinary emergency and critical care to increase cardiac output and improve tissue perfusion. Unfortunately, there are very few evidence-based guidelines to help direct fluid therapy in the clinical setting. Giving insufficient fluids and/or administering fluids too slowly to hypotensive patients with hypovolemia can contribute to continued hypoperfusion and increased morbidity and mortality. Similarly, giving excessive fluids to a volume unresponsive patient can contribute to volume overload and can equally increase morbidity and mortality. Therefore, assessing a patient's volume status and fluid responsiveness, and monitoring patient's response to fluid administration is critical in maintaining the balance between meeting a patient's fluid needs vs. contributing to complications of volume overload. This article will focus on the physiology behind fluid responsiveness and the methodologies used to estimate volume status and fluid responsiveness in the clinical setting.
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Affiliation(s)
- Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Kris Gommeren
- Department of Companion Animals, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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24
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Mitchell OJ, Teran F, Patel S, Baston C. Critical Care Echocardiography: A Primer for the Nephrologist. Adv Chronic Kidney Dis 2021; 28:244-251. [PMID: 34906309 DOI: 10.1053/j.ackd.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 12/16/2022]
Abstract
Critical care echocardiography (CCE) refers to the goal-directed use of transthoracic or transesophageal echocardiography and represents one of the most common applications of critical care ultrasound. CCE can be performed at the point of care, is easily repeated following changes in clinical status, and does not expose the patient to ionizing radiation. Nephrologists who participate in the care of patients in the intensive care unit will regularly encounter CCE as part of the decision-making and bedside management of ICU patients. The four primary indications for CCE are the characterization of shock, evaluation of preload tolerance, evaluation of volume responsiveness, and serial hemodynamic assessment to evaluate response to therapeutic interventions. This article provides an overview of the anatomical structures that are routinely assessed in basic CCE, describes how these findings are incorporated into the clinical assessment of critically ill patients, and introduces some common applications of advanced CCE.
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25
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Miller A, Peck M, Clark T, Conway H, Olusanya S, Fletcher N, Coleman N, Parulekar P, Aron J, Kirk-Bayley J, Wilkinson JN, Wong A, Stephens J, Rubino A, Attwood B, Walden A, Breen A, Waraich M, Nix C, Hayward S. FUSIC HD. Comprehensive haemodynamic assessment with ultrasound. J Intensive Care Soc 2021; 23:325-333. [DOI: 10.1177/17511437211010032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
FUSIC haemodynamics (HD) – the latest Focused Ultrasound in Intensive Care (FUSIC) module created by the Intensive Care Society (ICS) – describes a complete haemodynamic assessment with ultrasound based on ten key clinical questions: 1. Is stroke volume abnormal? 2. Is stroke volume responsive to fluid, vasopressors or inotropes? 3. Is the aorta abnormal? 4. Is the aortic valve, mitral valve or tricuspid valve severely abnormal? 5. Is there systolic anterior motion of the mitral valve? 6. Is there a regional wall motion abnormality? 7. Are there features of raised left atrial pressure? 8. Are there features of right ventricular impairment or raised pulmonary artery pressure? 9. Are there features of tamponade? 10. Is there venous congestion? FUSIC HD is the first system of its kind to interrogate major cardiac, arterial and venous structures to direct time-critical interventions in acutely unwell patients. This article explains the rationale for this accreditation, outlines the training pathway and summarises the ten clinical questions. Further details are included in an online supplementary appendix.
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Affiliation(s)
- Ashley Miller
- Department of Intensive Care, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Marcus Peck
- Department of Intensive Care, Frimley Park Hospital NHS Foundation Trust, Surrey, UK
| | - Tom Clark
- Department of Intensive Care, Royal Devon and Exeter NHS Foundation Trust, Devon, UK
| | - Hannah Conway
- Department of Intensive Care, Glenfield Hospital, Leicester, UK
| | - Segun Olusanya
- Department of Intensive Care, Barts Health NHS Trust, London, UK
| | - Nick Fletcher
- Department of Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nick Coleman
- Department of Intensive Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Prashant Parulekar
- Department of Intensive Care, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Jonathan Aron
- Department of Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Justin Kirk-Bayley
- Department of Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Surrey, UK
| | | | - Adrian Wong
- Department of Intensive Care, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jennie Stephens
- Department of Intensive Care, Royal Cornwall Hospitals NHS Trust, Cornwall, UK
| | - Antonio Rubino
- Department of Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Ben Attwood
- Department of Intensive Care, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Andrew Walden
- Department of Intensive Care, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Andrew Breen
- Department of Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Manprit Waraich
- Department of Intensive Care, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Catherine Nix
- Department of Intensive Care, University Hospital Limerick, Dooradoyle, Limerick Ireland
| | - Simon Hayward
- Department of Intensive Care, Blackpool Victoria Hospital, Blackpool, UK
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26
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Musolino AM, Buonsenso D, Massolo AC, Gallo M, Supino MC, Boccuzzi E. Point of care ultrasound in the paediatric acute care setting: Getting to the 'heart' of respiratory distress. J Paediatr Child Health 2021; 57:318-322. [PMID: 33295654 DOI: 10.1111/jpc.15308] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 01/13/2023]
Abstract
Point-of-care ultrasound (POCUS) is a growing interesting tool in the emergency setting. Its usefulness in diagnostic and therapeutic pathway of patients with respiratory distress in addition to clinical evaluation is well established in adult emergency medicine while paediatric specific data, although growing, remain limited. We report a case series of paediatric patients presenting with respiratory distress successfully diagnosed with cardiac dysfunction following POCUS evaluations. Lung POCUS, in combination with cardiac POCUS, is a very useful supplementary diagnostic tool to assess the breathless child and to rapidly identify life-threatening primary etiologies or secondary physiologies. Thus, fast echocardiography is a desirable aid for paediatric emergency physicians and should be supported in all paediatric emergency settings following an adequate training that is mandatory regarding image acquisition and data interpretation.
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Affiliation(s)
- Anna M Musolino
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, A. Gemelli University Polyclinic Foundation, IRCCS, Rome, Italy.,Department of Basic Biotechnological Sciences, Intensivological and Perioperative Clinics, Catholic University of the Sacred Heart, Rome, Italy
| | - Anna C Massolo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mariasara Gallo
- Specialization School in Anesthesia, Resuscitation and Pain Therapy, Sapienza University of Rome, Rome, Italy
| | - Maria C Supino
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Elena Boccuzzi
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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27
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Boehm D, Menke H. A History of Fluid Management-From "One Size Fits All" to an Individualized Fluid Therapy in Burn Resuscitation. ACTA ACUST UNITED AC 2021; 57:medicina57020187. [PMID: 33672128 PMCID: PMC7926800 DOI: 10.3390/medicina57020187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/08/2021] [Accepted: 02/14/2021] [Indexed: 12/26/2022]
Abstract
Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future.
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Affiliation(s)
- Dorothee Boehm
- Correspondence: ; Tel.: +69-8405-5141; Fax: +69-8405-5144
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28
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EL-Nawawy AA, Omar OM, Hassouna HM. Role of Inferior Vena Cava Parameters as Predictors of Fluid Responsiveness in Pediatric Septic Shock: A Prospective Study. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1724034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractFluid resuscitation is the initial therapy for septic shock worldwide. Prediction of fluid responsiveness is essential for optimizing fluid administration. Only few pediatric studies have evaluated the role of inferior vena cava (IVC) as a reliable predictor of fluid responsiveness. The aim of this study was to evaluate the role of IVC parameters as predictors of fluid responsiveness in children (under the age of 5 years) having septic shock at different times from admission. A prospective observational study included 51 children having septic shock. It was conducted in the nine-bedded pediatric intensive care unit of a university hospital from January 1, 2018, to the August 31, 2018. Echocardiography was used to assess minimal and maximal IVC diameters and its distensibility index with simultaneous assessment of stroke volume (SV), at 1, 6, and 24 hours from admission. The decision to give fluid in these children was thereby based on the presence of at least one sign of inadequate tissue perfusion. SV was reassessed directly after administration of a fluid bolus of 10 mL/kg over 10 minutes. Fluid responsiveness was considered adequate when there was ≥ 10% increase in SV after fluid bolus. Minimal IVC diameter indexed to body surface area and its distensibility index can be predictors of fluid responsiveness at all times: 1 hour (area under curve [AUC] = 0.88; 95% confidence interval [CI] = 0.77–0.96), 6 hours (AUC = 0.86; 95% CI = 0.67–0.97), and 24 hours (AUC = 0.77; 95% CI = 0.6–0.95). IVC distensibility index can also predict fluid responsiveness at 1 hour (AUC= 0.87; 95% CI = 0.74–0.95), 6 hours (AUC = 0.86; 95% CI = 0.73–0.94), and 24 hours (AUC = 1; 95% CI = 0.77–1). The cutoff points of each parameter differed from time to time (contradicts with previous statement that says it is predictor at all times). The maximum IVC diameter could not predict fluid responsiveness at any time from admission. Minimal IVC diameter and its distensibility index were feasible noninvasive surrogates of fluid responsiveness in pediatric septic shock at different times from admission.
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Affiliation(s)
- Ahmed Ahmed EL-Nawawy
- Pediatric Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
| | - Omneya Magdy Omar
- Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
| | - Hadir Mohamed Hassouna
- Pediatric Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
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Koratala A, Kazory A. Point of Care Ultrasonography for Objective Assessment of Heart Failure: Integration of Cardiac, Vascular, and Extravascular Determinants of Volume Status. Cardiorenal Med 2021; 11:5-17. [PMID: 33477143 DOI: 10.1159/000510732] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Lingering congestion portends poor outcomes in patients with heart failure (HF) and is a key target in their management. Studies have shown that physical exam has low yield in this setting and conventional methods for more precise assessment and monitoring of volume status (e.g., body weight, natriuretic peptides, and chest radiography) have significant inherent shortcomings. SUMMARY Point of care ultrasonography (POCUS) is a noninvasive versatile bedside diagnostic tool that enhances the sensitivity of conventional physical examination to gauge congestion in these patients. It also aids in monitoring the efficacy of decongestive therapy and bears prognostic significance. In this narrative review, we discuss the role of focused sonographic assessment of the heart, venous system, and extravascular lung water/ascites (i.e., the pump, pipes, and the leaks) in objective assessment of fluid volume status. Key Messages: Since each of the discussed components of POCUS has its limitations, a combinational ultrasound evaluation guided by the main clinical features would be the key to reliable assessment and effective management of congestion in patients with HF.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA,
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida, USA
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Machine learning methods to improve bedside fluid responsiveness prediction in severe sepsis or septic shock: an observational study. Br J Anaesth 2021; 126:826-834. [PMID: 33461735 DOI: 10.1016/j.bja.2020.11.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Passive leg raising (PLR) predicts fluid responsiveness in critical illness, although restrictions in mobilising patients often preclude this haemodynamic challenge being used. We investigated whether machine learning applied on transthoracic echocardiography (TTE) data might be used as a tool for predicting fluid responsiveness in critically ill patients. METHODS We studied, 100 critically ill patients (mean age: 62 yr [standard deviation: 14]) with severe sepsis or septic shock prospectively over 24 months. Transthoracic echocardiography measurements were performed at baseline, after PLR, and before and after a standardised fluid challenge in learning and test populations (n=50 patients each). A 15% increase in stroke volume defined fluid responsiveness. The machine learning methods used were classification and regression tree (CART), partial least-squares regression (PLS), neural network (NNET), and linear discriminant analysis (LDA). Each method was applied offline to determine whether fluid responsiveness may be predicted from left and right cardiac ventricular physiological changes detected by cardiac ultrasound. Predictive values for fluid responsiveness were compared by receiver operating characteristics (area under the curve [AUC]; mean [95% confidence intervals]). RESULTS In the learning sample, the AUC values were PLR 0.76 (0.62-0.89), CART 0.83 (0.73-0.94), PLS 0.97 (0.93-1), NNET 0.93 (0.85-1), and LDA 0.90 (0.81-0.98). In the test sample, the AUC values were PLR 0.77 (0.64-0.91), CART 0.68 (0.54-0.81), PLS 0.83 (0.71-0.96), NNET 0.83 (0.71-0.94), and LDA 0.85 (0.74-0.96) respectively. The PLS model identified inferior vena cava collapsibility, velocity-time integral, S-wave, E/Ea ratio, and E-wave as key echocardiographic parameters. CONCLUSIONS Machine learning generated several models for predicting fluid responsiveness that were comparable with the haemodynamic response to PLR.
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de Oliveira GCV, Teixeira-Neto FJ, Dalmagro TL, Alfonso A, Celeita-Rodríguez N, Lobo CPC, Lourenço MLG. Use of aortic flow indexes derived from transthoracic echocardiography to evaluate response to a fluid challenge in anesthetized dogs. Vet Anaesth Analg 2021; 48:187-197. [PMID: 33551352 DOI: 10.1016/j.vaa.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the ability of transthoracic echocardiographic aortic flow measurements to discriminate response to a fluid challenge (FC) in healthy anesthetized dogs. STUDY DESIGN Prospective experimental study. ANIMALS A total of 48 isoflurane-anesthetized dogs (14.2-35.0 kg) undergoing elective surgery. METHODS Fluid responsiveness was evaluated before surgery by FC (lactated Ringer's 10 mL kg-1 intravenously over 5 minutes). Percentage increases in transpulmonary thermodilution stroke volume (ΔSVTPTD) >15% from values recorded before FC defined responders to volume expansion. A group of 24 animals were assigned as nonresponders (ΔSVTPTD ≤15%). When ΔSVTPTD was >15% after the first FC, additional FC were administered until ΔSVTPTD was ≤15%. Final fluid responsiveness status was based on the response to the last FC. Percentage increases after FC in aortic flow indexes [velocity time integral (ΔVTIFC) and maximum acceleration (ΔVmaxFC)] and in mean arterial pressure (ΔMAPFC) were compared with ΔSVTPTD. RESULTS After one FC, 24 animals were responders. For nonresponders, ΔSVTPTD was ≤15% after one, two and three FCs in eight/24, 15/24 and one/24 animals, respectively. The FC that defined responsiveness increased ΔSVTPTD by 29 (18-53)% in responders and by 8 (-3 to 15)% in nonresponders [mean (range)]. The area under the receiver operating characteristics curve (AUROC) of ΔVTIFC (0.901) was larger than the AUROCs of ΔVmaxFC (0.774, p = 0.041) and ΔMAPFC (0.519, p < 0.0001). ΔMAPFC did not predict responsiveness (p = 0.826). Best cut-off thresholds for discriminating responders, with respective zones of diagnostic uncertainty (gray zones) were >14.7 (10.8-17.6)% for ΔVTIFC and >8.6 (-0.3 to 14.7)% for ΔVmaxFC. Animals within the gray zone were 17% (ΔVTIFC) and 50% (ΔVmaxFC). CONCLUSIONS AND CLINICAL RELEVANCE Changes in VTI induced by FC can determine responsiveness with reasonable accuracy in dogs and could play an important role in goal-directed fluid therapy.
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Affiliation(s)
- Guillermo C V de Oliveira
- Department of Veterinary Surgery and Animal Reproduction, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - Francisco J Teixeira-Neto
- Department of Veterinary Surgery and Animal Reproduction, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil; Department of Anesthesiology, Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.
| | - Tábata L Dalmagro
- Department of Anesthesiology, Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - Angélica Alfonso
- Department of Veterinary Surgery and Animal Reproduction, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - Nathalia Celeita-Rodríguez
- Department of Anesthesiology, Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - César P C Lobo
- Department of Anesthesiology, Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - Maria L G Lourenço
- Department of Veterinary Surgery and Animal Reproduction, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
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Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, Baidya DK, Trikha A. Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021; 25:310-316. [PMID: 33790513 PMCID: PMC7991757 DOI: 10.5005/jp-journals-10071-23764] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. How to cite this article: Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al. Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. CTRI/Trial Reg No: www.ctri.nic.in, CTRI/2017/11/010434.
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Affiliation(s)
- Ganesh Chowhan
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Riddhi Kundu
- Department of Critical Care Medicine, Manipal Hospitals, Dwarka, New Delhi, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh K Arora
- Department of Liver Transplant, Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ravinder K Batra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Sahu S, Sam A, Ponnappan K. Fluid management in kidney disease patients for nontransplant and transplantation surgeries. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_203_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Henríquez-Camacho C, Miralles-Aguiar F, Bernabeu-Wittel M. Emerging applications of clinical ultrasonography. Rev Clin Esp 2021; 221:45-54. [PMID: 32654759 DOI: 10.1016/j.rce.2020.01.013] [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: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 11/26/2022]
Abstract
In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).
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Affiliation(s)
- C Henríquez-Camacho
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, Españan
| | - F Miralles-Aguiar
- Unidad Clínica de Anestesiología y Reanimación, Hospital Universitario Puerta del Mar, Cádiz, España
| | - M Bernabeu-Wittel
- Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Henríquez-Camacho C, Miralles-Aguiar F, Bernabeu-Wittel M. Emerging applications of clinical ultrasonography. Rev Clin Esp 2020; 221:45-54. [PMID: 33998478 DOI: 10.1016/j.rceng.2020.01.004] [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: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 10/22/2022]
Abstract
In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).
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Affiliation(s)
- C Henríquez-Camacho
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | - F Miralles-Aguiar
- Unidad Clínica de Anestesiología y Reanimación, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - M Bernabeu-Wittel
- Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
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Ramsingh D, Ghazal E, Gordon B, Ross P, Goltiao D, Alschuler M, Pugh J, Holsclaw M, Mason L. Relationship Between Evaluations of Tracheal Tube Position Using Ultrasound and Fluoroscopy in an Infant and Pediatric Population. J Clin Med 2020; 9:jcm9061707. [PMID: 32498387 PMCID: PMC7355502 DOI: 10.3390/jcm9061707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/11/2020] [Accepted: 05/28/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction: A non-radiographic technique to measure the location of the tracheal tube (TT) in children is of value given the risk of inappropriate TT placement along with concerns about radiation exposure. Airway point-of-care ultrasound (POCUS) has demonstrated utility in children, but the examinations vary by age and may require non-traditional techniques or utilize less common probes. This study evaluated the performance of measuring the tracheal location of the cuffed TT using a novel, linear probe-based POCUS examination over a wide age range of children. After adjusting for the subjects’ height and TT size, ultrasound measurements of the TT cuff location were compared with fluoroscopy measurements of the TT tip location. Methods: Perioperative pediatric patients (<10 years) requiring a cuffed TT were enrolled. After routine TT placement, ultrasound and fluoroscopy images were obtained. Measurements from the TT cuff to the cricoid cartilage were obtained from the POCUS examination. Chest fluoroscopy was reviewed to measure the TT’s distance from the carina. Both measurements were then compared after scaling for patient height. The duration of the ultrasound examination and image quality scores were also recorded. Results: Forty-one patients were enrolled, with a median age of 3 (25th/75th percentile: 1.50/7.00) years. The POCUS examination identified the TT cuff in all cases with the highest image quality score. The median POCUS exam time was 112 (25th/75th percentile: 80.00/156.00) seconds. There was a strong correlation between the POCUS measurements and the fluoroscopy measurements, r = −0.7575, 95% CI [−0.8638, −0.5866 ], p < 0.001). Conclusions: Our results demonstrate a strong correlation between POCUS TT localization measurements and traditional measurements via fluoroscopy. This study further supports the utility of POCUS for pediatric care.
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Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
- Correspondence: ; Tel.: +1-909-558-4475; Fax: +909-558-0187
| | - Elizabeth Ghazal
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Brent Gordon
- Department of Pediatric Cardiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA;
| | - Philip Ross
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Darren Goltiao
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Matt Alschuler
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Justin Pugh
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Matthew Holsclaw
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
| | - Linda Mason
- Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA MC-2532-D, USA; (E.G.); (P.R.); (D.G.); (M.A.); (J.P.); (M.H.); (L.M.)
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Chen PH, Chan KC, Liao MH, Wu CY. Accuracy of dynamic preload variables for predicting fluid responsiveness in patients with pediatric liver cirrhosis: A prospective study. Paediatr Anaesth 2020; 30:455-461. [PMID: 31900969 DOI: 10.1111/pan.13819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 12/09/2019] [Accepted: 01/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND We have previously reported that dynamic preload variables predicted fluid responsiveness in adult patients with liver cirrhosis. However, pediatric patients with cirrhosis may present with unique hemodynamic characteristics, and therefore, the predictive accuracy of these variables in such patients must be clarified. AIMS To investigate the accuracy of dynamic preload variables for predicting fluid responsiveness in pediatric patients with cirrhosis. METHODS A total of 27 pediatric patients with cirrhosis undergoing orthotopic liver transplantation were enrolled in this study. Patients' pulse pressure variation, stroke volume variation, stroke volume index, and central venous pressure were measured using the calibrated pulse contour cardiac output system. The plethysmographic variability index was measured using a Masimo Radical 7 co-oximeter. During the hepatic dissection phase of the surgery, repeated intraoperative fluid challenges with 10 mL kg-1 of crystalloid within 15 minutes were administered. Fluid responsiveness was defined as an increase in stroke volume index of ≥15% after fluid challenge. RESULTS A total of 61 fluid challenges were administered resulting in 15 fluid responders and 46 fluid nonresponders. Fluid challenge induced significant decreases in all three dynamic preload variables but not in the fluid nonresponders. However, the area under the receiver operating characteristic curves for pulse pressure variation, stroke volume variation, plethysmographic variability index, and central venous pressure for predicting fluid responsiveness were 0.67 (95% confidence interval: 0.52-0.82; P = .0255), 0.68 (95% confidence interval: 0.54-0.83; P = .0140), 0.56 (95% confidence interval: 0.40-0.71; P = .4724), and 0.57 (95% confidence interval: 0.40-0.74; P = .4192), respectively. CONCLUSIONS Dynamic preload variables do not predict fluid responsiveness in pediatric patients with liver cirrhosis.
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Affiliation(s)
- Pin-Hsin Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Min-Hsiu Liao
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Influence of maternal aerobic exercise during pregnancy on fetal cardiac function and outflow. Am J Obstet Gynecol MFM 2020; 2:100095. [PMID: 33345961 DOI: 10.1016/j.ajogmf.2020.100095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/22/2020] [Accepted: 02/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Risk factors for cardiovascular disease, the leading cause of death, have been documented in children as young as 3 years of age. Maternal environment (eg, exercise) influences fetal development and long-term health. Thus, the development of the fetal cardiovascular system during pregnancy is likely a preliminary indicator of cardiac health at birth and a proxy for the future risk of cardiovascular disease throughout life. OBJECTIVE The purpose of this study was to assess the effects of supervised prenatal aerobic exercise at recommended levels on fetal cardiac function and outflow in the third trimester of pregnancy. We hypothesized that fetuses of aerobically trained women compared with fetuses of nonexercising women would exhibit increased cardiac function and greater cardiac output. STUDY DESIGN Secondary data analyses of a 20-week, randomized controlled exercise intervention trial in pregnant women between 2015 and 2018 in Eastern North Carolina were performed. Eligibility criteria included pregnant women <16 weeks gestation, singleton pregnancy, aged 18-40 years, body mass index of 18.5-34.99 kg/m2, physician clearance letter for exercise participation, reliable transportation, and method of communication. Exclusion criteria included the presence of chronic conditions (eg, type 1 or 2 diabetes mellitus), current medications known to adversely affect fetal growth (eg, antidepressants), alcohol, smoking, or illicit drug use. The patient cohort consisted of 133 eligible pregnant women who were assigned randomly to either an aerobic exercise (n=66) group that participated in 150 minutes of supervised, moderate-intensity (40-59% VO2peak; 12-14 on Borg Rating of Perceived Exertion) aerobic exercise per week or a nonexercising group (n=61) that consisted of 150 minutes per week of light (<40% VO2peak) stretching and relaxation breathing techniques. Between 34 and 36 weeks gestation, a fetal echocardiogram was performed to assess fetal cardiac function, which included fetal heart rate, right- and left-ventricular stroke volume, stroke volume index, cardiac output, cardiac output index, and cardiac outflow that included pulmonary and aortic valve diameters, peak flow velocity, and peak flow velocity-time integral. Fetal activity state (quiet vs active) during the echocardiogram and maternal aerobic capacity served as covariates. Intention-to-treat and per-protocol (participants who attended ≥80% of exercise sessions) analysis of covariance regression models were performed. RESULTS Of the 127 randomly assigned participants, 66 and 50 participants were included in the intention-to-treat and per-protocol analyses, respectively. Prenatal aerobic exercise significantly increased fetal right-ventricular cardiac measures of right ventricular stroke volume (P=.001) and stroke index via velocity-time integral (P=.003), right ventricular cardiac output (P=.002), cardiac index via velocity-time integral (P=.006), pulmonary artery diameter (P=.02), and pulmonary valve velocity-time integral (P=.03). Only in the intention-to-treat analysis was a significant difference in fetal left ventricular cardiac outflow observed; there was a greater aortic valve peak velocity (P=.04) found among fetuses of aerobically trained pregnant women. No other statistically significant between-group differences were found. CONCLUSION The findings of this study demonstrate that participation in prenatal aerobic exercise at recommended levels may improve fetal cardiac function and outflow parameters. Follow-up cardiovascular measures in the postnatal period are needed to determine potential long-term effects on the offspring's cardiac function and outflow.
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Tung Chen Y, Blancas Gómez-Casero R, Quintana Díaz M, Villén Villegas T, Cobo Mora J, Carballo Cardona C. Results of a Prospective Study to Evaluate the Impact of Point-of-Care Ultrasound in the Enhancement of Gastrointestinal Bleeding Risk Scores. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:279-287. [PMID: 31379015 DOI: 10.1002/jum.15101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/08/2019] [Accepted: 07/07/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. METHODS Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. RESULTS In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). CONCLUSIONS The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.
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Affiliation(s)
- Yale Tung Chen
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X. El Sabio, Madrid, Spain
| | - Rafael Blancas Gómez-Casero
- Department of Medicine, Universidad Alfonso X. El Sabio, Madrid, Spain
- Department of Critical Care, Hospital Universitario del Tajo, Aranjuez, Spain
| | | | - Tomás Villén Villegas
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Julio Cobo Mora
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
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Shah SB, Bhargava AK, Hariharan U, Jain CR, Kulkarni A, Gupta N. Goal-directed fluid therapy using transoesophageal echocardiographic inferior venacaval index in patients with low left ventricular ejection fraction undergoing major cytoreductive surgery: A clinical trial. Saudi J Anaesth 2020; 14:7-14. [PMID: 31998013 PMCID: PMC6970374 DOI: 10.4103/sja.sja_215_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/02/2019] [Indexed: 01/23/2023] Open
Abstract
Background and Aims: This study aims to trans oesophageal echo cardiographically (TOE) measure inferior venacava diameter (IVCD) during inspiration and expiration in poor left ventricular ejection fraction (LVEF) patients undergoing cytoreductive oncosurgery, to ascertain if any correlation exists between, caval index (DeltaIVCD), and stroke volume variation (SVV), and to compare DeltaIVCD-guided versus SVV-guided fluid therapy. Methods: In this prospective, parallel group, interventional study, seventy American Society of Anesthesiologists-III patients, aged 30-75 years, weighing 40-90 kg, with LVEF ≤40% undergoing cytoreductive surgery were included and randomised to group-D (DeltaIVCD-guided fluid therapy) and group-S (SVV-guided fluid therapy). Patients with oesophageal lesions were excluded. After standard endotracheal anaesthesia, arterial and internal jugular vein catheters were placed. A TOE probe was inserted in the interventional group-D. Quantification of IVCD respiratory variations was done. Heart rate (HR), arterial oxygen saturation (SPO2), mean arterial pressure, end tidal carbondioxide (EtCO2), central venous pressure, SVV, IVCD, and urine output (UO) were recorded every 30 min. Post-operative arterial blood gas analysis, lung-ultrasound, chest-radiograph, and serum creatinine were done. Statistical Analysis: Pearson's correlation coefficient as measure of strength of linear relationship, calculation of regression equation, and unpaired t-test for normally distributed continuous variables were used. Results: A positive correlation between DeltaIVCD and SVV (r = 0.751) was observed. A regression equation was obtained for SVV (SVV = [0.317 × DeltaIVCD] + 5.877). Serum lactate, estimated glomerular filtration rate, HR, and UO were within normal limits in group-D. There was no pulmonary oedema. Conclusion: DeltaIVCD-guided intravenous fluid therapy is valuable in low LVEF patients where tight fluid control is essential and any fluid overload may precipitate cardiac failure.
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Affiliation(s)
- Shagun Bhatia Shah
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Ajay Kumar Bhargava
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Uma Hariharan
- Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | - Chamound Rai Jain
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Anita Kulkarni
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Namrata Gupta
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
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Jahan N, Kalshetty K, Setlur R, Jaiswal A, Dwivedi D. Inferior vena cava collapsibility index for the assessment of fluid responsiveness among spontaneously breathing preoperative fasting patients - An observational study. JOURNAL OF MARINE MEDICAL SOCIETY 2020. [DOI: 10.4103/jmms.jmms_64_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Faqin LMD, Jinrui WMD, Xing YMD, Aiping YMD, Ji-Bin LMD, Linxue QMD, Huixiong XMD, Ligang CMD, Mingxing XMD, Xi LMD, Chengzhong PMD, Yi HMD, Haiyan KMD, Shengzheng WMD, Xi YMD, Bin TMD, Huaping JMD, Qingyi MMD, Jie LMD, Ruizhong YMD. Chinese Expert Consensus on Critical Care Ultrasound Applications at COVID-19 Pandemic. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2020. [DOI: 10.37015/audt.2020.200029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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El-Nawawy AA, Farghaly PM, Hassouna HM. Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Indian J Crit Care Med 2020; 24:344-349. [PMID: 32728327 PMCID: PMC7358867 DOI: 10.5005/jp-journals-10071-23432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Aim To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. Materials and methods A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. Findings Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. Conclusion Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. Clinical significance Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. How to cite this article El-Nawawy AA, Farghaly PM, Hassouna HM, Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Int J Clin Pediatr Dent 2020;24(5):344-349.
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Affiliation(s)
- Ahmed A El-Nawawy
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Passant M Farghaly
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
| | - Hadir M Hassouna
- Pediatric Department (PICU), Faculty of Medicine, Alexandria University, Egypt
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Bissell BD, Mefford B. Pathophysiology of Volume Administration in Septic Shock and the Role of the Clinical Pharmacist. Ann Pharmacother 2019; 54:388-396. [PMID: 31694386 DOI: 10.1177/1060028019887160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Objective: To review physiological rationale and evidence base surrounding fluid harm to prepare the clinical pharmacist for accountability regarding volume-related outcomes. Data Sources: A PubMed/MEDLINE search was conducted using the following terms: (fluid therapy) AND [(critical care) OR (sepsis)] from 1966 to August 2019 published in English. Study Selection and Data Extraction: A total of 3364 citations were reviewed with only relevant clinical data extracted. Data Synthesis: Although early fluid resuscitation may be a necessary component to decrease mortality in the majority of patients with septic shock admitted to the intensive care unit (ICU), the benefit of continued administration after the first 24 hours is uncertain. Paradoxically, a positive fluid balance secondary to intravenous fluid receipt has been associated with diverse and perpetuating detriment on a multitude of organ systems after the first 24 hours of ICU stay. Continued clinical harm has been demonstrated on patient outcomes such as rates of mortality and length of stay. Despite the growing body of evidence supporting the potential adverse aspects of positive fluid balance, fluid overload remains common during critical care admission. Conclusion: Physiological concerns to overly zealous fluid administration and subsequent volume overload are vast. Relevance to Patient Care and Clinical Practice: Optimization of fluid balance in critically ill patients with sepsis is primed for clinical pharmacy intervention. Critical care pharmacists have the potential to improve patient care by optimizing fluid pharmacotherapy while potentially reducing adverse events, days on mechanical ventilation, and length of ICU stay.
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He F, Li X, Thapa S, Li C, Luo J, Dai W, Liu J. Evaluation of volume responsiveness by pulse pressure variability and inferior vena cava dispensability index at different tidal volumes by mechanical ventilation. ACTA ACUST UNITED AC 2019; 52:e8827. [PMID: 31482978 PMCID: PMC6720221 DOI: 10.1590/1414-431x20198827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 02/05/2023]
Abstract
This study investigated the effects of tidal volume (TV) on the diagnostic value of pulse pressure variation (PPV) and the inferior vena cava dispensability index (IVC-DI) for volume responsiveness during mechanical ventilation. In patients undergoing elective surgery with mechanical ventilation, different TVs of 6, 9, and 12 mL/kg were given for two min. The left ventricular outflow tract velocity-time integral (VTI) was measured by transthoracic echocardiography. The IVC-DI was measured at sub-xyphoid transabdominal long axis. The PPV was measured via the radial artery and served as baseline. Index measurements were repeated after fluid challenge. VTI increased by more than 15% after fluid challenge, which was considered as volume responsive. Seventy-nine patients were enrolled, 38 of whom were considered positive volume responsive. Baseline data between the response group and the non-response group were similar. Receiver operating characteristic curve confirmed PPV accuracy in diagnosing an increase in volume responsiveness with increased TV. When TV was 12 mL/kg, the PPV area under the curve (AUC) was 0.93 and the threshold value was 15.5%. IVC-DI had the highest diagnostic accuracy at a TV of 9 mL/kg and an AUC of 0.79, with a threshold value of 15.3%. When TV increased to 12 mL/kg, the IVC-DI value decreased. When the TV was 9 and 12 mL/kg, PPV showed improved performance in diagnosing volume responsiveness than did IVC-DI. PPV diagnostic accuracy in mechanically ventilated patients was higher than IVC-DI. PPV accuracy in predicting volume responsiveness was increased by increasing TV.
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Affiliation(s)
- Fujuan He
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Xiaoqiang Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Suman Thapa
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Chi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Jiawei Luo
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Wenyan Dai
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Wuhou District, Chengdu, Sichuan, China
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Silversides JA, Perner A, Malbrain MLNG. Liberal versus restrictive fluid therapy in critically ill patients. Intensive Care Med 2019; 45:1440-1442. [DOI: 10.1007/s00134-019-05713-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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Xu LY, Tu GW, Cang J, Hou JY, Yu Y, Luo Z, Guo KF. End-expiratory occlusion test predicts fluid responsiveness in cardiac surgical patients in the operating theatre. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:315. [PMID: 31475185 PMCID: PMC6694235 DOI: 10.21037/atm.2019.06.58] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether a 20-second end-expiratory occlusion (EEO) test can predict fluid responsiveness in cardiac surgery patients in the operating theatre. METHODS This prospective study enrolled 75 mechanically ventilated patients undergoing elective coronary artery bypass grafting surgery. Hemodynamic data coupled with transesophageal echocardiography monitoring of the velocity time integral (VTI) and the peak velocity (Vmax) at the left ventricular outflow tract were collected at each step (baseline 1, EEO, baseline 2 and fluid challenge). Patients were divided into fluid responders (increase in VTI ≥15%) and non-responders (increase in VTI <15%) after a fluid challenge (6 mL 0.9% saline per kg, given in 10 minutes). RESULTS Fluid challenge significantly increased the VTI by more than 15% in 36 (48%) patients (responders). An increase in VTI greater than 5% during the EEO test predicted fluid responsiveness with a sensitivity of 81% and a specificity of 93%. The area under the receiver-operating characteristic curve (AUROC) of ΔVTI-EEO was 0.90 [95% confidence interval (CI): 0.83-0.97]. ΔVmax-EEO was poorly predictive of fluid responsiveness, with an AUC of 0.75 (95% CI: 0.63-0.86). CONCLUSIONS Changes in VTI induced by a 20-second EEO can reliably predict fluid responsiveness in cardiac surgical patients in the operating theatre, whereas the changes in Vmax cannot.
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Affiliation(s)
- Li-Ying Xu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jun-Yi Hou
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ying Yu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Crit Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Ke-Fang Guo
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Furtado S, Reis L. Inferior vena cava evaluation in fluid therapy decision making in intensive care: practical implications. Rev Bras Ter Intensiva 2019; 31:240-247. [PMID: 31271627 PMCID: PMC6649212 DOI: 10.5935/0103-507x.20190039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/09/2018] [Indexed: 01/03/2023] Open
Abstract
The fluid resuscitation of patients with acute circulatory failure aims to
increase systolic volume and consequently improve cardiac output for better
tissue oxygenation. However, this effect does not always occur because
approximately half of patients do not respond to fluids. The evaluation of fluid
responsiveness before their administration may help to identify patients who
would benefit from fluid resuscitation and avoid the risk of fluid overload in
the others. The dynamic parameters of fluid responsiveness evaluation are
promising predictive factors. Of these, the echocardiographic measurement of the
respiratory variation in the inferior vena cava diameter is easy to apply and
has been used in the hemodynamic evaluation of intensive care unit patients.
However, the applicability of this technique has many limitations, and the
present studies are heterogeneous and inconsistent across specific groups of
patients. We review the use of the inferior vena cava diameter respiratory
variation, measured via transthoracic echocardiography, to decide whether to
administer fluids to patients with acute circulatory failure in the intensive
care unit. We explore the benefits and limitations of this technique, its
current use, and the existing evidence.
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Affiliation(s)
- Sofia Furtado
- Departamento de Medicina Interna - Unidade 1.2, Hospital São José, Centro Hospitalar Universitário Lisboa Central - Lisboa, Portugal.,Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Universitário Lisboa Central - Lisboa, Portugal
| | - Luís Reis
- Unidade de Urgência Médica, Hospital São José, Centro Hospitalar Universitário Lisboa Central - Lisboa, Portugal
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Oricco S, Rabozzi R, Meneghini C, Franci P. Usefulness of focused cardiac ultrasonography for predicting fluid responsiveness in conscious, spontaneously breathing dogs. Am J Vet Res 2019; 80:369-377. [PMID: 30919671 DOI: 10.2460/ajvr.80.4.369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the diagnostic usefulness of focused cardiac ultrasonography and selected echocardiographic variables for predicting fluid responsiveness in conscious, spontaneously breathing dogs with various clinical conditions. ANIMALS 26 dogs (15 males and 11 females) with a median age of 84 months (range, 12 to 360 months) and median body weight of 8 kg (range, 2 to 35 kg) referred for various clinical conditions. PROCEDURES Left ventricular end-diastolic internal diameter normalized to body weight (LVIDDn), left ventricular volume score (LVVS), left ventricular end-diastolic volume index (EDVI), aortic velocity time integral (VTIAo), and aortic peak flow velocity (VmaxAo) were echocardiographically measured before and after IV administration of a bolus of lactated Ringer solution (4 mL/kg) over a 1-minute period. Dogs were classified on the basis of the observed change in aortic stroke volume following fluid administration as responders (≥ 15%) or nonresponders (< 15%) to fluid administration. Receiver operating characteristic curves were generated for the ability of LVVS, LVIDDn, EDVI, VTIAo, and VmaxAo to predict responder status. RESULTS 13 dogs were classified as responders and 13 as nonresponders. Areas under the receiver operating characteristic curves (95% confidence intervals) for predicting fluid responsiveness were as follows: VTIAo, 0.91 (0.74 to 0.99); LVIDDn, 0.85 (0.66 to 0.96); EDVI, 0.85 (0.65 to 0.96); LVVS, 0.85 (0.65 to 0.96); and VmaxAo, 0.75 (0.54 to 0.90). CONCLUSIONS AND CLINICAL RELEVANCE The evaluated echocardiographic variables were useful for noninvasive prediction of fluid responsiveness in conscious dogs and could be valuable for informing clinical decisions regarding fluid therapy.
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Biasucci DG, Cina A, Calabrese M, Antoniucci ME, Cavaliere C, Bevilacqua F, Cavaliere F. Size and shape of the inferior vena cava before and after a fluid challenge: a pilot study. Minerva Anestesiol 2018; 85:514-521. [PMID: 30482000 DOI: 10.23736/s0375-9393.18.13041-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Recent meta-analyses failed to support the reliability of ultrasound assessment of the inferior vena cava (IVC) to predict fluid responsiveness. However, the techniques utilized were heterogeneous. We hypothesized that the variability of the elliptic section and caliber of the IVC along its course may influence ultrasound evaluation. Therefore, we investigated IVC size and shape at four levels, before and after a fluid challenge. METHODS Twenty mechanically-ventilated adult patients who received a fluid challenge after cardiac surgery were enrolled. They were regarded as responders if the cardiac index increased more than 15%. Before and after the fluid challenge, IVC anteroposterior (AP) and lateral (LA) diameters, the flat ratio, and the distensibility index were assessed by ultrasound just above the iliac veins, at the confluence of the renal veins, before the confluence of the hepatic veins (where blood flow velocity was also measured), and after it. RESULTS At all levels, IVC section was elliptical, so that IVC diameters varied between a minimum and a maximum according to the measurement angle. Such interval increased in correspondence of the renal veins, where IVC section was more eccentric. The distensibility index was higher when assessed on AP diameters. After the fluid challenge, non-responders showed a diffuse increase of AP diameters, whereas responders showed an increase of blood velocity before the confluence of the hepatic veins. CONCLUSIONS The elliptic section should be considered when assessing IVC size. AP diameters are shorter and more affected by the respiratory cycle. After a fluid challenge, an increase of blood velocity associated with unchanged AP diameters may suggest fluid responsiveness.
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Affiliation(s)
- Daniele G Biasucci
- Intensive Care Unit, "A. Gemelli" University Hospital Foundation IRCCS, Rome, Italy -
| | - Alessandro Cina
- Department of Radiology, A. Gemelli Policlinic IRCCS Foundation, Rome, Italy.,Unit of Cardiac Anesthesia and Cardiac Surgical Intensive Care, A. Gemelli Policlinic IRCCS Foundation, Rome, Italy
| | | | | | - Carlo Cavaliere
- Department of Sense Organs, La Sapienza University, Rome, Italy
| | | | - Franco Cavaliere
- Unit of Cardiac Anesthesia and Cardiac Surgical Intensive Care, A. Gemelli Policlinic IRCCS Foundation, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
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