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Haemodynamic monitoring in acute heart failure - what you need to know. Adv Cardiol 2022; 18:90-100. [PMID: 36051835 PMCID: PMC9421519 DOI: 10.5114/aic.2022.118524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 12/03/2022]
Abstract
Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.
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Abstract
PURPOSE OF REVIEW Hemodynamic investigations are required in patients with shock to identify the type of shock, to select the most appropriate treatments and to assess the patient's response to the selected therapy. We discuss how to select the most appropriate hemodynamic monitoring techniques in patients with shock as well as the future of hemodynamic monitoring. RECENT FINDINGS Over the last decades, the hemodynamic monitoring techniques have evolved from intermittent toward continuous and real-time measurements and from invasive toward less-invasive approaches. In patients with shock, current guidelines recommend the echocardiography as the preferred modality for the initial hemodynamic evaluation. In patients with shock nonresponsive to initial therapy and/or in the most complex patients, it is recommended to monitor the cardiac output and to use advanced hemodynamic monitoring techniques. They also provide other useful variables that are useful for managing the most complex cases. Uncalibrated and noninvasive cardiac output monitors are not reliable enough in the intensive care setting. SUMMARY The use of echocardiography should be initially encouraged in patients with shock to identify the type of shock and to select the most appropriate therapy. The use of more invasive hemodynamic monitoring techniques should be discussed on an individualized basis.
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Yin W, Li Y, Wang S, Zeng X, Qin Y, Wang X, Chao Y, Zhang L, Kang Y, (CCUSG) CCUSG. The PIEPEAR Workflow: A Critical Care Ultrasound Based 7-Step Approach as a Standard Procedure to Manage Patients with Acute Cardiorespiratory Compromise, with Two Example Cases Presented. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4687346. [PMID: 29992144 PMCID: PMC6016228 DOI: 10.1155/2018/4687346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/04/2018] [Accepted: 05/16/2018] [Indexed: 02/05/2023]
Abstract
Critical care ultrasound (CCUS) has been widely used as a useful tool to assist clinical judgement. The utilization should be integrated into clinical scenario and interact with other tests. No publication has reported this. We present a CCUS based "7-step approach" workflow-the PIEPEAR Workflow-which we had summarized and integrated our experience in CCUS and clinical practice into, and then we present two cases which we have applied the workflow into as examples. Step one is "problems emerged?" classifying the signs of the deterioration into two aspects: acute circulatory compromise and acute respiratory compromise. Step two is "information clear?" quickly summarizing the patient's medical history by three aspects. Step three is "focused exam launched": (1) focused exam of the heart by five views: the assessment includes (1) fast and global assessment of the heart (heart glance) to identify cases that need immediate life-saving intervention and (2) assessing the inferior vena cava, right heart, diastolic and systolic function of left heart, and systematic vascular resistance to clarify the hemodynamics. (2) Lung ultrasound exam is performed to clarify the predominant pattern of the lung. Step four is "pathophysiologic changes reported." The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes. Step five is "etiology explored" diagnosing the etiology by integrating Step two and Step four and searching for the source of infection, according to the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should be applied if needed. Step six is "action" supporting the circulation and respiration sticking to Step four. Treat the etiologies according step five. Step seven is "recheck to adjust." Repeat focused ultrasound and other tests to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis. With two cases as examples presented, we insist that applying CCUS with 7-step approach workflow is easy to follow and has theoretical advantages. The coming research on its value is expected.
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Affiliation(s)
- Wanhong Yin
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Yi Li
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Shouping Wang
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Xueying Zeng
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Yao Qin
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Hospital of Tsinghua University, Beijing 100016, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yan Kang
- Department of Critical Care Medicine, West China School of Medicine/West China Hospital, Sichuan University, 37 Guoxue Avenue, Chengdu 610041, China
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John Doyle D, Dahaba AA, LeManach Y. Advances in anesthesia technology are improving patient care, but many challenges remain. BMC Anesthesiol 2018; 18:39. [PMID: 29653517 PMCID: PMC5899388 DOI: 10.1186/s12871-018-0504-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 02/08/2023] Open
Abstract
Although significant advances in clinical monitoring technology and clinical practice development have taken place in the last several decades, in this editorial we argue that much more still needs to be done. We begin by identifying many of the improvements in perioperative technology that have become available in recent years; these include electroencephalographic depth of anesthesia monitoring, bedside ultrasonography, advanced neuromuscular transmission monitoring systems, and other developments. We then discuss some of the perioperative technical challenges that remain to be satisfactorily addressed, such as products that incorporate poor software design or offer a confusing user interface. Finally we suggest that the journal support initiatives to help remedy this problem by publishing reports on the evaluation of medical equipment as a means to restore the link between clinical research and clinical end-users.
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Affiliation(s)
- D John Doyle
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA. .,Department of General Anesthesiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE, PO Box 112412, Abu Dhabi, UAE.
| | - Ashraf A Dahaba
- Priv.-Doz. Dr.med.university, Division of General Anaesthesiology, Emergency- and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Yannick LeManach
- Departments of Anesthesia & Health Research Methods, Evidence, and Impact, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main Street West Hamilton, Hamilton, ON, L8S 4L8, Canada.,Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
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Yin W, Li Y, Zeng X, Qin Y, Wang D, Zou T, Su L, Kang Y. The utilization of critical care ultrasound to assess hemodynamics and lung pathology on ICU admission and the potential for predicting outcome. PLoS One 2017; 12:e0182881. [PMID: 28806783 PMCID: PMC5555697 DOI: 10.1371/journal.pone.0182881] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/26/2017] [Indexed: 02/05/2023] Open
Abstract
Aim Critical care ultrasound (CCUS) has been used by many Intensive Care Units(ICUs) worldwide, so as to guiding the diagnosis and the treatment. However, none of the publications currently systematically describe the utilization of CCUS to analyze the characteristics of hemodynamics and lung pathology upon the new admission to ICU and its potential role in patients’ prognosis prediction. In this retrospective clinical study, we have demonstrated and analyzed the characteristics of hemodynamics and lung pathology assessed by CCUS and investigated its potential to predict patient outcome. Methods We have described and analyzed the epidemic characteristics of hemodynamics and lung pathology assessed by CCUS on ICU admission, which based on our database of 451 cases from the biggest medical center in Western China, between November 2014 and October 2015. The patients’ demographics, clinical characteristics, prognosis and ultrasonic pattern of hemodynamics and lung pathology had been analyzed. A bivariate logistic regression model was established to identify the correlation between the ultrasonic variables on admission and the ICU mortality. Results The mean age of the 451 patients was 56.7±18.7 years; the mean APACHE II score was 19.0±7.9, the ICU mortality was 30.6%. Patients received CCUS examination of pericardial, right ventricle (RV) wall motion, left ventricle (LV) wall motion, LV systolic function, LV diastolic function, lung and volume of inferior vena cava (IVC) were 423(93.8%), 418(92.7%), 392(86.9%), 389(86.3%), 383(84.9%), 440(97.6%), 336(74.5%), respectively; The univariate analysis revealed that length of mechanical ventilation was significantly correlated with the diameter of IVC, tricuspid annular plane systolic excursion(TAPSE), mitral annular plane systolic excursion(MAPSE), early diastolic transmitral velocity to early mitral annulus diastolic velocity(E/e’) (p = 0.016, 0.011, 0.000, 0.049, respectively); The TAPSE, ejection fraction(EF), MAPSE, lung ultrasound score (LUS score) (p = 0.000, 0.028, 0.000, 0.011, respectively) were significantly related to ICU mortality. The multivariate analysis demonstrated that APACHE II, age, TAPSE, E/e’ are the independent risk factors for ICU mortality in our study. Conclusion CCUS examination on ICU admission which performed by the experienced physician provide valuable information to assist the caregivers in understanding the comprehensive outlook of the characteristics of hemodynamics and lung pathology. Those key variables obtained by CCUS predict the possible prognosis of patients, hence deserve more attention in clinical decision making.
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Affiliation(s)
- Wanhong Yin
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yi Li
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Xueying Zeng
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yao Qin
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Dong Wang
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Tongjuan Zou
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Ling Su
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- * E-mail:
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Laher AE, Watermeyer MJ, Buchanan SK, Dippenaar N, Simo NCT, Motara F, Moolla M. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. Am J Emerg Med 2017; 35:1335-1347. [PMID: 28366285 DOI: 10.1016/j.ajem.2017.03.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023] Open
Abstract
The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
| | - Matthew J Watermeyer
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Sean K Buchanan
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nicole Dippenaar
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Affiliation(s)
- Dheeraj Arora
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
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Abstract
PURPOSE OF REVIEW Hemodynamic exploration is mandatory in patients with shock to identify the type of shock, to select the best therapeutic strategy, and to assess the efficacy of the selected therapy. In this review, we summarize the characteristics of the main available hemodynamic monitoring systems and emphasize on how to select the most appropriate ones in patients with circulatory shock. RECENT FINDINGS Over the past decade, hemodynamic monitoring techniques have progressively evolved from intermittent toward real-time measurements and from invasive toward less invasive approaches. Nowadays, echocardiography is recommended as the first-line modality of hemodynamic evaluation in patients with shock. Current guidelines recommend reserving advanced hemodynamic monitoring systems for patients not responding to the initial therapy and/or for complex conditions such as combination of shock with acute respiratory distress syndrome. Invasive and noninvasive uncalibrated cardiac output monitors, as well as esophageal Doppler, could find their place in the perioperative context rather than in patients with shock. SUMMARY The use of echocardiography should be encouraged at the initial period of shock to identify main involved mechanisms and to select the appropriate therapy. The use of more invasive monitoring systems should be discussed on an individualized basis.
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Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 2016; 42:324-332. [DOI: 10.1007/s00134-015-4168-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022]
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Donati A, Carsetti A, Damiani E, Adrario E, Romano R, Pelaia P. Fluid responsiveness in critically ill patients. Indian J Crit Care Med 2015; 19:375-6. [PMID: 26180427 PMCID: PMC4502487 DOI: 10.4103/0972-5229.160263] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Abele Donati
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Rocco Romano
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Paolo Pelaia
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
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