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Liu Y, Han Z, Wang J, Wang Q, Qie X. Inferior vena cava collapsibility index for predicting hypotension after spinal anesthesia in patients undergoing total knee arthroplasty. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01468-4. [PMID: 39382631 DOI: 10.1007/s00101-024-01468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/14/2024] [Accepted: 07/29/2024] [Indexed: 10/10/2024]
Abstract
OBJECTIVE This study aimed to identify risk factors associated with hypotension in patients undergoing total knee arthroplasty (TKA) under spinal anesthesia. METHOD A total of 200 patients (50-75 years of age) who underwent elective TKA under spinal anesthesia between October 2023 and January 2024 were enrolled. Patients were divided into two groups (hypotensive and nonhypotensive) depending on the occurrence of postspinal anesthesia hypotension (PSAH). Patient characteristics (age, sex, body mass index, and medical history), blood pressure, heart rate, and ultrasound data before anesthesia were documented. Multivariate logistic regression models were used to determine risk factors for hypotension after spinal anesthesia. Furthermore, a nomogram was constructed according to independent predictive factors. The area under the curve (AUC) and calibration curves were employed to assess the performance of the nomogram. RESULTS In total, 175 patients were analyzed and 79 (45.1%) developed PSAH. Logistic regression analysis revealed that variability of the inferior vena cava (odds ratio, OR, 1.147; 95% confidence interval, CI: 1.090-1.207; p < 0.001) and systolic arterial blood pressure (SABP, OR 1.078; 95% CI: 1.043-1.115; p < 0.001) were independent risk factors for PSAH. Receiver operating characteristic (ROC) curve analysis showed that the AUC of the inferior vena cava collapsibility index (IVCCI) and SABP alone were 0.806 and 0.701, respectively, while the AUC of both combined was 0.841. Specifically, an IVCCI of > 37.5% and systolic arterial blood pressure of > 157 mm Hg were considered threshold values. Furthermore, we found that the combination had a better predictive value with higher AUC value, sensitivity, and specificity than the index alone. The nomogram model and calibration curves demonstrated the satisfactory predictive performance of the model. CONCLUSION Elevated preoperative systolic arterial blood pressure and a higher IVCCI were identified as independent risk factors for hypotension in patients receiving spinal anesthesia, which may help guide personalized treatment.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Hebei Province Key Laboratory of Integrated Traditional and Western Medicine in Neurological Rehabilitation, Cangzhou, China
| | - Ziyu Han
- Basic Medical College, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jianhua Wang
- Department of Anesthesiology, Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Hebei Province Key Laboratory of Integrated Traditional and Western Medicine in Neurological Rehabilitation, Cangzhou, China
| | - Qiujun Wang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaojuan Qie
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, Shijiazhuang, China.
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Park EJ, Cho AR, Kim HJ, Lee HJ, Jeon S, Baik J, Do W, Kang C, Kang Y. Preoperative echocardiography as a predictor of spinal anesthesia-induced hypotension in older patients with mild left ventricular diastolic dysfunction: a retrospective observational study. Anesth Pain Med (Seoul) 2024; 19:134-143. [PMID: 38725168 PMCID: PMC11089297 DOI: 10.17085/apm.23161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/21/2024] [Accepted: 03/11/2024] [Indexed: 05/15/2024] Open
Abstract
BACKGROUND Spinal anesthesia-induced hypotension (SAH) frequently occurs in older patients, many of whom have mild left ventricular (LV) diastolic dysfunction, often asymptomatic at rest. This study investigated the association between preoperative echocardiographic measurements and SAH in older patients with mild LV diastolic dysfunction. METHODS We conducted a retrospective observational study using data from electronic medical records. The patients ≥ 65 years old who underwent spinal anesthesia for urologic surgery between January 2016 and December 2017 and whose preoperative echocardiography within 6 months before surgery revealed grade I LV diastolic dysfunction were recruited. SAH was investigated using the anesthesia records. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. RESULTS A total of 163 patients were analyzed. SAH and significant SAH developed in 55 (33.7%) patients. The mitral inflow E velocity was an independent risk factor for SAH (odds ratio [OR], 0.886; 95% confidence interval [CI], 0.845-0.929; P < 0.001). The area under the ROC curve for mitral inflow E velocity to predict SAH was 0.819 (95% CI, 0.752-0.875; P < 0.001). If mitral inflow E velocity was ≤ 60 cm/s, SAH was predicted with a sensitivity of 83.6% and specificity of 70.4%. CONCLUSIONS The preoperative mitral inflow E velocity demonstrated the greatest predictability of SAH in older patients with mild LV diastolic dysfunction. This may assist in identifying patients at high risk of SAH and guiding preventive strategies in the future.
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Affiliation(s)
- Eun Ji Park
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hyae-Jin Kim
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hyeon-Jeong Lee
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Soeun Jeon
- Department of Anesthesia and Pain Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jiseok Baik
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Wangseok Do
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Christine Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yerin Kang
- Department of Anesthesia and Pain Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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Dong S, Wang Q, Wang S, Zhou C, Wang H. Hypotension prediction index for the prevention of hypotension during surgery and critical care: A narrative review. Comput Biol Med 2024; 170:107995. [PMID: 38325215 DOI: 10.1016/j.compbiomed.2024.107995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/17/2023] [Accepted: 01/13/2024] [Indexed: 02/09/2024]
Abstract
Surgeons and anesthesia clinicians commonly face a hemodynamic disturbance known as intraoperative hypotension (IOH), which has been linked to more severe postoperative outcomes and increases mortality rates. Increased occurrence of IOH has been positively associated with mortality and incidence of myocardial infarction, stroke, and organ dysfunction hypertension. Hence, early detection and recognition of IOH is meaningful for perioperative management. Currently, when hypotension occurs, clinicians use vasopressor or fluid therapy to intervene as IOH develops but interventions should be taken before hypotension occurs; therefore, the Hypotension Prediction Index (HPI) method can be used to help clinicians further react to the IOH process. This literature review evaluates the HPI method, which can reliably predict hypotension several minutes before a hypotensive event and is beneficial for patients' outcomes.
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Affiliation(s)
- Siwen Dong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Qing Wang
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - Shuai Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Congcong Zhou
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China; Biosensor National Special Laboratory, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou 310027, China
| | - Hongwei Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China.
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Chowdhury SR, Datta PK. Comments on: Efficacy of inferior vena cava collapsibility index and caval aorta index in predicting the incidence of hypotension after spinal anaesthesia- A prospective, blinded, observational study. Indian J Anaesth 2023; 67:1027-1028. [PMID: 38213692 PMCID: PMC10779979 DOI: 10.4103/ija.ija_697_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/06/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Sumit R Chowdhury
- Department of Neuro-Anaesthesiology and Critical Care, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Priyankar Kumar Datta
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Ahluwalia P, Gupta B. Clinical utility of VExUS score for anaesthesiologists. Indian J Anaesth 2023; 67:941-942. [PMID: 38044918 PMCID: PMC10691597 DOI: 10.4103/ija.ija_230_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
- Pallavi Ahluwalia
- Department of Anaesthesiology, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India
| | - Bhavna Gupta
- Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
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Chang YJ, Liu CC, Huang YT, Wu JY, Hung KC, Liu PH, Lin CH, Lin YT, Chen IW, Lan KM. Assessing the Efficacy of Inferior Vena Cava Collapsibility Index for Predicting Hypotension after Central Neuraxial Block: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:2819. [PMID: 37685357 PMCID: PMC10487093 DOI: 10.3390/diagnostics13172819] [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: 08/05/2023] [Revised: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
The use of ultrasonography to predict spinal-induced hypotension (SIH) has gained significant attention. This diagnostic meta-analysis aimed to investigate the reliability of the inferior vena cava collapsibility index (IVCCI) in predicting SIH in patients undergoing various surgeries. Databases, including Embase, Cochrane Library, Medline, and Google Scholar, were screened until 28 July 2023, yielding 12 studies with 1076 patients (age range: 25.6-79 years) undergoing cesarean section (CS) (n = 4) or non-CS surgeries (n = 8). Patients with SIH had a significantly higher IVCCI than those without SIH (mean difference: 11.12%, 95% confidence interval (CI): 7.83-14.41). The pooled incidence rate of SIH was 40.5%. IVCCI demonstrated satisfactory overall diagnostic reliability (sensitivity, 77%; specificity, 82%). The pooled area under the curve (AUC) was 0.85, indicating its high capability to differentiate patients at risk of PSH. The Fagan nomogram plot demonstrated a positive likelihood ratio (PLR) of 4 and a negative likelihood ratio (NLR) of 0.28. The results underscore the robustness and discriminative ability of IVCCI as a predictive tool for SIH. Nevertheless, future investigations should focus on assessing its applicability to high-risk patients and exploring the potential enhancement in patient safety through its incorporation into clinical practice.
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Affiliation(s)
- Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
- Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City 82445, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
- School of Medicine, I-Shou University, Kaohsiung City 82445, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70101, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Ping-Hsin Liu
- Department of Anesthesiology, E-Da Dachang Hospital, I-Shou University, Kaohsiung City 80794, Taiwan
| | - Chien-Hung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City 71004, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City 71004, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City 71004, Taiwan
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Lal J, Jain M, Rahul, Singh AK, Bansal T, Vashisth S. Efficacy of inferior vena cava collapsibility index and caval aorta index in predicting the incidence of hypotension after spinal anaesthesia- A prospective, blinded, observational study. Indian J Anaesth 2023; 67:523-529. [PMID: 37476444 PMCID: PMC10355364 DOI: 10.4103/ija.ija_890_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 07/22/2023] Open
Abstract
Background and Aim Spinal anaesthesia-induced hypotension (SAIH) is a frequent side effect of spinal anaesthesia. SAIH is usually observed in patients with hypovolemia. Ultrasonography has evolved as a non-invasive tool for volume status assessment. Methods This prospective, blinded, observational study was conducted on 75 adult patients who required spinal anaesthesia after receiving ethical approval and registering the study. Ultrasonographic evaluation of the aorta and the inferior vena cava (IVC) was done preoperatively, and the IVC collapsibility index (IVCCI) and caval aorta index were calculated. The incidence of SAIH was recorded. The strength of the association between different parameters and SAIH was calculated. To find out the value of the optimal cut-off for the prediction of SAIH, receiver operating characteristic (ROC) analysis for various ultrasound parameters was done. The bidirectional stepwise selection was utilised for multivariate analysis to choose the single best predictor. Results SAIH was observed in 36 patients. Among demographic parameters, age, female gender, and height showed a medium correlation. Among ultrasonographic measurements, minimum IVC internal diameter (IVCmin) and IVCCI showed a strong association with SAIH. The best parameter regarding area under the ROC curve (AUC) and diagnostic accuracy was IVCCI (0.828 and 85%, respectively). On multivariate analysis, age (95% CI [1.01, 1.12], P = 0.024) and IVCCI (95% CI [1.05, 1.18], P < 0.001) were significant independent predictors. At a cut-off point of ≥43.5%, IVCCI accurately predicted SAIH (sensitivity 81% and specificity 90%). Conclusion Preoperative ultrasonographic assessment of IVC to evaluate its collapsibility index is a convenient, cost-effective, and reproducible tool for predicting SAIH.
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Affiliation(s)
- Jatin Lal
- Department of Anaesthesiology, PGIMS, Rohtak, Haryana, India
| | - Mamta Jain
- Department of Anaesthesiology, PGIMS, Rohtak, Haryana, India
| | - Rahul
- Department of Critical Care Medicine, Max Superspeciality Hospital Saket, Delhi, India
| | | | - Teena Bansal
- Department of Anaesthesiology, PGIMS, Rohtak, Haryana, India
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Chowdhury SR, Datta PK, Maitra S, Rawat D, Baidya DK, Roy A, Nath S. The use of preoperative inferior vena cava ultrasound to predict anaesthesia-induced hypotension: a systematic review. Anaesthesiol Intensive Ther 2023; 55:18-31. [PMID: 37306268 PMCID: PMC10156560 DOI: 10.5114/ait.2023.125310] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/09/2022] [Indexed: 09/20/2023] Open
Abstract
Preoperative ultrasound assessment of inferior vena cava (IVC) diameter and the collapsi-bility index might identify patients with intravascular volume depletion. The purpose of this review was to gather the existing evidence to find out whether preoperative IVC ultrasound (IVCUS) derived parameters can reliably predict hypotension after spinal or general anaesthesia. PubMed was searched to identify research articles that addressed the role of IVC ultrasound in predicting hypotension after spinal and general anaesthesia in adult patients. We included 4 randomized control trials and 17 observational studies in our final review. Among these, 15 studies involved spinal anaesthesia and 6 studies involved general anaesthesia. Heterogeneity with respect to the patient populations under evaluation, definitions used for hypotension after anaesthesia, IVCUS assessment methods, and cut-off values for IVCUS-derived parameters to predict hypotension precluded pooled meta-analysis. The maximum and minimum reported sensitivity of the IVC collapsibility index (IVCCI) for predicting post-spinal hypotension was 84.6% and 58.8% respectively, while the maximum and minimum specificities were 93.1% and 23.5% respectively. For the prediction of hypotension after general anaesthesia induction, the reported ranges of sensitivity and specificity of IVCCI were 86.67% to 45.5% and 94.29% to 77.27%, respectively. Current literature on the predictive role of IVCUS for hypotension after anaesthesia is heterogeneous both in methodology and in results. Standardization of the definition of hypotension under anaesthesia, method of IVCUS assessment, and the cut-offs for IVC diameter and the collapsibility index for prediction of hypotension after anaesthesia are necessary for drawing clinically relevant conclusions.
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Affiliation(s)
- Sumit Roy Chowdhury
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Priyankar Kumar Datta
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Souvik Maitra
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dimple Rawat
- Clinical Epidemiology Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Avishek Roy
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Nath
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Yılmaz A, Demir U, Taşkın Ö, Soylu VG, Doğanay Z. Can Ultrasound-Guided Femoral Vein Measurements Predict Spinal Anesthesia-Induced Hypotension in Non-Obstetric Surgery? A Prospective Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1615. [PMID: 36363572 PMCID: PMC9695314 DOI: 10.3390/medicina58111615] [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: 10/17/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 09/10/2023]
Abstract
Background and objectives: To investigate whether ultrasound (US)-guided femoral vein (FV) and inferior vena cava (IVC) measurements obtained before spinal anesthesia (SA) can be utilized to predict SA-induced hypotension (SAIH) and to identify risk factors associated with SAIH in patients undergoing non-obstetric surgery under SA. Methods: This was a prospective observational study conducted between November 2021 and April 2022. The study included 95 patients over the age of 18 with an American Society of Anesthesiologists (ASA) physical status score of 1 or 2. The maximum and minimum diameters of FV and IVC were measured under US guidance before SA initiation, and the collapsibility index values of FV and IVC were calculated. Patients with and without SAIH were compared. Results: SAIH was observed in 12 patients (12.6%). Patients with and without SAIH were similar in terms of age [58 (IQR: 19-70) vs. 48 (IQR: 21-71; p = 0.081) and sex (males comprised 63.9% of the SAIH and 75.0% of the non-SAIH groups) (p = 0.533). According to univariate analysis, no significant relationship was found between SAIH and any of the FV or IVC measurements. Multiple logistic regression analysis revealed that having an ASA class of 2 was the only independent risk factor for SAIH development (p = 0.014), after adjusting for age, sex, and all other relevant parameters. Conclusions: There is not enough evidence to accept the feasibility of utilizing US-guided FV or IVC measurements to screen for SAIH development in patients undergoing non-obstetric surgery under SA. For this, multicenter studies with more participants are needed.
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Affiliation(s)
- Ayşe Yılmaz
- Department of Anesthesiology and Reanimation, Kastamonu University, 37150 Kastamonu, Turkey
| | - Ufuk Demir
- Department of Anesthesiology and Reanimation, Kastamonu University, 37150 Kastamonu, Turkey
| | - Öztürk Taşkın
- Department of Anesthesiology and Reanimation, Kastamonu University, 37150 Kastamonu, Turkey
| | | | - Zahide Doğanay
- Department of Anesthesiology and Reanimation, Kastamonu University, 37150 Kastamonu, Turkey
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Bajwa SJS, Gupta N, Rana S, Sharma S. Inferior vena cava collapsibility index: Speculation, mirage, or reality? Indian J Anaesth 2022; 66:S291-S293. [PMID: 36425917 PMCID: PMC9680716 DOI: 10.4103/ija.ija_805_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesiology and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India
| | - Shelly Rana
- Department of Anaesthesia, Dr. Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, India
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