Echocardiographic features of right ventricle in septic patients with elevated central venous pressure

BACKGROUND

Elevated central venous pressure (CVP) is deemed as a sign of right ventricular (RV) dysfunction. We aimed to characterize the echocardiographic features of RV in septic patients with elevated CVP, and quantify associations between RV function parameters and 30-day mortality.

METHODS

We retrospectively reviewed a cohort of septic patients with CVP ≥ 8 mmHg in a tertiary hospital intensive care unit. General characteristics and echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), pulmonary vascular resistance (PVR) as well as prognostic data were collected. Associations between RV function parameters and 30-day mortality were assessed using Cox regression models.

RESULTS

Echocardiography was performed in 244 septic patients with CVP ≥ 8 mmHg. Echocardiographic findings revealed that various types of abnormal RV function can occur individually or collectively. Prevalence of RV systolic dysfunction was 46%, prevalence of RV enlargement was 34%, and prevalence of PVR increase was 14%. In addition, we collected haemodynamic consequences and found that prevalence of systemic venous congestion was 16%, prevalence of RV-pulmonary artery decoupling was 34%, and prevalence of low cardiac index (CI) was 23%. The 30-day mortality of the enrolled population was 24.2%. In a Cox regression analysis, TAPSE (HR:0.542, 95% CI:0.302-0.972, p = 0.040) and PVR (HR:1.384, 95% CI:1.007-1.903, p = 0.045) were independently associated with 30-day mortality.

CONCLUSIONS

Echocardiographic findings demonstrated a high prevalence of RV-related abnormalities (RV enlargement, RV systolic dysfunction and PVR increase) in septic patients with elevated CVP. Among those echocardiographic parameters, TAPSE and PVR were independently associated with 30-day mortality in these patients.

Goal-directed fluid therapy during post-resection phase in low central venous pressure assisted laparoscopic hepatectomy: a randomized controlled superiority trial

PURPOSE

The purpose of this prospective single blinded randomized controlled trial was to find out whether goal-directed fluid therapy (GDFT) strategy in post-transection period in low central venous pressure (CVP) assisted laparoscopic hepatectomy (LH) has more benefit than traditional fluid strategy.

METHODS

Between April 2020 and Dec 2021, patients who were scheduled for laparoscopic liver resection surgery were eligible to participate in the study. Patients were randomly divided into two groups: control group that received traditional fluid strategy in post-transection period in low CVP assisted laparoscopic hepatectomy and GDFT strategy group that received GDFT strategy in post-transection period. The primary outcome parameter is the incidence of postoperative complications. Secondary outcome parameters include perioperative clinical outcomes, postoperative clinical outcomes, length of hospital stay after surgery, postoperative lactic acid, fluids and vasoactive medications during the operation.

RESULTS

A total of 159 patients in the control group and 160 patients in the GDFT were included. Two groups had no significant difference in the incidence of postoperative complications including pneumonia (P = 0.34), acute kidney injury (P = 0.72), hepatic insufficiency (P = 0.25), pleural effusion (P = 0.08) and seroperitoneum (P = 1.00), respectively. The amount of perioperative urine output is fewer in GDFT group than in the control group (P = 0.0354), while other perioperative variables and postoperative variables were comparable between two groups.

CONCLUSIONS

The results show the implementation of GDFT strategy is not associated with fewer postoperative complications. GDFT strategy did not result in improved outcomes in low CVP-assisted laparoscopic hepatectomy.

Central venous pressure combined with renal venous impedance index in predicting the acute kidney injury after thoracic and abdominal (non-cardiac) surgery

BACKGROUND

In the 21st century, 13% of patients undergoing open abdominal surgery, 25% of patients undergoing heart surgery, and 57% of patients admitted to the intensive care unit (ICU) are affected by acute kidney injury (AKI).

METHODS

This prospective observational study included patients admitted directly to the ICU between June 2021 and December 2021.

RESULTS

A total of 81 patients were enrolled after thoracic and abdominal (non-cardiac) surgery; 36 patients (44.4%) were diagnosed with AKI occurred within 7 days after surgery. Six-hour postoperative central venous pressure(CVP) was a risk factor for AKI in thoracic and abdominal (non-cardiac) postoperative patients (odds ratio [OR], 1.418; 95% confidence intervals [CI], 1.106-1.819; P = 0.006). Six-hour postoperative vein impedance index(VII) and CVP were significantly positively correlated (P = 0.031). The combination of 6-h postoperative VII with CVP (VII ≥0.34, CVP ≥7.5 mmHg) showed an area under the curve (AUC) of 0.787, In the subgroup analysis of patients with 6-h postoperative CVP <7.5 mmHg, there was a significant statistical difference in 6-h postoperative VII between the groups and those without AKI (P = 0.048). At 6-h postoperative CVP <7.5 mmHg, VII of ≥0.44 had a predictive value for AKI after thoracic and abdominal (non-cardiac) surgery, with an AUC of 0.669, a sensitivity of 41.2%, and a specificity of 94.4%.

CONCLUSION

Six-hour postoperative CVP combined with VII can better predict the occurrence of AKI occurred within 7 days after thoracic and abdominal (non-cardiac) surgery but cannot predict the severity of AKI.

Early persistent exposure to high CVP is associated with increased mortality and AKI in septic shock: A retrospective study

PURPOSE

This study's objective was to investigate the association between exposure to different intensities of central venous pressure (CVP) over time in patients with septic shock with 28-day mortality and acute kidney injury (AKI).

MATERIALS AND METHODS

We obtained data from the AmsterdamUMCdb, which includes data on patients ≥18 years old with septic shock undergoing CVP monitoring. The primary outcome was mortality by day 28. Piecewise exponential additive mixed models were used to estimate the strength of the association over time.

RESULTS

9668 patients were included in the study. They exhibited 8.2% overall mortality at 28 days and 41.1% AKI incidence. Daily time-weighted average CVP was strongly associated with increased mortality at 28 days, primarily within 24 h of ICU admission. The mortality rate of patients was lowest when the CVP was 6-12 cmH2O. When the time of high CVP (TWA-CVP >12 cmH2O) exposure within the first 24 h was >5 h, the risk of death increased by 2.69-fold. Additionally, patients exposed to high CVP had a significantly increased risk of developing AKI.

CONCLUSIONS

The optimal CVP range for patients with septic shock within 24 h of ICU admission is 6-12 cmH2O. Mortality increased when patients were exposed to high CVP for >5 h.

Risk factors of major bleeding detected by machine learning method in patients undergoing liver resection with controlled low central venous pressure technique

BACKGROUND

Controlled low central venous pressure (CLCVP) technique has been extensively validated in clinical practices to decrease intraoperative bleeding during liver resection process; however, no studies to date have attempted to propose a scoring method to better understand what risk factors might still be responsible for bleeding when CLCVP technique was implemented.

METHODS

We aimed to use machine learning to develop a model for detecting the risk factors of major bleeding in patients who underwent liver resection using CLCVP technique. We reviewed the medical records of 1077 patients who underwent liver surgery between January 2017 and June 2020. We evaluated the XGBoost model and logistic regression model using stratified K-fold cross-validation (K = 5), and the area under the receiver operating characteristic curve, the recall rate, precision rate, and accuracy score were calculated and compared. The SHapley Additive exPlanations was employed to identify the most influencing factors and their contribution to the prediction.

RESULTS

The XGBoost classifier with an accuracy of 0.80 and precision of 0.89 outperformed the logistic regression model with an accuracy of 0.76 and precision of 0.79. According to the SHapley Additive exPlanations summary plot, the top six variables ranked from most to least important included intraoperative hematocrit, surgery duration, intraoperative lactate, preoperative hemoglobin, preoperative aspartate transaminase, and Pringle maneuver duration.

CONCLUSIONS

Anesthesiologists should be aware of the potential impact of increased Pringle maneuver duration and lactate levels on intraoperative major bleeding in patients undergoing liver resection with CLCVP technique.   What is already known on this topic-Low central venous pressure technique has already been extensively validated in clinical practices, with no prediction model for major bleeding. What this study adds-The XGBoost classifier outperformed logistic regression model for the prediction of major bleeding during liver resection with low central venous pressure technique. How this study might affect research, practice, or policy-anesthesiologists should be aware of the potential impact of increased PM duration and lactate levels on intraoperative major bleeding in patients undergoing liver resection with CLCVP technique.

Effect of central venous pressure on fluid delivery during start-up of syringe infusion pumps for microinfusion

BACKGROUND

Intravenous administration of highly concentrated and potent drugs at low flow rates is common practice, particularly in critically ill children. Drug delivery during infusion start-up can be considerably delayed by intrinsic factors of syringe infusion pump assemblies. The impact of central venous pressures on the course of start-up fluid delivery of such microinfusions remains unknown.

METHODS

Infusion volumes delivered after activation of the start button in a conventional 50 mL syringe infusion pump assembly equilibrated (representing classical in vitro testing) and not equilibrated (representing real clinical conditions) to central venous pressure levels of 0, 10 and 20 mmHg at a set infusion flow rate of 1 mL/h were measured using a fluidic flow sensor.

RESULTS

The experimental setup mimicking real life conditions demonstrated considerable differences in fluid delivery during pump start-up depending on central venous pressure. A central venous pressure of 0 mmHg resulted in massive fluid delivery at infusion start-up, while central venous pressure levels of 10 and 20 mmHg resulted in retrograde flows with related mean (95% CI) zero-drug delivery times of 3.22 (2.98-3.46) min and 4.51 (4.33-4.69) min, respectively (p < .0001).

CONCLUSION

Depending on central venous pressure level, connection and starting a new syringe pump can result in significant antegrade or retrograde fluid volumes. In clinical practice, this can lead to hemodynamic instability and hence requires clinical alertness. Further research and methods to improve start-up performance in syringe infusion pump systems are desirable.

Correlation of Internal Jugular Vein Collapsibility With Central Venous Pressure in Patients With Liver Cirrhosis

We aimed to compare internal jugular vein and inferior vena cava ultrasonography as predictors of central venous pressure in cirrhotic patients. We performed ultrasound assessments of the internal jugular vein (IJV) and the inferior vena cava and then invasively measured central venous pressure (CVP). We then compared their correlation with CVP and performed area under the receiver operating characteristic curves to determine which had best sensitivity and specificity. IJV cross-sectional area collapsibility index at 30° correlated better with CVP ( r = -0.56, P < 0.001), and an IJV AP-CI at 30° ≤ 24.8% was better at predicting a CVP ≥8 mm Hg, with 100% sensitivity and 97.1% specificity. Thus, IJV point-of-care ultrasound might be superior than inferior vena cava point-of-care ultrasound as a predictor of CVP in cirrhotic patients.

Clinical value of CVP+VIVC in predicting fluid resuscitation in patients with septic shock

Objective

To explore the clinical value of central venous pressure (CVP) + inferior vena cava respiratory variability (VIVC) in fluid resuscitation in spontaneously breathing patients with septic shock.

Methods

In retrospective observational study, during October 2019 to December 2021, 145 patients with septic shock treated in our hospital were enrolled by the method of observational study. According to the change rate of cardiac output (ΔCO) ≥15% or ΔCO<15% after 30 minutes, they were assigned into volume-responsive and volume-unresponsive group depending early fluid resuscitation in sepsis. The clinical value of combination of CVP and VIVC in predicting fluid resuscitation in patients with septic shock was compared.

Results

The CVP of the study group was higher at 12h and 24h after fluid resuscitation, and the VIVC level of the study group at 6h, 12h and 24h after fluid resuscitation was higher (P<0.05). Pearson correlation analysis indicated that CVP, and VIVC levels were noticeably correlated with fluid resuscitation in patients with septic shock (P<0.05). The area under curve (AUC) of receiver operating characteristic curve (ROC) of CVP for predicting fluid resuscitation in septic shock patients was 0.694 and the cut-off value was 0.932, the sensitivity was 46.9%, and the specificity was 87.5%. VIVC predicted fluid resuscitation in septic shock patients with an AUC of 0.776, which was a cut-off value of 0.688, a sensitivity of 50.0%, and a specificity of 90.0%. Combination of CVP and VIVC predicted fluid resuscitation in septic shock patients with an AUC of 0.948, which was a cut-off value of 1.420, a sensitivity of 90.6%, and a specificity of 87.5%.

Conclusion

Combination of CVP and VIVC may have a good effect on the evaluation of volume responsiveness in patients with septic shock, which is better than single CVP and VIVC. Combination of CVP and VIVC can be adopted to predict fluid responsiveness volume responsiveness in septic shock patients, which is of great significance for guiding clinical fluid responsiveness therapy.

RESPIRATION-RELATED VARIATIONS IN CENTRAL VENOUS PRESSURE AS PREDICTORS OF FLUID RESPONSIVENESS IN SPONTANEOUSLY BREATHING PATIENTS

ABSTRACT

Objective : The hemodynamic parameters used to accurately predict fluid responsiveness (FR) in spontaneously breathing patients (SB) require specific material and expertise. Measurements of the central venous pressure (CVP) are relatively simple and, importantly, are feasible in many critically ill patients. We analyzed the accuracy of respiration-related variations in CVP (vCVP) to predict FR in SB patients and examined the optimization of its measurement using a standardized, deep inspiratory maneuver. Patients and Methods : We performed a monocentric, prospective, diagnostic evaluation. Spontaneously breathing patients in intensive care units with a central venous catheter were prospectively included. The vCVP was measured while the patient was spontaneously breathing, both with (vCVP-st) and without (vCVP-ns) a standardized inspiratory maneuver, and calculated as: Minimum inspiratory v-wave peak pressure - Maximum expiratory v-wave peak pressure. A passive leg raising-induced increase in the left ventricular outflow tract velocity-time integral ≥10% defined FR. Results : Among 63 patients, 38 (60.3%) presented FR. The vCVP-ns was not significantly different between responders and nonresponders (-4.9 mm Hg [-7.5 to -3.1] vs. -4.1 mm Hg [-5.4 to 2.8], respectively; P = 0.15). The vCVP-st was lower in responders than nonresponders (-9.7 mm Hg [-13.9 to -6.2] vs. -3.6 mm Hg [-10.6 to -1.6], respectively; P = 0.004). A vCVP-st < -4.7 mm Hg predicted FR with 89.5% sensitivity, a specificity of 56.0%, and an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.58 to 0.86) ( P = 0.004). Conclusion : When a central venous catheter is present, elevated values for vCVP-st may be useful to identify spontaneously breathing patients unresponsive to volume expansion. Nevertheless, the necessity of performing a standardized, deep-inspiration maneuver may limit its clinical application.

High central venous pressure amplitude predicts successful defibrillation in a porcine model of cardiac arrest

AIM

Increasing venous return during cardiopulmonary resuscitation (CPR) has been shown to improve hemodynamics during CPR and outcomes following cardiac arrest (CA). We hypothesized that a high central venous pressure amplitude (CVP-A), the difference between the maximum and minimum central venous pressure during chest compressions, could serve as a robust predictor of return of spontaneous circulation (ROSC) in addition to traditional measurements of coronary perfusion pressure (CPP) and end-tidal CO2 (etCO2) in a porcine model of CA.

METHODS

After 10 min of ventricular fibrillation, 9 anesthetized and intubated female pigs received mechanical chest compressions with active compression/decompression (ACD) and an impedance threshold device (ITD). CPP, CVP-A and etCO2 were measured continuously. All groups received biphasic defibrillation (200 J) at minute 4 of CPR and were classified into two groups (ROSC, NO ROSC). Mean values were analyzed over 3 min before defibrillation by repeated-measures Analysis of Variance and receiver operating characteristic (ROC).

RESULTS

Five animals out of 9 experienced ROSC. CVP-A showed a statistically significant difference (p = 0.003) between the two groups during 3 min of CPR before defibrillation compared to CPP (p = 0.056) and etCO2 (p = 0.064). Areas-under-the-curve in ROC analysis for CVP-A, CPP and etCO2 were 0.94 (95% Confidence Interval 0.86, 1.00), 0.74 (0.54, 0.95) and 0.78 (0.50, 1.00), respectively.

CONCLUSION

In our study, CVP-A was a potentially useful predictor of successful defibrillation and return of spontaneous circulation. Overall, CVP-A could serve as a marker for prediction of ROSC with increased venous return and thereby monitoring the beneficial effects of ACD and ITD.

Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children

OBJECTIVES

The Venous Excess Ultrasound (VExUS) score has been described as a useful tool to estimate the degree of venous congestion in adult patients. The present study aimed to analyze the feasibility and usefulness of the VExUS score to detect and grade central venous pressure (CVP) elevation in critically ill children.

METHODS

A cross-sectional pilot study was conducted in a tertiary-care pediatric intensive care unit between November 2020 and June 2021. All children in whom CVP was monitored, were enrolled. At the time of central venous catheter placement, CVP and VExUS score grade were determined, analyzing the inferior vena cava (IVC) diameter and the hepatic (HVD), portal (PVD), and intrarenal (IRVD) venous Doppler waveforms.

RESULTS

A total of 33 children were studied (median age 12.2 [interquartile range (IQR) 4.1-100.6] months old; median weight 8.5 [IQR 5.6-35] kg; 20 [60.6%] males). The VExUS score was successfully obtained in 100% of the patients and its severity was strongly associated with the CVP levels (P < .001). Analyzing the VExUS score components separately, IVC dilation (P < .001) and severe HVD (P = .026), mild IRVD (P = .005), and severe IRVD (P = .025) patterns were associated with elevated CVP. After adjustment for confounding factors, IRVD pattern remained the only independent variable associated with elevated CVP.

CONCLUSIONS

The VExUS score appears to be a feasible and potentially useful bedside noninvasive monitoring tool for the detection and grading of CVP elevation in critically ill children. Among all its components, IRVD assessment seems most associated with high CVP in this population.

Assessing jugular venous compliance with optical hemodynamic imaging by modulating intrathoracic pressure

SIGNIFICANCE

The internal jugular veins (IJV) are critical cerebral venous drainage pathways that are affected by right heart function. Cardiovascular disease and microgravity can alter central venous pressure (CVP) and venous return, which may contribute to increased intracranial pressure and decreased cardiac output. Assessing jugular venous compliance may provide insight into cerebral drainage and right heart function, but monitoring changes in vessel volume is challenging.

AIM

We investigated the feasibility of quantifying jugular venous compliance from jugular venous attenuation (JVA), a noncontact optical measurement of blood volume, along with CVP from antecubital vein cannulation.

APPROACH

CVP was progressively increased through a guided graded Valsalva maneuver, increasing mouth pressure by 2 mmHg every 2 s until a maximum expiratory pressure of 20 mmHg. JVA was extracted from a 1-cm segment between the clavicle and midneck. The contralateral IJV cross-sectional area (CSA) was measured with ultrasound to validate changes in the vessel size. Compliance was calculated using both JVA and CSA between four-beat averages over the duration of the maneuver.

RESULTS

JVA and CSA were strongly correlated (median and interquartile range) over the Valsalva maneuver across participants (r = 0.986, [0.983, 0.987]). CVP more than doubled on average between baseline and peak strain (10.7 ± 4.4 vs. 25.8 ± 5.4 cmH2O; p < 0.01). JVA and CSA increased nonlinearly with CVP, and both JVA- and CSA-derived compliance decreased progressively from baseline to peak strain (49% and 56% median reduction, respectively), with no significant difference in compliance reduction between the two measures (Z = - 1.24, p = 0.21). Pressure-volume curves showed a logarithmic relationship in both CSA and JVA.

CONCLUSIONS

Optical jugular vein assessment may provide new ways to assess jugular distention and cardiac function.

Correlation of internal jugular vein, common carotid artery, femoral artery and femoral vein diameters with central venous pressure

BACKGROUND

This study aimed to detect the correlation of central venous pressure (CVP) with the internal jugular vein (IJV), common carotid artery (CCA), femoral vein (FV), and femoral artery (FA) diameters measured with ultrasound (USG) in patients under mechanical ventilation to evaluate whether they are suitable to be used as an alternative low-cost and noninvasive method for the detection of CVP.

METHODS

A total of 40 patients aged from 18 to 90 who had been receiving therapy in the intensive care unit (ICU) were included in the study. Central venous catheter was placed into the patients through right IJV or subclavian vein in their first 24-hour of hospitalization and the right atrium pressure (RAP) was measured from the catheter, the tip of which was confirmed to reach right atrium. In the same session, CCA, IJV, FA, and FV diameters were measured with USG and their correlations with CVP were calculated. In addition, correlations of the measured venous and artery diameters between each other were detected as well.

RESULTS

There was a significantly high correlation between CVP and CCA diameter (R = 0.603, P < .000). There was a significantly low correlation between CVP and IJV diameter (R = 0.352, P = .026), a significantly low correlation between FA and FV diameters (R = 0.317, P = .047), a significantly low correlation between FA and CCA diameters (R = 0.330, P = .038), and a significantly low correlation between IJV and CCA diameters (R = 0.364, P = .020).

CONCLUSION

CVP and CCA diameters exhibited a high correlation. For detection of CVP, the ultrasonographic CCA diameter measurement can be used as an alternative noninvasive method which is easy to use and minimally affected by measurement errors of individuals and which has low learning curve compared with the other measurement methods.

Reducing Risk for Acute Kidney Injury After Living Donor Hepatectomy by Protocolized Fluid Restriction: Single-Center Experience

BACKGROUND

Acute kidney injury (AKI) is a potential complication after restricted fluid therapy for major surgery. The aim of this study was to evaluate the incidence of AKI for living liver donor hepatectomy in which applied intraoperative protocolized fluid restriction was used targeting a low central venous pressure (CVP) level with high pulse pressure variation (PPV) and systolic pressure variation (SPV).

MATERIAL AND METHODS

Living liver donors were admitted for this retrospective observational study. Low CVP <5 mm Hg with high PPV<20% and SPV<15% were the targets of the clinical protocol to reduce intraoperative blood loss via protocolized fluid management until the end of the hepatic parenchymal division. KDIGO criteria were used for AKI definition. The SPSS version 11.5 program was used for statistical analysis.

RESULTS

The study included 130 patients, 79 (60.8%) men and 51 (39.2%) women, with from 18 to 58 years of age. Donors underwent right and left lobe hepatectomies (116 and 14, respectively). The baseline CVP, the lowest CVP of hepatectomy, and the highest CVP measured after hepatectomy were 7.45 ± 2.41, 4.28 ± 1.12, 7.67 ± 2.09 mm Hg, respectively. Only 4 patients with right lobe hepatectomy developed AKI stage I (3.1%) in the first 24 hours. The 4 patients were recovered at 48 hours postoperatively.

CONCLUSION

This study demonstrated that a CVP target of <5 mm Hg and high PPV/SPV via a simple fluid management modality with protocolized-fluid restriction until the procurement may not cause AKI in living liver donors in a closed follow-up anesthesia approach.

[Clinical value of pulse pressure/central venous pressure ratio in low cardiac output syndrome after cardiac surgery]

OBJECTIVE

To explore the relationship between the pulse pressure/central venous pressure (PP/CVP) ratio and the cardiac output (CO) of patients after cardiac surgery from the basic principles of hemodynamics, and to further evaluate the predictive value of PP/CVP ratio in patients with secondary low cardiac output syndrome (LCOS) after cardiac surgery.

METHODS

A retrospective study was conducted, and patients who received pulse indicator continuous cardiac output (PiCCO) monitoring were enrolled at the department of critical care medicine of Peking Union Medical College Hospital from January 1, 2016, to September 1, 2021. Patients were divided into two groups: the LCOS group [cardiac index (CI) < 33.34 mL×s^-1×m^-2, 25 cases] and the non-LCOS group (CI ≥ 33.34 mL×s^-1×m^-2, 125 cases) according to the CI at 6 hours after surgery. The general clinical data and hemodynamic parameters were collected. Correlations between PP/CVP ratio and PiCCO monitoring indicators were performed with Pearson or Spearman correlation test. Receiver operator characteristic curve (ROC curve) analysis was carried out to evaluate the predictive value of the parameters in patients with LCOS after cardiac surgery.

RESULTS

A total of 150 patients with PiCCO monitoring after cardiac surgery were included. There were no differences in baseline characteristics between the two groups, while PP in the LCOS group was lower than that in the non-LCOS group [mmHg (1 mmHg ≈ 0.133 kPa): 40 (37, 44) vs. 55 (46, 64)], CVP was higher than that in the non-LCOS group [mmHg: 12 (11, 14) vs. 10 (8, 12)], and PP/CVP ratio in the LCOS group was lower than that in the non-LCOS group [3.3 (2.9, 3.7) vs. 5.5 (4.6, 6.8)], with significant differences (all P < 0.05). Correlation analysis results showed that PP/CVP ratio was positively correlated with CI, CO, and stroke volume index (SVI), respectively (r_s = 0.660, 0.592, 0.600, all P < 0.001). CI was negatively correlated with PP (r_s = 0.509, P < 0.001) and positively correlated with CVP (r_s = -0.297, P < 0.001). ROC curve analysis revealed that compared with PP, CVP, SVI and cardiac function index (CFI), PP/CVP ratio was the best predictor of LCOS after cardiac surgery [area under the ROC curve (AUC) was 0.94±0.02, P < 0.001], when the optimum cut-off value was 4.41, the sensitivity was 80.00%, and the specificity was 96.00%.

CONCLUSIONS

PP/CVP ratio was moderately positively correlated with CO after cardiac surgery, and PP/CVP ratio could be used as a prognostic predictor for LCOS after cardiac surgery.

Mechanical Cardiac Support with an Implantable Direct Cardiac Compression Device: Proof of Concept

Purpose

We examined the hemodynamic effects of a new, implantable, direct cardiac assist device in an ovine heart failure model.

Description

The device, which encompasses both left and right ventricles, is inserted through the pericardial apex and self-expands to encompass the heart without suturing. The intact pericardium anchors the device in place. The device has 2 concentric chamber layers: an internal chamber layer filled with fluid to conform to the heart and an external chamber layer filled with air that provides external compression and negative pressure to aid relaxation.

Evaluation

The device was implanted in 7 sheep with heart failure induced by microsphere embolization. Cardiac performance was assessed for 6 to 8 hours. The cardiac assist device provided cardiac systolic and diastolic assistance, as shown by pressure tracings of the left ventricle and aorta, pulmonary artery flow, and +dP/dt. Central venous pressure decreased during cardiac assistance. No anatomic damage was noted postmortem.

Conclusions

Systolic and diastolic cardiac assistance can be achieved with this device that compresses and relaxes in synchrony with the native cardiac cycle.

High Frame-Rate A-Mode Ultrasound System for Jugular Venous Pulse Tracking: A Feasibility Study

Jugular venous pulse (JVP) helps in the early detection of central venous pressure abnormalities and various cardiovascular diseases. Studies have been reported indicating that contour features of the JVP waveform provide crucial information regarding cardiac function. Although current ultrasound systems reliably provide the diameter measurements, they are limited by low frame rates resulting in poor resolution JVP cycles that are inadequate to yield distinguishable critical points. In this work, we propose an image-free high frame rate system for the assessment of JVP signals. The proposed A-mode ultrasound system acquires high fidelity JVP pulses with a temporal resolution of 4 ms and amplitude resolution of 10 µm. The functionality verification of the proposed system was performed by comparing it against a clinical-grade B-mode imaging system. A study was conducted on a cohort of 25 subjects in the 20-30 age group. While the system provided diameter measurements comparable to that of the imaging ones (r > 0.98, p < 0.05), it also yielded high-resolution JVP exhibiting the presence of all fiduciary points. This was a leveraging feature as opposed to the imaging system that possessed limited temporal and amplitude resolution. Clinical Relevance- The proposed system is a potential ultrasound means for measuring the diameter values from JV at the same time yielding the JVP critical points necessary for clinical analysis.

Spontaneous contractions of the human thoracic duct-Important for securing lymphatic return during positive pressure ventilation?

The thoracic duct is responsible for the circulatory return of most lymphatic fluid. The return is a well-timed synergy between the pressure in the thoracic duct, venous pressure at the thoracic duct outlet, and intrathoracic pressures during respiration. However, little is known about the forces determining thoracic duct pressure and how these respond to mechanical ventilation. We aimed to assess human thoracic duct pressure and identify elements affecting it during positive pressure ventilation and a brief ventilatory pause. The study examined pressures of 35 patients with severe congenital heart defects undergoing lymphatic interventions. Thoracic duct pressure and central venous pressure were measured in 25 patients during mechanical ventilation and in ten patients during both ventilation and a short pause in ventilation. TD contractions, mechanical ventilation, and arterial pulsations influenced the thoracic duct pressure. The mean pressure of the thoracic duct was 16 ± 5 mmHg. The frequency of the contractions was 5 ± 1 min^-1 resulting in an average increase in pressure of 4 ± 4 mmHg. During mechanical ventilation, the thoracic duct pressure correlated closely to the central venous pressure. TD contractions were able to increase thoracic duct pressure by 25%. With thoracic duct pressure correlating closely to the central venous pressure, this intrinsic force may be an important factor in securing a successful return of lymphatic fluid. Future studies are needed to examine the return of lymphatic fluid and the function of the thoracic duct in the absence of both lymphatic complications and mechanical ventilation.

Abfall von Sauerstoffsättigung und Blutdruck sowie Anstieg des zentralen Venendrucks im Rahmen eines Mitralklappenclippings bei einer 81-Jährigen

Hintergrund

Atriumseptumdefekte (ASD) im Rahmen eines endovaskulären Mitralklappenclippings sind potenziell hämodynamisch relevante Komplikationen. Ein sofortiger Verschluss mittels Okkluder kann eine sichere und effektive Therapie darstellen.

Fallzusammenfassung

Eine 81-jährige Patientin mit schwerer Dyspnoe bei vorbekannter hochgradiger Mitralklappeninsuffizienz wurde zum elektiven Mitralklappenclipping vorgestellt. Die Clipimplantation verlief komplikationslos. Nach Entfernung der transseptalen Schleuse kam es zu einem plötzlichen Abfall der Sauerstoffsättigung und des Blutdrucks sowie zu einem sofortigen Anstieg des zentralen Venendrucks. Es zeigte sich ein iatrogener Links-rechts-Shunt auf Vorhofebene mit relevantem Shuntvolumen. Daraufhin erfolgte der sofortige Verschluss mittels Vorhofseptumokkluder, was zu einer unmittelbaren Besserung der Kreislaufparameter und der Sauerstoffsättigung führte.

Schlussfolgerung

Ein Anstieg des zentralen Venendrucks, ein Blutdruckabfall oder Sättigungsabfall nach Rückzug der transseptalen steuerbaren Schleuse im Rahmen des Mitralklappenclippings sollte bezüglich eines möglichen ASD abgeklärt werden.

[Efficacy analysis of inferior vena cava variability combined with difference of central venous-to-arterial partial pressure of carbon dioxide on guiding fluid resuscitation in patients with septic shock]

OBJECTIVE

To investigate the effect of inferior vena cava variability (IVCV) combined with difference of central venous-to-arterial partial pressure of carbon dioxide (Pcv-aCO₂) on guiding fluid resuscitation in septic shock.

METHODS

Patients with septic shock admitted to the department of critical care medicine of Jiangxi Provincial People's Hospital from January 1, 2018 to December 31, 2020 were enrolled, and they were divided into control group and observation group according to random number table method. Patients in both groups were given fluid resuscitation according to septic shock fluid resuscitation guidelines. The patients in the control group received fluid resuscitation strictly according to the early goal-directed therapy (EGDT) strategy. Resuscitation target: central venous pressure (CVP) 12-15 cmH₂O (1 cmH₂O≈0.098 kPa), mean arterial pressure (MAP) > 65 mmHg (1 mmHg≈0.133 kPa), mean urine volume (UO) > 0.5 mL×kg^-1×h^-1, central venous oxygen saturation (ScvO₂) > 0.70. In the observation group, the endpoint of resuscitation was evaluated by IVCV dynamically monitored by bedside ultrasound and Pcv-aCO₂. Resuscitation target: fixed filling of inferior vena cava with diameter > 2 cm, IVCV < 18%, and Pcv-aCO₂ < 6 mmHg. The changes in recovery indexes before and 6 hours and 24 hours of resuscitation of the two groups were recorded, and the 6-hour efficiency of fluid resuscitation, 6-hour lactate clearance rate (LCR) and 6-hour and 24-hour total volume of resuscitation were also recorded; at the same time, the duration of mechanical ventilation, length of intensive care unit (ICU) stay, 28-day mortality and the incidence of acute renal failure and acute pulmonary edema between the two groups were compared.

RESULTS

A total of 80 patients were enrolled in the analysis, with 40 in the control group and 40 in the observation group. The MAP, CVP and ScvO₂ at 6 hours and 24 hours of resuscitation in the two groups were significantly higher than those before resuscitation, while Pcv-aCO₂ and blood lactic acid (Lac) were significantly decreased, and UO was increased gradually with the extension of resuscitation time, indicating that both resuscitation endpoint evaluation schemes could alleviate the shock state of patients. Compared with before resuscitation, IVCV at 6 hours and 24 hours of resuscitation in the observation group were decreased significantly [(17.54±4.52)%, (18.32±3.64)% vs. (27.49±10.56)%, both P < 0.05]. Compared with the control group, MAP and ScvO₂ at 6 hours of resuscitation in the observation group were significantly increased [MAP (mmHg): 69.09±4.64 vs. 66.37±4.32, ScvO₂: 0.666±0.033 vs. 0.645±0.035, both P < 0.05], 24-hour MAP was increased significantly (mmHg: 75.16±3.28 vs. 70.12±2.18, P < 0.05), but CVP was relatively lowered (cmH₂O: 9.25±1.49 vs. 10.25±1.05, P < 0.05), indicating that the fluid resuscitation efficiency was higher in the observation group. Compared with the control group, 6-hour LCR in the observation group was significantly increased [(55.64±6.23)% vs. (52.45±4.52)%, P < 0.05], 6-hour and 24-hour total volume of resuscitation was significantly decreased (mL: 2 860.73±658.32 vs. 3 568.54±856.43, 4 768.65±1 085.65 vs. 5 385.34±1 354.83, both P < 0.05), the duration of mechanical ventilation was significantly shortened (days: 6.78±3.45 vs. 8.45±2.85, P < 0.05), while the incidence of acute pulmonary edema was significantly decreased [2.5% (1/40) vs. 20.0% (8/40), P < 0.05]. There was no significant difference in the length of ICU stay, 28-day mortality or incidence of acute renal failure between the two groups.

CONCLUSIONS

Dynamic monitoring of IVCV and Pcv-aCO₂ can effectively guide the early fluid resuscitation of patients with septic shock, and compared with EGDT, it can significantly shorten the duration of mechanical ventilation, reduce the amount of fluid resuscitation, and reduce the incidence of acute pulmonary edema. Combined with its non-invasive characteristics, it has certain clinical advantages.

Is the Old Slandered Central Venous Pressure Back Again?

OBJECTIVE

Acute low cardiac output (CO) is a frequent scenario in pediatric cardiac intensive care units (PCICU). While fluid responsiveness has been studied extensively, literature is scarce for the immediate postoperative congenital heart surgery population admitted to PCICUs. This study analyzed the utility of hemodynamic, bedside ultrasound, and Doppler parameters for prediction of fluid responsiveness in infants and neonates in the immediate postoperative cardiac surgery period.

DESIGN

A prospective observational study.

SETTING

University affiliated, tertiary care hospital, PCICU.

PARTICIPANTS

Immediate postoperative pediatric patients displaying a presumed hypovolemic low CO state were included. A clinical, arterial derived, hemodynamic, sonographic, Doppler-based, and echocardiographic parameter assessment was performed, followed by a fluid bolus therapy.

INTERVENTIONS

Fifteen to 20 cc/kg crystalloid fluid bolus.

MAIN OUTCOME MEASURES

Fluid responsiveness was defined as an increase in cardiac index >10% by echocardiography.

RESULTS

Of 52 patients, 34 (65%) were fluid responsive. Arterial systolic pressure variation, continuous-Doppler preload parameters, and inferior vena-cava distensibility index (IVCDI) by bedside ultrasound all failed to predict fluid responsiveness. Dynamic central venous pressure (CVP) change yielded a significant but modest fluid responsiveness predictability of area under the curve 0.654 (P = 0.0375).

CONCLUSIONS

In a distinct population of mechanically ventilated, young, pediatric cardiac patients in the immediate postoperative period, SPV, USCOM preload parameters, as well as IVC-based parameters by bedside ultrasound failed to predict fluid responsiveness. Dynamic CVP change over several hours was the only parameter that yielded significant but modest fluid responsiveness predictability.

[Predictive value of carotid ultrasound in combination with passive leg raising on fluid responsiveness in critically ill patients]

OBJECTIVE

To investigate the value of monitor carotid velocity time integral (VTI) and corrected flow time (FTc) by bedside ultrasound before and after passive leg raising (PLR) in predicting fluid responsiveness in critically ill patients.

METHODS

A prospective observational study was conducted. Fifty patients with critical illness admitted to the First People's Hospital of Fuyang Hangzhou from January 2020 to March 2021 were enrolled. The clinical data including the gender, age, body mass index (BMI), acute physiology and chronic health evaluation II (APACHE II) score, and the duration of mechanical ventilation were recorded. The changes of carotid VTI and FTc were measured by bedside ultrasound, and the values of heart rate, mean arterial pressure (MAP), central venous pressure (CVP), stroke volume index (SVI), and intrathoracic blood volume index (ITBVI) were measured by pulse indicated continuous cardiac output (PiCCO) monitor before and after PLR in all patients. According to the changes of SVI before and after PLR, the patients were divided into fluid responsiveness positive group with the change rate of SVI ≥ 15% and fluid responsiveness negative group with the change rate of SVI < 15%. The differences in the values of VTI, FTc, CVP, and ITBVI obtained before and after PLR (ΔVTI, ΔFTc, ΔCVP and ΔITBVI) were calculated and then compared between the two groups. The predictive values of these indicators on fluid responsiveness in critically ill patients were analyzed by receiver operator characteristic curve (ROC curve), and their relationship with the difference in SVI (ΔSVI) obtained before and after PLR was evaluated by Pearson correlation analysis.

RESULTS

Fifty patients were all enrolled in this study, in which 27 patients were fluid response and 23 patients were fluid nonresponse. Basic clinical data were not different between the two groups. The values of ΔVTI, ΔFTc, ΔCVP, and ΔITBVI in fluid response were all significantly higher than those in fluid nonresponse [ΔVTI (cm): 2.07±1.16 vs. 0.67±0.86, ΔFTc (ms): 4.00±6.10 vs. 0.01±2.26, ΔCVP (cmH₂O, 1 cmH₂O = 0.098 kPa): 1.67±1.14 vs. 1.00±1.17, ΔITBVI (mL/m²): 98±69 vs. 48±70, all P < 0.05]. ROC curve analysis showed that ΔVTI, ΔFTc, ΔCVP and ΔITBVI were all positive for predicting fluid responsiveness, their area under ROC curve (AUC) and 95% confidence interval (95%CI) were 0.870 (0.769-0.972), 0.694 (0.547-0.841), 0.684 (0.535-0.832) and 0.709 (0.564-0.855), respectively. When using ΔVTI 0.92 cm, ΔFTc 1.45 ms, ΔCVP 1.50 cmH₂O and ΔITBVI 44.50 mL/m² as the threshold values, the sensitivities were 96.3%, 63.0%, 44.4% and 81.5%, and the specificities were 65.2%, 78.3%, 82.6% and 56.5%, respectively, in which the predictive value of ΔVTI was the largest. Pearson correlation analysis indicated that ΔVTI, ΔFTc, ΔCVP, and ΔITBVI were positively associated with ΔSVI (r values were 0.971, 0.334, 0.440, 0.650, P values were 0.000, 0.018, 0.001, 0.000, respectively).

CONCLUSIONS

Carotid ΔVTI and ΔFTc monitored by bedside ultrasound before and after PLR could be as effective as conventional indicators in predicting fluid responsiveness in critically ill patients, and the predictive value of ΔVTI was better than others.

Functional relationship of arterial blood pressure, central venous pressure and intracranial pressure in the early phase after subarachnoid hemorrhage

BACKGROUND

Intracranial pressure (ICP) and arterial blood pressure (ABP) are related to each other through cerebral autoregulation. Central venous pressure (CVP) is often measured to estimate cardiac filling pressures as an approximate measure for the volume status of a patient. Prior modelling efforts have formalized the functional relationship between CVP, ICP and ABP. However, these models were used to explain short segments of data during controlled experiments and have not yet been used to explain the slowly evolving ICP increase that occurs typically in patients after aneurysmal subarachnoid hemorrhage (SAH).

OBJECTIVE

To analyze the functional relationship between ICP, ABP and CVP recorded from SAH patients in the first five days after aneurysm.

METHODS

Two methods were used to elucidate this relationship on the running average of the signals: First, using Spearman correlation coefficients calculated over 30 min segments Second, for each patient, linear state space models of ICP as the output and ABP and CVP as inputs were estimated.

RESULTS

The mean and variance of the data and the correlation coefficients between ICP-ABP and ICP-CVP vary over time as the patient progresses through their stay in the ICU. On average, after an SAH event, the models show that a) ABP is the bigger driver of changes in ICP than CVP and that increasing ABP leads to reduction in ICP and (b) increasing CVP leads to an increase in ICP.

CONCLUSIONS

Finding a) agrees with the hypothesis that patients with subarachnoid hemorrhage have defective autoregulation, and b) agrees with the positive correlation observed between central venous pressure and intracranial pressure in the literature.

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists

BACKGROUND

Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients.

METHODS

Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence.

RESULTS

Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status.

CONCLUSIONS

These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.

Assessment of Fluid Status by Bioimpedance Analysis and Central Venous Pressure Measurement and Their Association with the Outcomes of Severe Acute Kidney Injury

Background and Objectives: Fluid disbalance is associated with adverse outcomes in critically ill patients with acute kidney injury (AKI). In this study, we intended to assess fluid status using bioimpedance analysis (BIA) and central venous pressure (CVP) measurement and to evaluate the association between hyperhydration and hypervolemia with the outcomes of severe AKI. Materials and Methods: A prospective study was conducted in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos. Forty-seven patients treated at the Intensive Care Unit (ICU) with severe AKI and a need for renal replacement therapy (RRT) were examined. The hydration level was evaluated according to the ratio of extracellular water to total body water (ECW/TBW) of bioimpedance analysis and volemia was measured according to CVP. All of the patients were tested before the first hemodialysis (HD) procedure. Hyperhydration was defined as ECW/TBW > 0.39 and hypervolemia as CVP > 12 cm H₂O. Results: According to bioimpedance analysis, 72.3% (n = 34) of patients were hyperhydrated. According to CVP, only 51.1% (n = 24) of the patients were hypervolemic. Interestingly, 69.6% of hypovolemic/normovolemic patients were also hyperhydrated. Of all study patients, 57.4% (n = 27) died, in 29.8% (n = 14) the kidney function improved, and in 12.8% (n = 6) the demand for RRT remained after in-patient treatment. A tendency of higher mortality in hyperhydrated patients was observed, but no association between hypervolemia and outcomes of severe AKI was established. Conclusions: Three-fourths of the patients with severe AKI were hyperhydrated based on bioimpedance analysis. However, according to CVP, only half of these patients were hypervolemic. A tendency of higher mortality in hyperhydrated patients was observed.

Comparison of norepinephrine, dopamine and dobutamine combined with enteral nutrition in the treatment of elderly patients harboring sepsis

The present study was performed in order to investigate the safety and efficacy of different vasoactive drugs combined with enteral nutrition in terms of treating elderly patients with sepsis. A total of 75 elderly patients with sepsis treated with enteral nutrition in our hospital were randomly divided into three groups: group A (n = 25), group B (n = 25) and group C (n = 25). The three groups were treated with dopamine, dobutamine and norepinephrine respectively. One week after treatment, the therapeutic effects of the three groups were compared, the vascular elastic indexes, hemodynamic indexes and levels of inflammatory factors of the three groups were measured. After treatment, the clinical effective rate of group C was evidently higher than that of group A and group B. The vascular elasticity coefficient and stiffness coefficient in group C were significantly lower than those in group A and group B, and the arterial compliance in group C was significantly higher than that in group A and group B (P < 0.05). The levels of MAP and PVRI in group C were significantly higher than those in group A and B, and the levels of CI, CVP and HR in group C were significantly lower than those in group A and group B (P < 0.05). Norepinephrine elicited greater effects in terms of improving hemodynamic indexes, vascular elasticity and reducing the level of inflammatory factors compared with dopamine and dobutamine in elderly patients harboring sepsis.

Optical Hemodynamic Imaging of Jugular Venous Dynamics During Altered Central Venous Pressure

OBJECTIVE

An optical imaging system is proposed for quantitatively assessing jugular venous response to altered central venous pressure.

METHODS

The proposed system assesses sub-surface optical absorption changes from jugular venous waveforms with a spatial calibration procedure to normalize incident tissue illumination. Widefield frames of the right lateral neck were captured and calibrated using a novel flexible surface calibration method. A hemodynamic optical model was derived to quantify jugular venous optical attenuation (JVA) signals, and generate a spatial jugular venous pulsatility map. JVA was assessed in three cardiovascular protocols that altered central venous pressure: acute central hypovolemia (lower body negative pressure), venous congestion (head-down tilt), and impaired cardiac filling (Valsalva maneuver).

RESULTS

JVA waveforms exhibited biphasic wave properties consistent with jugular venous pulse dynamics when time-aligned with an electrocardiogram. JVA correlated strongly (median, interquartile range) with invasive central venous pressure during graded central hypovolemia (r = 0.85, [0.72, 0.95]), graded venous congestion (r = 0.94, [0.84, 0.99]), and impaired cardiac filling (r = 0.94, [0.85, 0.99]). Reduced JVA during graded acute hypovolemia was strongly correlated with reductions in stroke volume (SV) (r = 0.85, [0.76, 0.92]) from baseline (SV: 79 ± 15 mL, JVA: 0.56 ± 0.10 a.u.) to -40 mmHg suction (SV: 59 ± 18 mL, JVA: 0.47 ± 0.05 a.u.; p 0.01).

CONCLUSION

The proposed non-contact optical imaging system demonstrated jugular venous dynamics consistent with invasive central venous monitoring during three protocols that altered central venous pressure.

SIGNIFICANCE

This system provides non-invasive monitoring of pressure-induced jugular venous dynamics in clinically relevant conditions where catheterization is traditionally required, enabling monitoring in non-surgical environments.

Type IV Collagen 7s Reflects Central Venous Pressure and Right Ventricular End-Diastolic Pressure in Patients with Congenital Heart Disease After Biventricular Repair

After congenital heart disease repair, right heart dysfunction facilitates venous stasis and elevated central venous pressure; however, methods to evaluate right heart dysfunction are limited. We aimed to evaluate right heart function using liver biomarkers. We investigated 62 patients more than 5 years after congenital heart surgery. The patients underwent cardiac catheterization in our hospital between January 2015 and December 2019. To evaluate liver status, type IV collagen 7s, procollagen type III peptide, and hyaluronic acid levels were measured. The mean age of the 62 patients was 14.0 ± 7.2 years. The mean central venous pressure was 6.8 ± 3.5 mmHg and mean right ventricular end-diastolic pressure was 7.9 ± 3.5 mmHg. The mean levels of serum type IV collagen 7s, procollagen type III peptide, and hyaluronic acid were 5.9 ± 1.6 ng/mL, 24.3 ± 15.5 ng/mL, and 18.5 ± 13.6 ng/mL, respectively. There was a good correlation between central venous pressure, right ventricular end-diastolic pressure and type IV collagen 7s (r = 0.67 and r = 0.64). There was no correlation between central venous pressure and the procollagen type III peptide (r = 0.003), and slight correlation between central venous pressure and hyaluronic acid (r = 0.31). There was no correlation between right ventricular end-diastolic pressure and the procollagen type III peptide (r = 0.003), and slight correlation between right ventricular end-diastolic pressure and hyaluronic acid (r = 0.31). We found that changes in the hemodynamics of the right heart system can be evaluated using liver fibrosis markers. Type IV collagen 7s reflects central venous pressure and right ventricular end-diastolic pressure in postoperative patients with congenital heart disease.

Analysis of volume management by comparing between critical care ultrasound examination and pulse indicator cardiac output in patients with septic shock

OBJECTIVE

To investigate volume management by comparing between critical care ultrasound examination and pulse indicator cardiac output (PICCO) in patient with septic shock.

METHODS

Patients with septic shock during July 2017 and June 2018 were included. Inferior Vena Cava (IVC), total end-diastolic volume index (GEDI), central venous pressure (CVP), lactic acid and oxygenation index were measured by ultrasound. First, the accuracy difference of IVC, GEDI and CVP estimation capacity was compared. According to the changes of IVCmin, IVCmax, and GEDI, they were divided into 5 groups to compare the differences of lactic acid and oxygenation index between the groups and the correlation of lactate and Oxygenation index (PaO2/FiO2) between IVC and GEDI was analyzed. The correlation of lactate and PaO2/FiO2 between B lines and extravascular pulmonary water index (ELWI) was noted.

RESULTS

The accuracy of IVC and GEDI in volume estimation was greater than 75%, significantly higher than that of CVP (53.3%) (P<0.05). The correlation results showed that GEDI was significantly correlated with IVCmax and IVCmin (P<0.05), while there was a significant correlation between b-line area and oxygenation index, ELWI and lactic acid, ELWI and oxygenation index (P<0.05). IVCmin, IVCmax and GEDI were respectively divided into 5 groups for comparing the difference between lactic acid and oxygenation. It was found that there were significant differences between the two indicators of IVCmin in different groups (P>0.05). The oxygenation index of the group ≤IVCmax was significantly lower than that of the group 0.5 ≤IVCmax < 1.0cm (P<0.05). The oxgenation indexes of groups 500≤GEDI < 600mL/m2; 600≤GEDI < 700mL/m2. 700≤GEDI < 800mL/m2 were significantly higher than that of group 0 < GEDI < 500mL/m2 (P<0.05).

CONCLUSIONS

Critical care ultrasound examination and PICCO are better methods than in volume management, but PICCO is more individualized, and PICCO in patients with valvular heart disease is not recommended.

Correlation of Central with Jugular and Upper-limb Venous Pressure Measurements

BACKGROUND

Correlation data of different external reference points and methods used to measure venous pressures are scarce in the literature. We correlated central venous pressure with jugular venous pressure measured from sternal angle and with jugular and upper-limb venous pressures from zero level corresponding to mid-right-atrium level.

METHODS

A hospital-based observational study in the medical and surgical intensive care units was conducted for period of one year. Central venous pressure was measured from right fourth intercostal space in mid-axillary line and jugular venous pressure from sternal angle and jugular and upper-limb venous pressures from horizontal plane through the midpoint of anteroposterior line from anterior end of right fourth intercostal space to back. We measured central venous pressure by central venous cannulation and jugular and upper-limb venous pressures clinically by JVP Meter®. Upper-limb venous pressure was indicated by collapse of visible veins in dorsum of hands as the arm was slowly raised from dependent position.

RESULTS

Correlation coefficient (r) values were 0.61 between central venous pressure and jugular venous pressure from zero level, 0.48 between central venous pressure and jugular venous pressure from sternal angle, and 0.31 between central and upper-limb venous pressures; and 0.67 and 0.50 between central venous pressure measured from right internal jugular vein and jugular venous pressure from zero level and sternal angle respectively and 0.52 and 0.44 between central venous pressure from right sub-clavian vein and jugular venous pressure from zero level and sternal angle respectively.

CONCLUSIONS

Different correlation values indicate the need to have future investigations and consensus on the common external reference point and methods to measure venous pressures.

Central venous pressure and the risk of diuretic-associated acute kidney injury in patients after cardiac surgery

BACKGROUND

When prescribing diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery.

METHODS

We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1-mm Hg increase in CVP among patients receiving intravenous loop diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting.

RESULTS

Among 4,164 patients receiving intravenous loop diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of diuretic use (n = 5,396), the adjusted risk ratio for AKI with diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP.

CONCLUSIONS

Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for diuretic therapy.

[Preliminary establishment of weaning prediction model]

OBJECTIVE

To establish a model that can predict weaning failure from ventilation through hemodynamic and fluid balance parameters.

METHODS

A retrospective analysis was conducted. The patients who underwent invasive mechanical ventilation for more than 24 hours and having spontaneous breathing test admitted to intensive care unit (ICU) of Tianjin Third Central Hospital from January 1st, 2017 to December 31st, 2018 were enrolled. The information was collected, which included the baseline data, hemodynamic parameters by pulse indicator continuous cardiac output (PiCCO) monitoring, B-type natriuretic peptide (BNP), urinary output, fluid balance in first 24 hours when patients admitted to ICU, and hemodynamic parameters by PiCCO monitoring, BNP, urinary output, fluid balance, diuretic usage, noradrenalin usage within 24 hours before weaning as well as usage of continuous renal replacement therapy (CRRT) during mechanical ventilation. According to weaning success or failure, the patients were divided into weaning success group and weaning failure group, and the statistical differences between the two groups were calculated. Variables with statistical significance within 24 hours before weaning were included in the multivariate Logistic regression analysis to establish weaning failure prediction model and find out the possible risk factors of weaning failure.

RESULTS

A total of 159 patients were included in this study, which included 138 patients in the weaning success group and 21 patients in the weaning failure group. There were no statistical differences in all hemodynamic parameters by PiCCO monitoring, BNP, urinary output, fluid balance within 24 hours into ICU between two groups. There were statistical differences in BNP (χ² = 9.262, P = 0.026), central venous pressure (CVP; χ² = 7.948, P = 0.047), maximum rate of the increase in pressure (dPmx; χ² = 10.486, P = 0.015), urinary output (χ² = 8.921, P = 0.030), fluid balance (χ² = 9.172, P = 0.027) within 24 hours before weaning between two groups. In addition, variable about cardiac index (CI; χ² = 7.789, P = 0.051) was included into multivariate Logistic regression model to improve the prediction model and enhance the accuracy of model. Finally, variables included in the multivariate Logistic regression model were BNP, CVP, CI, dPmx, urinary output, fluid balance volume, and the accuracy of the weaning failure prediction model was 92.9%, the sensitivity was 100%, and the specificity was 76.8%. When the model was adjusted by variables of age and noradrenalin usage, the accuracy of model to predict failure of weaning was 94.2%, the sensitivity was 100%, the specificity was 81.2%.

CONCLUSIONS

Weaning failure prediction model based on hemodynamic parameters by PiCCO monitoring and variables about liquid balance has high accuracy and can guide clinical weaning.

Increasing Blood Pressure by Greater Splanchnic Nerve Stimulation: a Feasibility Study

The splanchnic vascular compartment is the major reservoir for intravascular blood volume, and dysregulation of the compartment was implicated in a series of cardiovascular conditions. We explored feasibility and effectiveness of an implantable cuff system on the greater splanchnic nerve (GSN) in healthy canines for short- and long-term neuromodulation to affect the circulation. Five mongrel hounds underwent minimally invasive right-sided unilateral GSN cuff placement. All animals underwent same day GSN stimulation and repeat stimulation at 9-30 days. Stimulation parameter optimization was conducted both acutely and chronically. Parameters ranged from 1-250 Hz, 0.25 mA-35 mA, 0.1-0.5 ms, and 30-s pulse duration. Two animals were survived for 9 days and 3 animals for 30 days. Stimulation of the right GSN increased mean arterial blood pressure by 36.9 mmHg ± 13.4 (p < 0.0001), central venous pressure by 6.9 mmHg ± 1.7 (p < 0.0001), and mean pulmonary arterial pressure by 6.3 mmHg ± 2.0 (p < 0.0001). Peak effects were observed within 30 s, and magnitude of effects was comparable between stimulation cycles (p = 0.4). Stimulation-induced changes in hemodynamics were independent of afferent nerve fibers (pain response) or the adrenal gland. Necropsy showed no evidence of nerve damage on histologic studies up to 30 days after implantation. GSN stimulation via an implanted nerve cuff provided a reproducible and rapid method to increase arterial, central venous, and pulmonary arterial pressures. The neuromodulation cuff was well tolerated and elicited a response up to 30 days after implantation. The clinical application of GSN stimulation as a tool to change central and peripheral cardiovascular hemodynamics needs to be explored.

A novel method for transpulmonary pressure estimation using fluctuation of central venous pressure

The objective of the study is to develop a correction method for estimating the change in pleural pressure (ΔPpl) and plateau transpulmonary pressure (P_L) by using the change in central venous pressure (ΔCVP). Seven children (aged < 15 years) with acute respiratory failure (PaO₂/F_IO₂ < 300 mmHg), who were paralyzed and mechanically ventilated with a PEEP of < 10 cmH₂O and had central venous catheters and esophageal balloon catheters placed for clinical purposes, were enrolled prospectively. We compared change in esophageal pressure (ΔPes), ΔCVP, and ΔPpl calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl). cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where κ was the ratio of the change in airway pressure (ΔPaw) to ΔCVP during the occlusion test. cΔCVP-derived ΔPpl correlated better than ΔCVP with ΔPes (R² = 0.48, p = 0.08 vs. R² = 0.14, p = 0.4) with lesser bias and precision in Bland-Altman analysis. The plateau P_L calculated using the cΔCVP-derived ΔPpl (17.6 ± 2.6 cmH₂O) correlated well with the ΔPes-derived plateau P_L (18.1 ± 2.3 cmH₂O) (R² = 0.90, p = 0.001). Our correction method can estimate ΔPpl and plateau P_L from ΔCVP with a reasonable accuracy in paralyzed and mechanically ventilated pediatric patients with respiratory failure.

Age-dependent impairment of the erythropoietin response to reduced central venous pressure in HFpEF patients

Despite growing research interest in the pathophysiology of heart failure with preserved ejection fraction (HFpEF), it remains unknown whether central hemodynamic alterations inherently present in this condition do affect blood pressure and blood volume (BV) regulation. The present study sought to determine hemodynamic and endocrine responses to prolonged orthostatic stress in HFpEF patients. Central venous pressure (CVP) assessed via the internal jugular vein (IJV) aspect ratio with ultrasonography, arterial pressure and heart rate were determined at supine rest and during 2 hours of moderate (25-30°) head-up tilt (HUT) in 18 stable HFpEF patients (71.2 ± 7.3 years), 14 elderly (EC), and 10 young (YC) healthy controls. Parallel endocrine measurements comprised main BV-regulating hormones: pro-atrial natriuretic peptide, copeptin, aldosterone, and erythropoietin (EPO). At supine rest, the IJV aspect ratio was higher (>30%) in HFpEF patients compared with EC and YC, while mean arterial pressure was elevated in HFpEF patients (98.0 ± 13.1 mm Hg) and EC (95.6 ± 8.3 mm Hg) versus YC (87.3 ± 5.0 mm Hg) (P < 0.05). HUT increased heart rate (+10%) and reduced the IJV aspect ratio (-52%), with similar hemodynamic effects in all groups (P for interaction ≥ 0.322). The analysis of endocrine responses to HUT revealed a group×time interaction for circulating EPO, which was increased in YC (+10%) but remained unaltered in HFpEF patients and EC. The EPO response to a given reduction in CVP is similarly impaired in HFpEF patients and elderly controls, suggesting an age-dependent dissociation of EPO production from hemodynamic regulation in the HFpEF condition.

Comparison of Survival Prediction with Single versus Combination Use of Microcirculation End Point Resuscitation in Sepsis and Septic Shock

BACKGROUND

lactate clearance and central venous oxygen saturation (ScvO2) are two methods for determining tissue oxygenation adequacy. There is a controversy regarding method better associates with and predicts sepsis and septic shock patients' mortality. This study address the association of achieving one or two targets of microcirculatory resuscitation endpoints and early mortality in sepsis and septic shock.

METHODS

a cohort study was conducted in adult sepsis and septic shock patients in Intensive Care Unit, Cipto Mangunkusumo Hospital, Indonesia. Patients' resuscitation endpoints data and outcome were observed during the first 120 hours of hospitalization. Cox's proportional hazard regression analysis was used to analyse the early mortality risk in subject groups achieving lactate clearance target only, ScvO2 target only, both targets, and not achieving any target in 6 hours after onset of resuscitation adjusted for number of organ dysfunction.

RESULTS

subjects consisted of 268 patients. There were significant differences in the mortality risk between subjects who achieved both targets with subjects who achieved ScvO2 target only (adjusted hazard ratio [aHR] 13.47; 95% confidence interval [CI] 5.17-35.08) and subjects who not achieve any target (aHR 16.12; 95%CI 7.43-34.95). There were insignificant difference the early mortality risk between subjects who achieved both targets with subjects achieved lactate clearance target only (aHR 2.29; 95%CI 0.83-6.32).

CONCLUSION

in patients with sepsis and septic shock, achievement of lactate clearance and ScvO2 targets associates with similar early mortality risk compared to achievement of lactate clearance target only. However, it associates with lower early mortality risk compared with ScvO2 target only.

[Prognostic value of differences between peripheral arterial and venous blood gas analysis in patients with septic shock]

OBJECTIVE

To investigate the value of the difference between peripheral arterial and venous blood gas analysis for the prognosis of patients with septic shock after resuscitation.

METHODS

Patients with septic shock aged 18 to 80 years admitted to intensive care unit (ICU) of Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine from May 2016 to December 2017 were enrolled. The peripheral arterial blood and peripheral venous blood gas analysis were measured simultaneously after the early 6 hours resuscitation, including pH, partial pressure of oxygen (PO₂), partial pressure of carbon dioxide (PCO₂), base excess (BE), bicarbonate (HCO₃^-) and lactate (Lac) level, and the difference values between peripheral arterial and venous blood were calculated. According to the 28-day survival, the patients were divided into survival group and death group. Multiple Logistic regression analysis was used to analyze the risk factors of death, and the receiver operating characteristic curve (ROC) was used to analyze the prognostic value of blood gas analysis parameters for prognosis.

RESULTS

A total of 65 patients with septic shock resuscitation were enrolled in the study, 35 survived while 30 died during the 28-day period. (1) There was no significant difference in gender, age, and mean arterial pressure (MAP), central venous pressure (CVP), central venous oxygen saturation (ScvO₂) and norepinephrine (NE) dose between the two groups. (2) The arterial and venous Lac, the difference of Lac (ΔLac) and PCO₂ (ΔPCO₂) between arterial and venous blood in death group were significantly higher than those in survival group [arterial Lac (mmol/L): 7.40±3.10 vs. 4.82±2.91, venous Lac (mmol/L): 9.17±3.27 vs. 5.81±3.29, ΔLac (mmol/L): 1.77±0.54 vs. 0.99±0.60, ΔPCO₂ (mmHg, 1 mmHg = 0.133 kPa): 9.64±5.08 vs. 6.70±3.71, all P < 0.01], and there was no significant difference in the other arterial and venous blood gas analysis index and its corresponding differential difference between two groups. (3) Multiple Logistic regression analysis showed that ΔPCO₂ [β = 0.247, odd ratio (OR) = 1.280, 95% confidential interval (95%CI) = 1.057-1.550, P = 0.011], and ΔLac (β = 2.696, OR = 14.820, 95%CI = 2.916-75.324, P = 0.001) were the independent risk factors for the prognosis of septic shock. (4) It was shown by ROC curve analysis that arterial blood Lac, ΔLac and ΔPCO₂ had predictive value on prognosis of septic shock, the area under ROC curve (AUC) was 0.792, 0.857, 0.680, respectively (all P < 0.05). When the best cut-off value of arterial Lac was 4.00 mmol/L, the sensitivity was 100%, and the specificity was 62.86% for predictor of death in 28-day; when the best cut-off value of ΔLac was 1.25 mmol/L, the sensitivity was 93.33%, and the specificity was 68.57% for predictor of death in 28-day; when the best cut-off value of ΔPCO₂ was 4.35 mmHg, the sensitivity was 83.33%, and the specificity was 37.14% for predictor of death in 28-day.

CONCLUSIONS

Compared to other parameters, the difference between peripheral arterial and venous blood gas analysis, ΔPCO₂ and ΔLac had the best correlation with the prognosis of septic shock. The ΔPCO₂ and ΔLac are the independent prognostic predictors for 28-day survival.

Variability in alignment of central venous pressure transducer to physiologic reference point in the intensive care unit-A descriptive and correlational study

BACKGROUND

The phlebostatic axis is the most commonly used anatomical external reference point for central venous pressure measurements. Deviation in the central venous pressure transducer alignment from the phlebostatic axis causes inadequate pressure readings, which may affect treatment decisions for critically ill patients in intensive care units.

AIM

The primary aim of the study was to assess the variability in central venous pressure transducer levelling in the intensive care unit. We also assessed whether patient characteristics impacted on central venous pressure transducer alignment deviation.

METHODS

A sample of 61 critical care nurses was recruited and asked to place a transducer at the appropriate level for central venous pressure measurement. The measurements were performed in the intensive care unit on critically ill patients in supine and Fowler's positions. The variability among the participants using eyeball levelling and a laser levelling device was calculated in both sessions and adjusted for patient characteristics.

RESULTS

A significant variation was found among critical care nurses in the horizontal levelling of the pressure transducer placement when measuring central venous pressure in the intensive care unit. Using a laser levelling device did not reduce the deviation from the phlebostatic axis. Patient characteristics had little impact on the deviation in the measurements.

CONCLUSION

The anatomical external landmark for the phlebostatic axis varied between critical care nurses, as the variation in the central venous pressure transducer placement was not reduced with a laser levelling device. Standardisation of a zero-level for vascular pressures should be considered to reduce the variability in vascular pressure readings in the intensive care unit to improve patient treatment decisions. Further studies are needed to evaluate critical care nurses' knowledge and use of central venous pressure monitoring and whether assistive tools and/or routines can improve the accuracy in vascular pressure measurements in intensive care units.

Different Relevance of Peripheral, Central or Nighttime Blood Pressure Measurements in the Prediction of Chronic Kidney Disease Progression in Patients with Mild or No-Proteinuria

BACKGROUND/AIMS

Arterial hypertension is one of the leading factors aggravating the course of chronic kidney disease (CKD). It seems that the novel parameters used in the assessment of the blood pressure (BP) load (i.e. central blood pressure, nighttime blood pressure) may be more precise in predicting the cardiovascular risk and the progression of CKD in comparison with the traditional peripheral blood pressure measurements in the office conditions. The aim of the study was to assess the impact of the central, or nighttime blood pressure on the progression of CKD in patients with mild or no-proteinuria (autosomal, dominant polycystic kidney disease or IgA nephropathy).

METHODS

In each of the enrolled 46 patients with CKD stage 3 or 4, serum creatinine concentration was assessed, eGFR (MDRD) was calculated, also central blood pressure and pulse wave velocity (PWV) was assessed and the 24-hour ambulatory blood pressure monitoring (ABPM) was conducted at the beginning of the study and then repeated after one-year observation period.

RESULTS

During the observation period mean eGFR decreased from 44.1 (33.2-50.6) mL/min to 36.7 (29.7-46.3) mL/min. No significant differences were observed in the peripheral blood pressure or central blood pressure parameters. After one-year observation period the values of diastolic blood pressure dipping during the night significantly decreased from 16 (13-19) mmHg to 12 (10-15) mmHg; p< 0.05. The values of systolic dipping during the night or the mean BP values recorded in ABPM did not change significantly. Additionally, no significant differences in the PWV values were found. In the multivariate regression model the change of serum creatinine concentration was explained by the initial diastolic dipping values.

CONCLUSION

1. In patients with CKD stages 3 or 4 and mild or no- proteinuria, peripheral and central blood pressure did not change significantly during a one-year observation period despite the significant decline of eGFR and seems not to participate in the CKD progression. 2. Reduced magnitude of the diastolic dipping, which reflects the increase of diastolic blood pressure load during the nighttime, may play an important role in the pathogenesis of deterioration of kidney function in these patients.

Ultrasonographic assessment of the internal jugular vein for the estimation of central venous pressure in hemodialysis patients: A preliminary study

PURPOSE

To investigate a new noninvasive method to assess central venous pressure (CVP) in hemodialysis patients, based on the ultrasonographic measurement of the collapsing point of the internal jugular vein (CVPni).

MATERIALS AND METHODS

In this preliminary, noninterventional, single center study, we enrolled 22 dialyzed patients with an indwelling jugular catheter. CVPni was compared to the gold-standard invasive measurement of CVP using the central venous catheter (CVPi). Agreement between CVPi and CVPni was assessed by Bland and Altman Method. Correlation was assessed by linear regression.

RESULTS

A strong correlation was observed between CVPi and CVPni (OR = 3.47 [2.96; 4.07], P < .0001). For overloaded patients, the area under the curve for the operating characteristic curve was 0.971 (IC95: 0.915; 1.000). For under-loaded patients, area under the curve was 0.971 (IC95: 0.917; 1.000). The mean bias between intra-individual CVPi and CVPni measures was 0.57 cm H₂ O (SD: 3.1 cm H₂ O).

CONCLUSION

CVPni appears as a noninvasive and reliable technique. Further studies are required to confirm these results and to assess the direct clinical impact of this new method.

Cardiovascular system identification: Simulation study using arterial and central venous pressures

The paper presents a study of the identifiability of a lumped model of the cardiovascular system. The significance of this work from the existing literature is in the potential advantage of using both arterial and central venous (CVP) pressures, two signals that are frequently monitored in the critical care unit. The analysis is done on the system's state-space representation via control theory and system identification techniques. Non-parametric state-space identification is preferred over other identification techniques as it optimally assesses the order of a model, which best describes the input-output data, without any prior knowledge about the system. In particular, a recent system identification algorithm, namely Observer Kalman Filter Identification with Deterministic Projection, is used to identify a simplified version of an existing cardiopulmonary model. The outcome of the study highlights the following two facts. In the deterministic (noiseless) case, the theoretical indicators report that the model is fully identifiable, whereas the stochastic case reveals the difficulty in determining the complete system's dynamics. This suggests that even with the use of CVP as an additional pressure signal, the identification of a more detailed (high order) model of the circulatory system remains a challenging task.

Central Haemodynamics and Prediction of Cardiovascular Events in Patients With Erectile Dysfunction

BACKGROUND

We investigated whether central hemodynamics predict major adverse cardiovascular events (MACEs) in erectile dysfunction (ED) patients beyond traditional risk factors.

METHODS

MACEs in relation to aortic pressures and augmentation index (AIx) were analyzed in 398 patients (mean age, 56 years) with ED but without established cardiovascular (CV) disease.

RESULTS

During the mean follow-up period of 6.5 years, a total of 29 (6.5%) MACEs occurred. The adjusted relative risk of MACEs was 1.062 (95% confidence interval (CI), 1.016-1.116) for a 10-mm Hg increase of aortic systolic pressure, 1.119 (95% CI, 1.036-1.155) for a 10-mm Hg increase of aortic pulse pressure (PP), and 1.191 (95% CI, 1.056-1.372) for a 10% absolute increase of AIx. While aortic pressures and AIx did not significantly improve the C-statistic models, the calibration for all indices was satisfactory. Regarding reclassification, the integrated discrimination improvement index (IDI) indicated improvement in risk discrimination of the models that included AIx and aortic PP compared to the reference model in identifying MACEs (IDI = 0.0069; P = 0.024, and IDI = 0.0060; P = 0.036, respectively). The based on categories for 10-year coronary heart disease risk and adapted at 6.5 years overall net reclassification index showed marginal and indicative risk reclassification for AIx (15.7%, P = 0.12) and aortic PP (7.2%, P = 0.20) respectively.

CONCLUSIONS

Our results show for the first time that higher central pressures and AIx are associated with increased risk for a MACE in ED patients without known CV disease. Considering the adverse prognostic role of central hemodynamics on outcomes, the present findings may explain part of the increased CV risk associated with ED.