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Inferior Vena Cava Ultrasonography for Volume Status Evaluation: An Intriguing Promise Never Fulfilled. J Clin Med 2023; 12:jcm12062217. [PMID: 36983218 PMCID: PMC10053997 DOI: 10.3390/jcm12062217] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
The correct determination of volume status is a fundamental component of clinical evaluation as both hypovolaemia (with hypoperfusion) and hypervolaemia (with fluid overload) increase morbidity and mortality in critically ill patients. As inferior vena cava (IVC) accounts for two-thirds of systemic venous return, it has been proposed as a marker of volaemic status by indirect assessment of central venous pressure or fluid responsiveness. Although ultrasonographic evaluation of IVC is relatively easy to perform, correct interpretation of the results may not be that simple and multiple pitfalls hamper its wider application in the clinical setting. In the present review, the basic elements of the pathophysiology of IVC behaviour, potential applications and limitations of its evaluation are discussed.
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2
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Effect of inferior vena cava respiratory variability-guided fluid therapy after laparoscopic hepatectomy: a randomized controlled clinical trial. Chin Med J (Engl) 2023:00029330-990000000-00327. [PMID: 36752804 DOI: 10.1097/cm9.0000000000002484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND After major liver resection, the volume status of patients is still undetermined. However, few concerns have been raised about postoperative fluid management. We aimed to compare gut function recovery and short-term prognosis of the patients after laparoscopic liver resection (LLR) with or without inferior vena cava (IVC) respiratory variability-directed fluid therapy in the anesthesia intensive care unit (AICU). METHODS This randomized controlled clinical trial enrolled 70 patients undergoing LLR. The IVC respiratory variability was used to optimize fluid management of the intervention group in AICU, while the standard practice of fluid management was used for the control group. The primary outcome was the time to flatus after surgery. The secondary outcomes included other indicators of gut function recovery after surgery, postoperative length of hospital stay (LOS), liver and kidney function, the severity of oxidative stress, and the incidence of severe complications associated with hepatectomy. RESULTS Compared with patients receiving standard fluid management, patients in the intervention group had a shorter time to anal exhaust after surgery (1.5 ± 0.6 days vs. 2.0 ± 0.8 days) and lower C-reactive protein activity (21.4 [95% confidence interval (CI): 11.9-36.7] mg/L vs. 44.8 [95%CI: 26.9-63.1] mg/L) 24 h after surgery. There were no significant differences in the time to defecation, serum concentrations of D-lactic acid, malondialdehyde, renal function, and frequency of severe postoperative complications as well as the LOS between the groups. CONCLUSION Postoperative IVC respiratory variability-directed fluid therapy in AICU was facilitated in bowel movement but elicited a negligible beneficial effect on the short-term prognosis of patients undergoing LLR. TRIAL REGISTRATION ChiCTR-INR-17013093.
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Kim DW, Chung S, Kang WS, Kim J. Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 12:diagnostics12010049. [PMID: 35054215 PMCID: PMC8774961 DOI: 10.3390/diagnostics12010049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 01/08/2023] Open
Abstract
This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV) to predict fluid responsiveness in critically ill patients. Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 21 October 2021). The number of true positives, false positives, false negatives, and true negatives for the index test to predict fluid responsiveness was collected. We used a hierarchical summary receiver operating characteristics model and bivariate model for meta-analysis. Finally, 30 studies comprising 1719 patients were included in this review. The ultrasonographic variation of the IVC showed a pooled sensitivity and specificity of 0.75 and 0.83, respectively. The area under the receiver operating characteristics curve was 0.86. In the subgroup analysis, there was no difference between patients on mechanical ventilation and those breathing spontaneously. In terms of the IJV, SCV, and FV, meta-analysis was not conducted due to the limited number of studies. The ultrasonographic measurement of the variation in diameter of the IVC has a favorable diagnostic accuracy for predicting fluid responsiveness in critically ill patients. However, there was insufficient evidence in terms of the IJV, SCV, and FV.
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Affiliation(s)
- Do-Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61469, Korea;
| | - Seungwoo Chung
- Department of Critical Care Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Wu-Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
- Correspondence:
| | - Joongsuck Kim
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
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4
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Rass V, Bogossian EG, Ianosi BA, Peluso L, Kofler M, Lindner A, Schiefecker AJ, Putnina L, Gaasch M, Hackl WO, Beer R, Pfausler B, Taccone FS, Helbok R. The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study. Ann Intensive Care 2021; 11:176. [PMID: 34914011 PMCID: PMC8677880 DOI: 10.1186/s13613-021-00960-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00960-z.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner O Hackl
- Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consult: How Point of Care Ultrasound Helps Guide Medical Decision Making. Int J Gen Med 2021; 14:9789-9806. [PMID: 34938102 PMCID: PMC8685447 DOI: 10.2147/ijgm.s339476] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jake A Rice
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Brewer
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tyler Speaks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Choi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peiman Lahsaei
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Correspondence: Bryan T Romito Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9068, USATel +1 214 648 7674Fax +1 214 648 5461 Email
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Unal Akoglu E, Akoglu H. Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in adult patients? A systematic review and meta-analysis of diagnostic accuracy studies. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211029781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To systematically review the diagnostic utility of the respiratory variation of the inferior vena cava diameter measured using ultrasonography for predicting fluid responsiveness in adult patients and compare the three commonly used equations, inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability. Methods: We searched PubMed, Scopus, Web of Science and Cochrane library, and included studies investigating the diagnostic accuracy of the respiratory variation of the inferior vena cava measured using ultrasonography compared to a reference standard for measuring cardiac output after a fluid challenge for fluid responsiveness, and stratified participants as fluid responsive or not. We included studies conducted in the emergency department or intensive care unit. We excluded studies on paediatric, prehospital, cancer, pregnant, dialysis patients or healthy volunteers. Results: We retrieved 270 records and excluded 171 because of irrelevance, patient population or publication type. We screened the abstracts of 99 studies and then the full texts of 42 studies. Overall, 21 studies with 1321 patients were included, of whom 689 (52%) were fluid responsive. The mean threshold value for positive inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability was 17%, 35% and 12%, respectively. The heterogeneity between studies was high. Bivariate diagnostic random-effects meta-analysis was used to calculate the summary receiver operating characteristics curves. The overall accuracy, sensitivity and specificity of respiratory variation of the inferior vena cava diameter were 0.85, 0.72 and 0.81, respectively. The accuracy of inferior vena cava distensibility and inferior vena cava collapsibility was similar. The diagnostic utility of respiratory variation of the inferior vena cava diameter was lower but not statistically significant in mechanically ventilated patients compared with spontaneous breathing for predicting fluid responsiveness. Conclusion: The respiratory variation of the inferior vena cava diameter has moderate diagnostic utility for predicting fluid responsiveness independent of the equation used.
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Affiliation(s)
- Ebru Unal Akoglu
- Department of Emergency Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University School of Medicine, Istanbul, Turkey
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7
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Yıldızdaş D, Özgür Horoz Ö, Yöntem A, Ekinci F, Aslan N, Laflı Tunay D, Ilgınel MT. Point-of-care ultrasound assessment of the inferior vena cava distensibility index in mechanically ventilated children in the operating room. Turk J Med Sci 2021; 51:1071-1079. [PMID: 33315346 PMCID: PMC8283460 DOI: 10.3906/sag-2006-300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/12/2020] [Indexed: 11/03/2022] Open
Abstract
Background and aim Point-of-care ultrasound imaging of the inferior vena cava distensibility index is a potential indicator for determining fluid overload and dehydration in the mechanically ventilated patients. Data on inferior vena cava distensibility index and inferior vena cava distensibility variability are limited in mechanically ventilated pediatric patients. That is why our aim in this study was to measure inferior vena cava distensibility index and to obtain mean values in pediatric patients, ventilated in the operating room before the ambulatory surgical procedure started. Materials and methods This crosssectional study was performed between February 2019 and February 2020. Ultrasonographic measurements were performed in a total of 125 children. Results In a period of 13 months, the measurements were performed in a total of 125 children, of which 120 (62.5% male) met the criteria and were included in the study. Overall inferior vena cava distensibility index (%): mean ± SD: 6.8 ± 4.0, median (min–max): 5.7 (1.4–19.6), IQR: 3.8–8.7. Overall inferior vena cava distensibility variability (%): mean ± SD: 6.5 ± 3.7, median (min–max): 5.5 (1.4–17.8), IQR: 3.7–8.4. Conclusion Our study is the largest series of children in the literature in which inferior vena cava distensibility index measurements were investigated.
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Affiliation(s)
- Dinçer Yıldızdaş
- Department of Pediatric Intensive Care Unit, Medical Faculty, Çukurova University, Adana, Turkey
| | - Özden Özgür Horoz
- Department of Pediatric Intensive Care Unit, Medical Faculty, Çukurova University, Adana, Turkey
| | - Ahmet Yöntem
- Department of Pediatric Intensive Care Unit, Medical Faculty, Çukurova University, Adana, Turkey
| | - Faruk Ekinci
- Department of Pediatric Intensive Care Unit, Medical Faculty, Çukurova University, Adana, Turkey
| | - Nagehan Aslan
- Department of Pediatric Intensive Care Unit, Medical Faculty, Çukurova University, Adana, Turkey
| | - Demet Laflı Tunay
- Department of Anesthesiology and Reanimation, Medical Faculty, Çukurova University, Adana, Turkey
| | - Murat Türkeün Ilgınel
- Department of Anesthesiology and Reanimation, Medical Faculty, Çukurova University, Adana, Turkey
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8
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Millington SJ, Koenig S. Ultrasound Assessment of the Inferior Vena Cava for Fluid Responsiveness: Making the Case for Skepticism. J Intensive Care Med 2021; 36:1223-1227. [PMID: 34169764 PMCID: PMC9350457 DOI: 10.1177/08850666211024176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Determining whether a patient in shock is in a state of fluid
responsiveness (FR) has long been the Holy Grail for clinicians who
care for acutely ill patients. While various tools have been put forth
as solutions to this important problem, ultrasound assessment of the
inferior vena cava has received particular attention of late. Dozens
of studies have examined its ability to determine whether a patient
should receive volume expansion, and general enthusiasm has been
strengthened by the fact that it is easy to perform and non-invasive,
unlike many competing FR tests. A deeper examination of the technique,
however, reveals important concerns regarding inaccuracies in
measurement and a high prevalence of confounding factors. Furthermore,
a detailed review of the evidence (small individual studies, multiple
meta-analyses, and a single large trial) reveals that the tool
performs poorly in general and is unlikely to be helpful at the
bedside in circumstances where genuine clinical uncertainty
exists.
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Affiliation(s)
- Scott J Millington
- Intensive Care Unit, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
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9
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Akoglu EU, Demir H, Ozturk TC, Ar AY, Turan G. Respiratory variability of inferior vena cava at different mechanical ventilator settings. Am J Emerg Med 2021; 48:96-102. [PMID: 33866270 DOI: 10.1016/j.ajem.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/17/2021] [Accepted: 04/02/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Assessment of the respiratory changes of the inferior vena cava (IVC) diameter have been investigated as a reliable tool to estimate the volume status in mechanically ventilated and spontaneously breathing patients. Our purpose was to compare the echocardiographic measurements the IVC diameter, stroke volume and cardiac output in different positive pressure ventilation parameters. METHODS This prospective clinical study with crossover design was conducted in the Intensive Care Unit (ICU). Twenty-five sedated, paralyzed, intubated, and mechanically ventilated patients with volume control mode (CMV) in the ICU due to respiratory failure were included in the study. Positive End-Expiratory Pressure (PEEP) and Tidal Volume (TV) were changed in each patient consecutively (Group A: TV 6 ml/kg, PEEP 5 cmH20, B: TV 6, PEEP 8, C: TV 8, PEEP 5, D: TV 8, PEEP 8) and the changes in vital parameters, central venous pressure (CVP) and ultrasonographic changes in IVC and cardiac parameters were measured. All measures were compared between groups by robust repeated measures ANOVA with trimmed mean. RESULTS The respiratory changes of the IVC diameter and echocardiographic parameters showed no significant difference in separate mechanical ventilator settings. Significant difference was found in peak and plateau pressure values among groups (p < 0.05). CONCLUSION The results of our study suggest that IVC related parameters are not affected with different ventilatory settings. Further studies are needed to confirm the reliability of these parameters as a predictor of fluid assessment.
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Affiliation(s)
- Ebru Unal Akoglu
- Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey.
| | - Hasan Demir
- Marmara University Pendik Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Tuba Cimilli Ozturk
- Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Arzu Yildirim Ar
- Fatih Sultan Mehmet Training and Research Hospital, Department of Critical Care Medicine, Istanbul, Turkey
| | - Guldem Turan
- Fatih Sultan Mehmet Training and Research Hospital, Department of Critical Care Medicine, Istanbul, Turkey
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Amaya Zuñiga WF, Ospina-Tascón GA, Cruz Martínez LE. Predictors of fluid responsiveness in critically ill patients mechanically ventilated at low tidal volumes: systematic review and meta-analysis. Ann Intensive Care 2021; 11:28. [PMID: 33555488 PMCID: PMC7870741 DOI: 10.1186/s13613-021-00817-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/27/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Dynamic predictors of fluid responsiveness have shown good performance in mechanically ventilated patients at tidal volumes (Vt) > 8 mL kg−1. Nevertheless, most critically ill conditions demand lower Vt. We sought to evaluate the operative performance of several predictors of fluid responsiveness at Vt ≤ 8 mL kg−1 by using meta-regression and subgroup analyses. Methods A sensitive search was conducted in the Embase and MEDLINE databases. We searched for studies prospectively assessing the operative performance of pulse pressure variation (PPV), stroke volume variation (SVV), end-expiratory occlusion test (EEOT), passive leg raising (PLR), inferior vena cava respiratory variability (Δ-IVC), mini-fluid challenge (m-FC), and tidal volume challenge (VtC), to predict fluid responsiveness in adult patients mechanically ventilated at Vt ≤ 8 ml kg−1, without respiratory effort and arrhythmias, published between 1999 and 2020. Operative performance was assessed using hierarchical and bivariate analyses, while subgroup analysis was used to evaluate variations in their operative performance and sources of heterogeneity. A sensitivity analysis based on the methodological quality of the studies included (QUADAS-2) was also performed. Results A total of 33 studies involving 1,352 patients were included for analysis. Areas under the curve (AUC) values for predictors of fluid responsiveness were: for PPV = 0.82, Δ-IVC = 0.86, SVV = 0.90, m-FC = 0.84, PLR = 0.84, EEOT = 0.92, and VtC = 0.92. According to subgroup analyses, variations in methods to measure cardiac output and in turn, to classify patients as responders or non-responders significantly influence the performance of PPV and SVV (p < 0.05). Operative performance of PPV was also significantly affected by the compliance of the respiratory system (p = 0.05), while type of patient (p < 0.01) and thresholds used to determine responsiveness significantly affected the predictability of SVV (p = 0.05). Similarly, volume of fluids infused to determine variation in cardiac output, significantly affected the performance of SVV (p = 0.01) and PLR (p < 0.01). Sensitivity analysis showed no variations in operative performance of PPV (p = 0.39), SVV (p = 0.23) and EEOT (p = 0.15). Conclusion Most predictors of fluid responsiveness reliably predict the response of cardiac output to volume expansion in adult patients mechanically ventilated at tidal volumes ≤ 8 ml kg−1. Nevertheless, technical and clinical variables might clearly influence on their operative performance
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Anaesthesiology, Centro Policlínico del Olaya, Bogotá, Colombia. .,Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - Juan Daniel Caicedo Ruiz
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan José Diaztagle Fernández
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.,Fundación Universitaria de Ciencias de La Salud, Bogotá, Colombia.,Department of Internal Medicine, Hospital de San José, Bogotá, Colombia
| | | | | | - Luis Eduardo Cruz Martínez
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Amaya Zuñiga WF, Ospina-Tascón GA, Cruz Martínez LE. Predictors of fluid responsiveness in critically ill patients mechanically ventilated at low tidal volumes: systematic review and meta-analysis. Ann Intensive Care 2021. [DOI: https://doi.org/10.1186/s13613-021-00817-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Introduction
Dynamic predictors of fluid responsiveness have shown good performance in mechanically ventilated patients at tidal volumes (Vt) > 8 mL kg−1. Nevertheless, most critically ill conditions demand lower Vt. We sought to evaluate the operative performance of several predictors of fluid responsiveness at Vt ≤ 8 mL kg−1 by using meta-regression and subgroup analyses.
Methods
A sensitive search was conducted in the Embase and MEDLINE databases. We searched for studies prospectively assessing the operative performance of pulse pressure variation (PPV), stroke volume variation (SVV), end-expiratory occlusion test (EEOT), passive leg raising (PLR), inferior vena cava respiratory variability (Δ-IVC), mini-fluid challenge (m-FC), and tidal volume challenge (VtC), to predict fluid responsiveness in adult patients mechanically ventilated at Vt ≤ 8 ml kg−1, without respiratory effort and arrhythmias, published between 1999 and 2020. Operative performance was assessed using hierarchical and bivariate analyses, while subgroup analysis was used to evaluate variations in their operative performance and sources of heterogeneity. A sensitivity analysis based on the methodological quality of the studies included (QUADAS-2) was also performed.
Results
A total of 33 studies involving 1,352 patients were included for analysis. Areas under the curve (AUC) values for predictors of fluid responsiveness were: for PPV = 0.82, Δ-IVC = 0.86, SVV = 0.90, m-FC = 0.84, PLR = 0.84, EEOT = 0.92, and VtC = 0.92. According to subgroup analyses, variations in methods to measure cardiac output and in turn, to classify patients as responders or non-responders significantly influence the performance of PPV and SVV (p < 0.05). Operative performance of PPV was also significantly affected by the compliance of the respiratory system (p = 0.05), while type of patient (p < 0.01) and thresholds used to determine responsiveness significantly affected the predictability of SVV (p = 0.05). Similarly, volume of fluids infused to determine variation in cardiac output, significantly affected the performance of SVV (p = 0.01) and PLR (p < 0.01). Sensitivity analysis showed no variations in operative performance of PPV (p = 0.39), SVV (p = 0.23) and EEOT (p = 0.15).
Conclusion
Most predictors of fluid responsiveness reliably predict the response of cardiac output to volume expansion in adult patients mechanically ventilated at tidal volumes ≤ 8 ml kg−1. Nevertheless, technical and clinical variables might clearly influence on their operative performance
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Deng YJ, Dong J, Zhou JR, Chen D, Chen J. Dynamic assessment of the central vein throughout the cardiac cycle in adults with no right heart disease by cardiac CT. Clin Imaging 2020; 69:120-125. [PMID: 32717539 DOI: 10.1016/j.clinimag.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to investigate the effect of the cardiac cycle on the vena cava and determine the phase of measuring maximum diameters. METHODS A total of 152 patients who underwent cardiac computed tomography (CT) were included. Patients' basic information was collected. The major axis, minor axis, and cross-sectional area (CSA) of the vena cava in 10 phases reconstructed at 10% step from 5% to 95% R-R interval were measured in four planes (SVC1 layer: the bifurcation of the pulmonary artery; SVC2 layer: the superior vena cava (SVC) into the right atrium; IVC1 layer: the intersection of the inferior vena cava (IVC) and the right atrium; IVC2 layer: the IVC into the anterior hepatic plane). The difference in vena cava diameters between cardiac cycles was determined using the linear mixed model. RESULTS The variations in diameter and CSA of the SVC in cardiac cycles were statistically significant (p < 0.05), while those of the suprahepatic IVC were not. In the SVC1 layer, the maximum value of the SVC major and minor axes was observed in 85% and 45% phases, respectively, while that in the SVC2 layer was observed in 45% phases. The maximum SVC diameters in the SVC1 and SVC2 layers were 19.48 ± 2.57 mm and 17.43 ± 3.09 mm, respectively. The SVC and IVC diameters and CSA were positively correlated with the body surface area in the linear mixed model. CONCLUSION The maximum SVC diameter and CSA were mostly observed in 45% phase, which provides a reference for selecting the best phase to measure the abnormality of vena cava diameter in the future.
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Affiliation(s)
- Yu-Jiao Deng
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, Sichuan 646000, China
| | - Jing Dong
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, Sichuan 646000, China
| | - Jin-Rong Zhou
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, Sichuan 646000, China
| | - Dong Chen
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, Sichuan 646000, China
| | - Jing Chen
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, 25# Tai Ping Street, Luzhou, Sichuan 646000, China.
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The Value of the Inferior Vena Cava Area Distensibility Index and its Diameter Ratio for Predicting Fluid Responsiveness in Mechanically Ventilated Patients. Shock 2020; 52:37-42. [PMID: 31188800 DOI: 10.1097/shk.0000000000001238] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It is necessary to evaluate fluid responsiveness before fluid resuscitation. We evaluated the value of inferior vena cava (IVC) area respiratory variation and the IVC diameter ratio (IVC DR) for predicting fluid responsiveness in mechanically ventilated patients. METHODS A prospective observational study was performed in the intensive care unit between December 2017 and March 2018. Mechanically ventilated patients were enrolled and received ultrasound monitoring. IVC diameter distensibility index from the subxiphoid area (IVC-sx DDI), IVC diameter distensibility index from the right midaxillary line (IVC-rm DDI), IVC area distensibility index (IVC ADI), and IVC DR in cross-section were calculated by ultrasound monitoring IVC parameters. The enrolled patients were classified as nonresponders group and responders group according to whether the cardiac output increased by >10% after passive leg raising. RESULTS Data from 67 mechanically ventilated patients were analyzed. 55.2% of patients had positive fluid responsiveness. The area of receiver operating characteristic curves evaluating the ability of the IVC-sx DDI, IVC-rm DDI, IVC ADI, and IVC DR to predict the fluid responsiveness were 0.702, 0.686, 0.749, and 0.829, respectively. IVC DR level of 1.43 was predictive of positive fluid responsiveness with 90.0% specificity and 67.6% sensitivity. IVC ADI level of 10.2% was predictive of positive fluid responsiveness with 40.0% specificity and 97.3% sensitivity. CONCLUSIONS IVC ADI and its diameter ratio in cross-section had more value than IVC diameter distensibility index for predicting fluid responsiveness in mechanically ventilated patients.
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Critical Care Ultrasound Should Be a Priority First-Line Assessment Tool in Neurocritical Care. Crit Care Med 2020; 47:833-836. [PMID: 30870190 DOI: 10.1097/ccm.0000000000003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shah SB, Bhargava AK, Hariharan U, Jain CR, Kulkarni A, Gupta N. Goal-directed fluid therapy using transoesophageal echocardiographic inferior venacaval index in patients with low left ventricular ejection fraction undergoing major cytoreductive surgery: A clinical trial. Saudi J Anaesth 2020; 14:7-14. [PMID: 31998013 PMCID: PMC6970374 DOI: 10.4103/sja.sja_215_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/02/2019] [Indexed: 01/23/2023] Open
Abstract
Background and Aims: This study aims to trans oesophageal echo cardiographically (TOE) measure inferior venacava diameter (IVCD) during inspiration and expiration in poor left ventricular ejection fraction (LVEF) patients undergoing cytoreductive oncosurgery, to ascertain if any correlation exists between, caval index (DeltaIVCD), and stroke volume variation (SVV), and to compare DeltaIVCD-guided versus SVV-guided fluid therapy. Methods: In this prospective, parallel group, interventional study, seventy American Society of Anesthesiologists-III patients, aged 30-75 years, weighing 40-90 kg, with LVEF ≤40% undergoing cytoreductive surgery were included and randomised to group-D (DeltaIVCD-guided fluid therapy) and group-S (SVV-guided fluid therapy). Patients with oesophageal lesions were excluded. After standard endotracheal anaesthesia, arterial and internal jugular vein catheters were placed. A TOE probe was inserted in the interventional group-D. Quantification of IVCD respiratory variations was done. Heart rate (HR), arterial oxygen saturation (SPO2), mean arterial pressure, end tidal carbondioxide (EtCO2), central venous pressure, SVV, IVCD, and urine output (UO) were recorded every 30 min. Post-operative arterial blood gas analysis, lung-ultrasound, chest-radiograph, and serum creatinine were done. Statistical Analysis: Pearson's correlation coefficient as measure of strength of linear relationship, calculation of regression equation, and unpaired t-test for normally distributed continuous variables were used. Results: A positive correlation between DeltaIVCD and SVV (r = 0.751) was observed. A regression equation was obtained for SVV (SVV = [0.317 × DeltaIVCD] + 5.877). Serum lactate, estimated glomerular filtration rate, HR, and UO were within normal limits in group-D. There was no pulmonary oedema. Conclusion: DeltaIVCD-guided intravenous fluid therapy is valuable in low LVEF patients where tight fluid control is essential and any fluid overload may precipitate cardiac failure.
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Affiliation(s)
- Shagun Bhatia Shah
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Ajay Kumar Bhargava
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Uma Hariharan
- Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | - Chamound Rai Jain
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Anita Kulkarni
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
| | - Namrata Gupta
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India
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Mendes RDS, Oliveira MV, Padilha GA, Rocha NN, Santos CL, Maia LA, Fernandes MVDS, Cruz FF, Olsen PC, Capelozzi VL, de Abreu MG, Pelosi P, Rocco PRM, Silva PL. Effects of crystalloid, hyper-oncotic albumin, and iso-oncotic albumin on lung and kidney damage in experimental acute lung injury. Respir Res 2019; 20:155. [PMID: 31311539 PMCID: PMC6636113 DOI: 10.1186/s12931-019-1115-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/28/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Conflicting data have reported beneficial effects of crystalloids, hyper-oncotic albumin (20%ALB), and iso-oncotic albumin (5%ALB) in critically ill patients. Although hyper-oncotic albumin may minimize lung injury, recent studies have shown that human albumin may lead to kidney damage proportional to albumin concentration. In this context, we compared the effects of Ringer's lactate (RL), 20%ALB, and 5%ALB, all titrated according to similar hemodynamic goals, on pulmonary function, lung and kidney histology, and molecular biology in experimental acute lung injury (ALI). METHODS Male Wistar rats received Escherichia coli lipopolysaccharide intratracheally (n = 24) to induce ALI. After 24 h, animals were anesthetized and randomly assigned to receive RL, 20%ALB, or 5%ALB (n = 6/group) to maintain hemodynamic stability (distensibility index of inferior vena cava < 25%, mean arterial pressure > 65 mmHg). Rats were then mechanically ventilated for 6 h. Six animals, which received neither ventilation nor fluids (NV), were used for molecular biology analyses. RESULTS The total fluid volume infused was higher in RL compared to 5%ALB and 20%ALB (median [interquartile range], 10.8[8.2-33.2] vs. 4.8[3.6-7.7] and 4.3[3.9-6.6] mL, respectively; p = 0.02 and p = 0.003). B-line counts on lung ultrasound (p < 0.0001 and p = 0.0002) and serum lactate levels (p = 0.01 and p = 0.01) were higher in RL than 5%ALB and 20%ALB. Diffuse alveolar damage score was lower in 5%ALB (10.5[8.5-12]) and 20%ALB (10.5[8.5-14]) than RL (16.5[12.5-20.5]) (p < 0.05 and p = 0.03, respectively), while acute kidney injury score was lower in 5%ALB (9.5[6.5-10]) than 20%ALB (18[15-28.5], p = 0.0006) and RL (16 [15-19], p = 0.04). In lung tissue, mRNA expression of interleukin (IL)-6 was higher in RL (59.1[10.4-129.3]) than in 5%ALB (27.0[7.8-49.7], p = 0.04) or 20%ALB (3.7[7.8-49.7], p = 0.03), and IL-6 protein levels were higher in RL than 5%ALB and 20%ALB (p = 0.026 and p = 0.021, respectively). In kidney tissue, mRNA expression and protein levels of kidney injury molecule (KIM)-1 were lower in 5%ALB than RL and 20%ALB, while nephronectin expression increased (p = 0.01 and p = 0.01), respectively. CONCLUSIONS In a rat model of ALI, both iso-oncotic and hyper-oncotic albumin solutions were associated with less lung injury compared to Ringer's lactate. However, hyper-oncotic albumin resulted in greater kidney damage than iso-oncotic albumin. This experimental study is a step towards future clinical designs.
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Affiliation(s)
- Renata de S Mendes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Milena V Oliveira
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Gisele A Padilha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Nazareth N Rocha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Rio de Janeiro, Brazil
| | - Cintia L Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Ligia A Maia
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Marcos V de S Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Priscilla C Olsen
- Laboratory of Bacteriology and Clinical Immunology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vera L Capelozzi
- Department of Pathology, University of Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Rajajee V, Pandey AS, Williamson CA. Subarachnoid Hemorrhage and Therapy Formerly Known as “Triple-H”—New Directions. World Neurosurg 2019; 127:500-501. [DOI: 10.1016/j.wneu.2019.04.212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Samavedam S. Ten Papers that Changed My Practice in Neurocritical Care. Indian J Crit Care Med 2019; 23:S165-S168. [PMID: 31485128 PMCID: PMC6707489 DOI: 10.5005/jp-journals-10071-23197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neurocritical care is an ever growing specialty with paradigm changes being the norm. Some of the established practices like triple H therapy for SAH and steroids in pyogenic meningitis have seen major changes in published evidence. This article evaluates the evidence published over the last few years which resulted in a change in the authors approach to and practice of neuro intensive care. How to cite this article Samavedam S. Ten Papers that Changed My Practice in Neurocritical Care. Indian J Crit Care Med 2019;23(Suppl 2):S165-S168.
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Affiliation(s)
- Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
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Das SK, Choupoo NS, Pradhan D, Saikia P, Monnet X. Diagnostic accuracy of inferior vena caval respiratory variation in detecting fluid unresponsiveness: A systematic review and meta-analysis. Eur J Anaesthesiol 2019; 35:831-839. [PMID: 29901465 DOI: 10.1097/eja.0000000000000841] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The accuracy of respiratory variation of the inferior vena cava (rvIVC) in predicting fluid responsiveness, particularly in spontaneously breathing patients is unclear. OBJECTIVES To consider the evidence to support the accuracy of rvIVC in identifying patients who are unlikely to benefit from fluid administration. DESIGN Systematic review and meta-analysis. DATA SOURCE We searched MEDLINE, EMBASE, Cochrane Library, KoreaMed, LILCAS and WHO Clinical Trial Registry from inception to June 2017. ELIGIBILITY CRITERIA Case-control or cohort studies that evaluated the accuracy of rvIVC in living adult humans were included. A study was included in the meta-analysis if data enabling construction of 2 × 2 tables were reported, calculated or could be obtained from authors and met the above cited criteria. RESULT A total of 23 studies including 1574 patients were included in qualitative analysis. The meta-analysis involved 20 studies and 761 patients. Pooled sensitivity and specificity of rvIVC in 330 spontaneously breathing patients were 0.80 [95% confidence interval (CI) 0.68 to 0.89] and 0.79 (95% CI 0.60 to 0.90). Pooled sensitivity and specificity of rvIVC in 431 mechanically ventilated patients were 0.79 (95% CI 0.67 to 0.86) and 0.70 (95% CI 0.63 to 0.76). CONCLUSION Decreased inferior vena caval respiratory variation is moderately accurate in predicting fluid unresponsiveness both in spontaneous and mechanically ventilated patients. The findings of this review should be used in the appropriate clinical context and in conjunction with other clinical assessments of fluid status. IDENTIFIER CRD 42017068028.
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Affiliation(s)
- Saurabh K Das
- From the Department of Critical Care, Artemis Hospital, Gurgaram, Haryana (SKD), Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Education and Research, Dr Ram Monohar Lohia Hospital, New Delhi, Delhi (NSC), Department of Anaesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya (DP), Department of Anaesthesiology and Critical Care, Guwahati Medical College, Guwahati, Assam, India (PS) and AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service de Réanimation Médicale, Paris, France (XM)
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Ultrasound assessment of the inferior vena cava for fluid responsiveness: easy, fun, but unlikely to be helpful. Can J Anaesth 2019; 66:633-638. [PMID: 30919234 DOI: 10.1007/s12630-019-01357-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023] Open
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Utagawa A. Fluid Management for Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Si X, Xu H, Liu Z, Wu J, Cao D, Chen J, Chen M, Liu Y, Guan X. Does Respiratory Variation in Inferior Vena Cava Diameter Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-analysis. Anesth Analg 2018; 127:1157-1164. [DOI: 10.1213/ane.0000000000003459] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Wang Y, Jiang Y, Wu H, Wang R, Wang Y, Du C. Assessment of fluid responsiveness by inferior vena cava diameter variation in post-pneumonectomy patients. Echocardiography 2018; 35:1922-1925. [PMID: 30338549 PMCID: PMC6587495 DOI: 10.1111/echo.14172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/16/2018] [Accepted: 09/20/2018] [Indexed: 11/30/2022] Open
Abstract
Aim First, the inferior vena cava dilatation index (DIVC) was measured by ultrasound, and then the reliability of DIVC as an indicator to predict volume responsiveness in patients undergoing mechanical ventilation after pneumonectomy was evaluated. Methods Pulse indicator continuous cardiac output (Picco) as gold standard was performed to sedated mechanically ventilated post‐pneumonectomy patients in intensive care unit of Nanjing Thoracic Hospital from August 2014 to December 2016. Meanwhile, ultrasound measurement to inferior vena cava (IVC) diameter at the end inspiration (Dmax) and the end of expiration (Dmin) was performed. DIVC = (Dmax − Dmin)/Dmin. Above values were recorded at baseline and then after fluid resuscitation challenge (7 mL/kg hydroxyethyl starch). An increase in cardiac index of more than 15% was used as the standard for fluid responsiveness. Patients were divided into responsive group and non‐responsive group. A receiver operating characteristic (ROC) curve was then used to determine the sensitivity and specificity of DIVC in predicting fluid responsiveness after pneumonectomy. Results Eighteen patients were enrolled. 10 patients were divided into responsive group and eight in non‐responsive group. DIVC in responsive group was significantly higher than in non‐responsive group (P < 0.01). By setting DIVC ≥ 15% as a measure of fluid responsiveness, sensitivity was 81.8% and specificity was 85.7%. Conclusion DIVC is a reliable indicator of capacity responsiveness in mechanically ventilated post‐pneumonectomy patients.
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Affiliation(s)
- Yan Wang
- Intensive Care Unit, Nanjing Chest Hospital, Nanjing, China
| | - Yinghou Jiang
- Intensive Care Unit, Nanjing Chest Hospital, Nanjing, China
| | - Hongning Wu
- Ultrasonic Department, Nanjing Chest Hospital, Nanjing, China
| | - Runfeng Wang
- Intensive Care Unit, Nanjing Chest Hospital, Nanjing, China
| | - Ying Wang
- Intensive Care Unit, Nanjing Chest Hospital, Nanjing, China
| | - Cheng Du
- Intensive Care Unit, Nanjing Chest Hospital, Nanjing, China
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Poblete RA, Cen SY, Zheng L, Emanuel BA. Serum Lactic Acid Following Aneurysmal Subarachnoid Hemorrhage Is a Marker of Disease Severity but Is Not Associated With Hospital Outcomes. Front Neurol 2018; 9:593. [PMID: 30083130 PMCID: PMC6064931 DOI: 10.3389/fneur.2018.00593] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
Background: Following aneurysmal subarachnoid hemorrhage, peripherally-drawn lactic acid has been associated with poor outcomes; however, its clinical significance is unknown. We investigated admission factors and patient outcomes associated with serum lactic acid in this population. Methods: This was a retrospective observational study of 105 consecutive patients with serum lactate collected within 24 h of admission. Primary objectives were to determine the incidence of admission lactic acidemia, and factors positively and negatively associated with lactate levels. We also sought to determine if admission lactic acidemia was associated with patient outcomes, including vasospasm, delayed cerebral ischemia, mortality, and discharge disposition. Results: Admission serum lactic acid was elevated in 56 patients (53% of the cohort). Levels were positively associated with Hunt & Hess and modified Fisher grade, glucose, troponin I and white blood cell counts, and negatively associated with GCS and ventilator-free days. Admission lactate was not associated with the development of vasospasm or delayed cerebral ischemia. Patients with elevated lactic acid more often died during hospitalization, and less often were discharged home. After adjusting for other predictors of poor outcome, the adjusted odds of inpatient mortality (OR 0.97, 95% CI 0.79–1.20; p = 0.80) and discharge to home (OR 1.00, 95% CI 0.80–1.26; p = 0.97) was not associated with admission lactic acid. Conclusions: Early serum lactic acid elevation is common following aneurysmal subarachnoid hemorrhage and is associated with the clinical and radiographic grade of hemorrhage. Levels did not independently predict short-term outcomes when adjusted for established predictors of poor outcome. Further study is needed to determine the clinical significance of peripherally-drawn lactic acid in aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Steven Yong Cen
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Ling Zheng
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Benjamin A Emanuel
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Prada G, Vieillard-Baron A, Martin AK, Hernandez A, Mookadam F, Ramakrishna H, Diaz-Gomez JL. Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth 2018; 33:1559-1583. [PMID: 30077562 DOI: 10.1053/j.jvca.2018.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Indexed: 02/03/2023]
Abstract
Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.
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Affiliation(s)
- Gabriel Prada
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne-Billancourt, France; Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint-Quentin En Yvelines, France; INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Phoenix, AZ.
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Greenstein YY, Koenig SJ. A Woman in Her 60s With Septic Shock, Abdominal Pain, and a Positive Urinalysis. Chest 2018; 145:e7-e9. [PMID: 27845650 DOI: 10.1378/chest.13-2455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/11/2013] [Indexed: 11/01/2022] Open
Affiliation(s)
- Yonatan Y Greenstein
- Division of Pulmonary, Critical Care, and Sleep Medicine, Hofstra North Shore - Long Island Jewish Health System, New Hyde Park, NY.
| | - Seth J Koenig
- Division of Pulmonary, Critical Care, and Sleep Medicine, Hofstra North Shore - Long Island Jewish Health System, New Hyde Park, NY
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Molokoane-Mokgoro K, Goldstein LN, Wells M. Ultrasound evaluation of the respiratory changes of the inferior vena cava and axillary vein diameter at rest and during positive pressure ventilation in spontaneously breathing healthy volunteers. Emerg Med J 2018. [PMID: 29523722 DOI: 10.1136/emermed-2016-205944] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Ultrasound assessment of the inferior vena cava (IVC) has gained favour in aiding fluid management decisions for controlled, mechanically ventilated patients as well as in non-mechanically ventilated, spontaneously breathing patients. Its utility in spontaneously breathing patients during positive pressure non-invasive ventilation has not yet been determined. The use of the axillary vein, as an alternative option to the IVC due to its ease of accessibility and independence from intra-abdominal pressure, has also not been evaluated. The aim of this study was to assess respiratory variation in IVC and axillary vein diameters in spontaneously breathing participants (Collapsibility Index) and with the application of increasing positive end-expiratory pressure (PEEP) via positive pressure non-invasive ventilation (Distensibility Index). METHODS The IVC and axillary vein diameters of 28 healthy adult volunteers were measured, using ultrasound, at baseline and with increasing PEEP via non-invasive ventilation. The Collapsibility Index and Distensibility Index of these vessels were calculated and compared for each vessel. The association between increasing PEEP levels and the indices was evaluated. RESULTS Positive pressure delivered via non-invasive ventilation produced a similar degree of diameter change in the IVC and the axillary vein, that is, the Distensibility Index was similar whether measured in the IVC or the axillary vein (P=0.21, 0.47 and 0.17 at baseline, 5 and 10 cmH2O PEEP, respectively). Individual study participants' IVC and axillary veins, however, had variable responses to PEEP; that is, there appeared to be no consistent relationship between PEEP and the diameter changes. CONCLUSION While the axillary vein could potentially be used as an alternative vessel to the IVC to assess for volume responsiveness in controlled, mechanically ventilated patients as well as in non-mechanically ventilated, spontaneously breathing patients, neither vein should be used to guide fluid management decisions in spontaneously breathing patients during positive pressure non-invasive ventilation.
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Affiliation(s)
- Keamogetswe Molokoane-Mokgoro
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lara Nicole Goldstein
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mike Wells
- Division of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kukulski P, Ward M, Carter K. Ultrasound for Volume Assessment in Patients with Shock: Effectiveness of an Educational Intervention for Fourth-year Medical Students. Cureus 2018; 10:e2129. [PMID: 29610713 PMCID: PMC5878096 DOI: 10.7759/cureus.2129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Objective Shock is a common emergency condition with high morbidity and mortality, and judicious fluid resuscitation can significantly affect outcomes. The use of a bedside echocardiogram and evaluation of the inferior vena cava (IVC) via ultrasound (US) for collapsibility can predict volume status. Additionally, the Association of American Medical Colleges (AAMC) Entrustable Professional Activities (EPA) 10 states that residents need to be able to address a patient with a critical illness, including hypotension, on Day 1 of residency. Existing literature revealed no published curriculum to teach medical students these skills. We aimed to determine the effectiveness of an educational intervention to teach fourth-year medical students how to utilize IVC US measurement and echocardiography to assist in volume assessment of patients presenting with shock. Methods Students participated in an hour session on the first day of the emergency medicine (EM) clerkship. Didactic effectiveness was evaluated by comparing results on a pre-test and post-test. The test was administered to residents and attendings during the first week of the academic year to gain evidence for content validity. Students also responded to a survey to evaluate learner satisfaction. Results The average score on the validation test was 68.4% (standard deviation (SD): 21.6%, number (n) = 38) for residents and attendings, and 47.4% (SD: 19.4, n = 13) for interns. Students scored an average of 45.6% (SD: 23.6, n = 83) on the pre-test and 66.4% (SD: 22.1 n = 72) on the post-test, p < 0.01 (degrees of freedom (df) = 153, t = 5.7), Cohen's d = 0.92. The satisfaction survey showed 97.6% of students felt the session was worthwhile, 96.4% would recommend it to other students, and 83.1% felt it taught new information. Conclusion These results show that the educational intervention provides a significant increase in knowledge regarding volume assessment and the use of echocardiogram and IVC US. Additionally, students rated the course highly and felt that it provided information not otherwise taught in medical school. This curriculum addresses the AAMC EPA 10, as it increases students’ readiness to address hypotension and could add significant value to the medical school curriculum.
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Affiliation(s)
- Paul Kukulski
- Emergency Medicine, The University of Chicago Medicine
| | | | - Keme Carter
- Emergency Medicine, The University of Chicago Medicine
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Orso D, Paoli I, Piani T, Cilenti FL, Cristiani L, Guglielmo N. Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018; 35:354-363. [PMID: 29343170 DOI: 10.1177/0885066617752308] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Fluid responsiveness is the ability to increase the cardiac output in response to a fluid challenge. Only about 50% of patients receiving fluid resuscitation for acute circulatory failure increase their stroke volume, but the other 50% may worsen their outcome. Therefore, predicting fluid responsiveness is needed. In this purpose, in recent years, the assessment of the inferior vena cava (IVC) through ultrasound (US) has become very popular. The aim of our work was to systematically review all the previously published studies assessing the accuracy of the diameter of IVC or its respiratory variations measured through US in predicting fluid responsiveness. DATA SOURCES We searched in the MEDLINE (PubMed), Embase, Web of Science databases for all relevant articles from inception to September 2017. STUDY SELECTION Included articles specifically addressed the accuracy of IVC diameter or its respiratory variations assessed by US in predicting the fluid responsiveness in critically ill ventilated or not, adult or pediatric patients. DATA EXTRACTION We included 26 studies that investigated the role of the caval index (IVC collapsibility or distensibility) and 5 studies on IVC diameter. DATA SYNTHESIS We conducted a meta-analysis for caval index with 20 studies: The pooled area under the curve, logarithmic diagnostic odds ratio, sensitivity, and specificity were 0.71 (95% confidence interval [CI]: 0.46-0.83), 2.02 (95% CI: 1.29-2.89), 0.71 (95% CI: 0.62-0.80), and 0.75 (95% CI: 0.64-0.85), respectively. CONCLUSION An extreme heterogeneity of included studies was highlighted. Ultrasound evaluation of the diameter of the IVC and its respiratory variations does not seem to be a reliable method to predict fluid responsiveness.
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Affiliation(s)
- Daniele Orso
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Irene Paoli
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Tommaso Piani
- Division of Pre-Hospital and Retrieval Medicine, Department of Anaesthesia and Intensive Care Medicine, ASUIUD "Santa Maria della Misericordia," Udine, Italy
| | - Francesco L Cilenti
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Lorenzo Cristiani
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Nicola Guglielmo
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
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Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2018; 84:37-49. [PMID: 29019796 DOI: 10.1097/ta.0000000000001719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE Systematic Review, level II.
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Trifi A, Abdellatif S, Daly F, Nasri R, Touil Y, Ben Lakhal S. Ultrasound stroke volume variation induced by passive leg raising and fluid responsiveness: An observational cohort study. Med Intensiva 2017; 43:10-17. [PMID: 29258779 DOI: 10.1016/j.medin.2017.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/24/2017] [Accepted: 11/11/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the performance of the ultrasound measurement of stroke volume (SV) coupled to passive leg raising (PLR) in predicting fluid responsiveness (FR). DESIGN A prospective cohort study was carried out in patients requiring volume expansion (VE). A transthoracic Doppler echocardiography (TTE) device was used for the measurement of SV. Four measurements were obtained: before and 90s after PLR, and before and after VE. The patients were subsequently classified according to their hemodynamic response to VE. Responders were defined by an increase in SV of at least 15% in response to VE. RESULTS Thirty maneuvers were studied. An increase in SV>15% in response to PLR was recorded in 21 cases. Hemodynamic indices taken in the first stage showed significant differences in the distensibility index of the inferior vena cava (dIVC), in the velocity-time integral of aortic blood flow (VTIAo) and in SV, with respective p-values of 0.009, 0.012 and 0.025. The SV changes induced by VE were significantly correlated to the SV changes induced by PLR, with a Spearman coefficient of 0.77 and a linear equation y=0.82 x+1.68. Fluid responsiveness can be efficiently predicted by assessing the effects of PLR on SV monitored by Doppler TTE, with a sensitivity of 94.7% and a negative predictive value of 88%. CONCLUSION Our data support the interest of Doppler TTE as an effective tool in predicting FR through the assessment of SV in response to PLR, in hemodynamically unstable patients.
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Affiliation(s)
- A Trifi
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia.
| | - S Abdellatif
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - F Daly
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - R Nasri
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - Y Touil
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
| | - S Ben Lakhal
- Medical Intensive Care Unit, University Hospital Center La Rabta, Tunis, Tunisia; Faculty of Medicine, University Tunis El Manar, Tunis, Tunisia
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Abstract
Many systemic complications follow aneurysmal subarachnoid hemorrhage and are primarily due to sympathetic nervous system activation. These complications play an important role in the overall outcome of patients. The purpose of this review is to provide an update on the diagnosis, pathophysiology, and management of systemic complications specifically associated with aneurysmal subarachnoid hemorrhage. Special focus has been made on systemic complications that occur more frequently in patients with aneurysmal subarachnoid hemorrhage compared to other stroke subtypes and in the neurocritical care patient population. These complications include neurogenic pulmonary edema, electrocardiographic changes, troponin elevation, neurogenic stunned myocardium, hyponatremia, and anemia.
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Affiliation(s)
- Ravi Garg
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL, 60153, USA
| | - Barak Bar
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, 2160 S. First Avenue, Maywood, IL, 60153, USA.
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Bilgili B, Haliloglu M, Tugtepe H, Umuroglu T. The Assessment of Intravascular Volume with Inferior Vena Cava and Internal Jugular Vein Distensibility Indexes in Children Undergoing Urologic Surgery. J INVEST SURG 2017; 31:523-528. [PMID: 28952826 DOI: 10.1080/08941939.2017.1364806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this work is to assess the predictive value, for fluid responsiveness (FR), of the inferior vena cava distensibility index (IVC-DI) and internal jugular vein distensibility index (IJV-DI) in pediatric surgical patients. MATERIAL AND METHODS Prior to being placed under general anesthesia, 24 surgical patients were enrolled. Baseline parameters were recorded with the patient in the semirecumbent position (Stage 1). Next, the passive leg raising (PLR) maneuver was carried out and a second measurement was recorded (Stage 2). Patients with an increase in the cardiac index (CI) of >10%, induced by PLR, were considered to be responders (R), otherwise they were classified as nonresponders (NR). At both stages, CI and DI of the IVC and IJV were measured. RESULTS Responders had higher IVC-DI and IVJ-DI than NR in stage 1 (both p <.001). In stage 2, IVC-DI and IJV-DI were not different in R and NR groups (p =.164, p =.201). Utilizing cut-off values of > 22.7% for IVC-DI and > 25% for IJV-DI, these parameters had positive correlation coefficients, both in R and NR of, respectively, 0.626 and 0.929. CONCLUSIONS The IVC-DI predicts FR in anesthetized pediatric patients and correlates well with the IJV-DI; both may be used as prediction markers of FR in children.
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Affiliation(s)
- Beliz Bilgili
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Murat Haliloglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
| | - Halil Tugtepe
- b Marmara University, School of Medicine , Department of Pediatric Surgery , Pendik, Istanbul , Turkey
| | - Tumay Umuroglu
- a Marmara University, School of Medicine , Department of Anesthesiology and Reanimation , Pendik, Istanbul , Turkey
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Toscani L, Aya HD, Antonakaki D, Bastoni D, Watson X, Arulkumaran N, Rhodes A, Cecconi M. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:207. [PMID: 28774325 PMCID: PMC5543539 DOI: 10.1186/s13054-017-1796-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Background The fluid challenge is considered the gold standard for diagnosis of fluid responsiveness. The objective of this study was to describe the fluid challenge techniques reported in fluid responsiveness studies and to assess the difference in the proportion of ‘responders,’ (PR) depending on the type of fluid, volume, duration of infusion and timing of assessment. Methods Searches of MEDLINE and Embase were performed for studies using the fluid challenge as a test of cardiac preload with a description of the technique, a reported definition of fluid responsiveness and PR. The primary outcome was the mean PR, depending on volume of fluid, type of fluids, rate of infusion and time of assessment. Results A total of 85 studies (3601 patients) were included in the analysis. The PR were 54.4% (95% CI 46.9–62.7) where <500 ml was administered, 57.2% (95% CI 52.9–61.0) where 500 ml was administered and 60.5% (95% CI 35.9–79.2) where >500 ml was administered (p = 0.71). The PR was not affected by type of fluid. The PR was similar among patients administered a fluid challenge for <15 minutes (59.2%, 95% CI 54.2–64.1) and for 15–30 minutes (57.7%, 95% CI 52.4–62.4, p = 1). Where the infusion time was ≥30 minutes, there was a lower PR of 49.9% (95% CI 45.6–54, p = 0.04). Response was assessed at the end of fluid challenge, between 1 and 10 minutes, and >10 minutes after the fluid challenge. The proportions of responders were 53.9%, 57.7% and 52.3%, respectively (p = 0.47). Conclusions The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1796-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Toscani
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cristo Re Hospital, Via delle Calasanziane 25, 00167, Rome, Italy
| | - Hollmann D Aya
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK. .,Anaesthetic Department, East Surrey Hospital, Surrey & Sussex Healthcare Trust, Canada Avenue, Redhill, Surrey, RH1 5 RH, UK.
| | - Dimitra Antonakaki
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cardiology Department, Broomfield Hospital, Mid-Essex Healthcare Trust, Court Road, Broomfield, Chelmsford, CM1 7ET, UK
| | - Davide Bastoni
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Dipartimento di Medicina Sperimentale, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ximena Watson
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Nish Arulkumaran
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Andrew Rhodes
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
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Nedel WL, Simas DM, Marin LG, Morais VD, Friedman G. Respiratory Variation in Femoral Vein Diameter Has Moderate Accuracy as a Marker of Fluid Responsivity in Mechanically Ventilated Septic Shock Patients. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2713-2717. [PMID: 28756901 DOI: 10.1016/j.ultrasmedbio.2017.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 12/16/2022]
Abstract
Ultrasound (US) is considered the first step in evaluation of patients with shock; respiratory variation of the inferior vena cava (inferior vena cava collapsibility [IVCc]) is an important measurement in this scenario that can be impaired by patient condition or technical skills. The main objective of this study was to evaluate if respiratory variation of the femoral vein (femoral vein collapsibility [FVc]), which is easier to visualize, can adequately predict fluid responsiveness in septic shock patients. Forty-five mechanically ventilated septic shock patients in a mixed clinical-surgical, 30-bed intensive care unit were enrolled in this study. All patients underwent assessments of FVc, IVCc and cardiac output using a portable US device. The passive leg raising test was used to evaluate fluid responsiveness. FVc presented an area under the receiver operating characteristic curve of 0.678 (95% confidence interval: 0.519-0.837, p = 0.044) with a cutoff point of 17%, yielding a sensitivity of 62% and specificity of 65% in predicting fluid responsiveness. IVCc had greater diagnostic accuracy compared with FVc, with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval: 0.563-0.903, p = 0.024) and a cutoff point of 29%, yielding a sensitivity of 47% and specificity of 86%. In conclusion, FVc has moderate accuracy when employed as an indicator of fluid responsiveness in spontaneously mechanically ventilated septic shock patients.
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Affiliation(s)
- Wagner Luis Nedel
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil.
| | | | - Luiz Gustavo Marin
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | | | - Gilberto Friedman
- Postgraduate Program in Pneumological Sciences, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil
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Schmidt GA. POINT: Should Acute Fluid Resuscitation Be Guided Primarily by Inferior Vena Cava Ultrasound for Patients in Shock? Yes. Chest 2017; 151:531-532. [DOI: 10.1016/j.chest.2016.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022] Open
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Focused Real-Time Ultrasonography for Nephrologists. Int J Nephrol 2017; 2017:3756857. [PMID: 28261499 PMCID: PMC5312502 DOI: 10.1155/2017/3756857] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/09/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.
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Distensibility index of the inferior vena cava in experimental acute respiratory distress syndrome. Respir Physiol Neurobiol 2016; 237:7-12. [PMID: 28017906 DOI: 10.1016/j.resp.2016.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 01/23/2023]
Abstract
We determined the accuracy of distensibility index of inferior vena cava (dIVC) for evaluation of fluid responsiveness in rats with acute respiratory distress syndrome (ARDS) and validated this index for use in rat models. In protocol 1, E. coli lipopolysaccharide was administered in Wistar rats (n=7). After 24h, animals were mechanically ventilated, and stroke volume (SV) and dIVC quantified after blood drainage and subsequent volume expansion (albumin 20%). A receiver operating characteristic (ROC) curve was plotted to determine the optimal dIVC cutoff. In protocol 2, rats (n=10) were divided into fluid-responders (SV increase >5%) and nonresponders (SV increase <5%). The dIVC cutoff obtained from protocol 1 was 25%. Fluid responders had a 2.5 relative risk of low dIVC (<25%). The sensitivity, specificity, positive predictive, and negative predictive values for dIVC were 74%, 62%, 59%, and 76%, respectively. In conclusion, a dIVC threshold <25% was associated with positive response after volume expansion and could be used to titrate fluids in endotoxin-induced ARDS.
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Sonographic aorta/IVC cross-sectional area index for evaluation of dehydration in children. Am J Emerg Med 2016; 34:1840-4. [DOI: 10.1016/j.ajem.2016.06.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 06/13/2016] [Accepted: 06/13/2016] [Indexed: 11/22/2022] Open
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Murthy SB, Caplan J, Levy AP, Pradilla G, Moradiya Y, Schneider EB, Shalom H, Ziai WC, Tamargo RJ, Nyquist PA. Haptoglobin 2-2 Genotype Is Associated With Cerebral Salt Wasting Syndrome in Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2016; 78:71-6. [PMID: 26348010 DOI: 10.1227/neu.0000000000001000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Haptoglobin (Hp) genotype has been shown to be a predictor of clinical outcomes in subarachnoid hemorrhage. Cerebral salt wasting (CSW) has been suggested to precede the development of symptomatic vasospasm. OBJECTIVE To determine if Hp genotype was associated with CSW and subsequent vasospasm after aneurysmal subarachnoid hemorrhage. METHODS Hp genotypic determination was done for patients admitted with a diagnosis of subarachnoid hemorrhage. Outcome measures included CSW, delayed cerebral infarction, and Glasgow Outcome Score of 4 to 5 at 30 days. Criteria for CSW included hyponatremia <135 mEq/L, and urine output >4 L in 12 hours with urine sodium >40 mEq/L. RESULTS A total of 133 patients were included in the study. The 3 Hp subgroups did not differ in terms of baseline characteristics. CSW occurred in 1 patient (3.4%) with Hp 1-1, 8 (14.0%) patients with Hp 2-1, and 15 (31.9%) patients with Hp 2-2 (P = .004). In the multivariate regression model, Hp 2-2 was associated with CSW (odds ratio [OR]: 4.94; CI: 1.78-17.43; P = .01), but Hp 2-1 was not (OR: 2.92; CI: 0.56-4.95; P = .15) compared with Hp 1-1. There were no associations between Hp genotypes and functional outcome or delayed cerebral infarction. CSW was associated with delayed cerebral infarction (OR: 7.46; 95% CI: 2.54-21.9; P < .001). CONCLUSION Hp 2-2 genotype was an independent predictor of CSW after subarachnoid hemorrhage. Because CSW is strongly associated with delayed cerebral infarction, the use of Hp genotype testing requires more investigation, and larger prospective confirmation is warranted. Additionally, a more objective definition of CSW needs to be delineated.
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Affiliation(s)
- Santosh B Murthy
- *Division of Neurosciences Critical Care and‡Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;§Department of Medicine, Technion Institute of Technology, Haifa, Israel;¶Department of Neurological Surgery, Emory University, Atlanta, Georgia;‖Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland
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Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review. J Trauma Acute Care Surg 2016; 80:511-8. [PMID: 26670112 DOI: 10.1097/ta.0000000000000941] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.
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Sobczyk D, Nycz K, Andruszkiewicz P, Wierzbicki K, Stapor M. Ultrasonographic caval indices do not significantly contribute to predicting fluid responsiveness immediately after coronary artery bypass grafting when compared to passive leg raising. Cardiovasc Ultrasound 2016; 14:23. [PMID: 27267175 PMCID: PMC4897915 DOI: 10.1186/s12947-016-0065-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/01/2016] [Indexed: 11/10/2022] Open
Abstract
Background Appropriate fluid management is one of the most important elements of early goal-directed therapy after cardiothoracic surgery. Reliable determination of fluid responsivenss remains the fundamental issue in volume therapy. The purpose of the study was to assess the usefulness of dynamic IVC-derived parameters (collapsibility index, distensibility index) in comparison to passive leg raising, in postoperative fluid management in mechanically ventilated patients with left ventricular ejection fraction ≥ 30 %, immediately after elective coronary artery bypass grafting. Methods Prospective observational case series study including 35 patients with LVEF ≥ 30 %, undergoingelective coronary artery bypass grafting was conducted. Transthoracic echocardiography, passive leg raising and intravenous administration of saline were performed in all study subjects. Dynamic parameters derived from ultrasonographic assessment of the IVC diameter (collapsibility index–CI and distensibility index–DI), cardiac output Results There were 24 (68.57 %) responders in the study population. There were no statistical differences between the groups in relation to: clinical parameters, pre- and postoperative LVEF, fluid balance and CVP. Change in cardiac output after passive leg raising correlated significantly with that after the volume expansion (p=0.000, r=0.822). Dynamic IVC derivatives were slightly higher in fluid responders, however this trend did not reach statistical significance. None of the caval indices correlated with fluid responsiveness. Conclusion Dynamic IVC-derived parameters do not predict fluid responsiveness in mechanically ventilated patients with preserved ejection fraction immediately after elective coronary artery bypass grafting. Passive leg raising is not inferior to volume expansion in differentiating between fluid responders and nonresponders. Immediate fluid challenge after CABG is safe and well tolerated. Electronic supplementary material The online version of this article (doi:10.1186/s12947-016-0065-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorota Sobczyk
- Department of Interventional Cardiology, John Paul II Hospital, Cracow, Poland. .,Emergency and Admission Department, John Paul II Hospital, Pradnicka 80, 31 202, Cracow, Poland.
| | - Krzysztof Nycz
- Emergency and Admission Department, John Paul II Hospital, Pradnicka 80, 31 202, Cracow, Poland
| | - Pawel Andruszkiewicz
- 2nd Department of Anaesthesiology and Intensive Care, Warsaw Medical University, Warsaw, Poland
| | - Karol Wierzbicki
- Cardiovascular Surgery and Transplantology Department, Medical College, Jagiellonian University, Cracow, Poland
| | - Maciej Stapor
- Department of Interventional Cardiology, John Paul II Hospital, Cracow, Poland
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van der Jagt M. Fluid management of the neurological patient: a concise review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:126. [PMID: 27240859 PMCID: PMC4886412 DOI: 10.1186/s13054-016-1309-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Maintenance fluids in critically ill brain-injured patients are part of routine critical care. Both the amounts of fluid volumes infused and the type and tonicity of maintenance fluids are relevant in understanding the impact of fluids on the pathophysiology of secondary brain injuries in these patients. In this narrative review, current evidence on routine fluid management of critically ill brain-injured patients and use of haemodynamic monitoring is summarized. Pertinent guidelines and consensus statements on fluid management for brain-injured patients are highlighted. In general, existing guidelines indicate that fluid management in these neurocritical care patients should be targeted at euvolemia using isotonic fluids. A critical appraisal is made of the available literature regarding the appropriate amount of fluids, haemodynamic monitoring and which types of fluids should be administered or avoided and a practical approach to fluid management is elaborated. Although hypovolemia is bound to contribute to secondary brain injury, some more recent data have emerged indicating the potential risks of fluid overload. However, it is acknowledged that many factors govern the relationship between fluid management and cerebral blood flow and oxygenation and more research seems warranted to optimise fluid management and improve outcomes.
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Affiliation(s)
- Mathieu van der Jagt
- Department of Intensive Care (Office H-611) and Erasmus MC Stroke Center, Erasmus Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Broilo F, Meregalli A, Friedman G. Right internal jugular vein distensibility appears to be a surrogate marker for inferior vena cava vein distensibility for evaluating fluid responsiveness. Rev Bras Ter Intensiva 2016; 27:205-11. [PMID: 26465243 PMCID: PMC4592113 DOI: 10.5935/0103-507x.20150042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 06/30/2015] [Indexed: 12/31/2022] Open
Abstract
Objective To investigate whether the respiratory variation of the inferior vena cava
diameter (∆DIVC) and right internal jugular vein diameter (∆DRIJ) are correlated
in mechanically ventilated patients. Methods This study was a prospective clinical analysis in an intensive care unit at a
university hospital. Thirty-nine mechanically ventilated patients with hemodynamic
instability were included. ∆DIVC and ∆DRIJ were assessed by echography. Vein
distensibility was calculated as the ratio of (A) Dmax - Dmin/Dmin and (B) Dmax -
Dmin/ mean of Dmax - Dmin and expressed as a percentage. Results ∆DIVC and ∆DRIJ were correlated by both methods: (A) r = 0.34, p = 0.04 and (B) r
= 0.51, p = 0.001. Using 18% for ∆DIVC, indicating fluid responsiveness by method
(A), 16 patients were responders and 35 measurements showed agreement (weighted
Kappa = 0.80). The area under the ROC curve was 0.951 (95%CI 0.830 - 0.993; cutoff
= 18.92). Using 12% for ∆DIVC, indicating fluid responsiveness by method (B), 14
patients were responders and 32 measurements showed agreement (weighted Kappa =
0.65). The area under the ROC curve was 0.903 (95%CI 0.765 - 0.973; cut-off value
= 11.86). Conclusion The respiratory variation of the inferior vena cava and the right internal jugular
veins are correlated and showed significant agreement. Evaluation of right
internal jugular vein distensibility appears to be a surrogate marker for inferior
vena cava vein distensibility for evaluating fluid responsiveness.
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Affiliation(s)
- Fabiano Broilo
- Unidade de Terapia Intensiva Central, Complexo Hospitalar Santa Casa, Porto Alegre, RS, BR
| | - Andre Meregalli
- Unidade de Terapia Intensiva Central, Complexo Hospitalar Santa Casa, Porto Alegre, RS, BR
| | - Gilberto Friedman
- Programa de Pós-Graduação em Ciências Pneumológicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, BR
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Effect of Hydroxyethyl Starch Solution on Incidence of Acute Kidney Injury in Patients Suffering from Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2016; 26:34-40. [DOI: 10.1007/s12028-016-0265-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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48
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Díaz-Gómez JL, Via G, Ramakrishna H. Focused cardiac and lung ultrasonography: implications and applicability in the perioperative period. Rom J Anaesth Intensive Care 2016; 23:41-54. [PMID: 28913476 DOI: 10.21454/rjaic.7518.231.lus] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Focused ultrasonography in anesthesia (FUSA) can be a procedural and diagnostic tool, as well as potentially a tool for monitoring, and can facilitate the perioperative management of surgical patients. Its utilization is proposed within the anesthesiologist and/or intensivist scope of practice. However, there are significant barriers to more generalized use, but evidence continues to evolve that might one day make this practice a standard of care in the perioperative period. Currently, the most widely used applications of FUSA include the guidance and characterization of perioperative shock (acute cor pulmonale, left ventricular dysfunction, cardiac tamponade, and hypovolemia) and acute respiratory failure (pneumothorax, acute pulmonary edema, large pleural effusion, major atelectasis, and consolidation). Increased diagnostic accuracy of all of these clinical conditions makes FUSA valuable in the perioperative period. Furthermore, FUSA can be applied to other anesthesiology fields, such as airway management and evaluation of gastric content in surgical emergencies.
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Affiliation(s)
- José L Díaz-Gómez
- Department of Critical Care Medicine, Mayo Clinic FL, USA.,Department of Anesthesiology, Mayo Clinic FL, USA.,Department of Neurologic Surgery, Mayo Clinic FL, USA
| | - Gabriele Via
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Poor outcome is associated with less negative fluid balance in patients with aneurysmal subarachnoid hemorrhage treated with prophylactic vasopressor-induced hypertension. Ann Intensive Care 2016; 6:25. [PMID: 27033710 PMCID: PMC4816937 DOI: 10.1186/s13613-016-0128-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/14/2016] [Indexed: 11/23/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) is a serious condition associated with high mortality rates and long-term disability. We investigated the impact of fluid balance on neurologic outcome after adjustment for possible confounders related to intensive care therapy and extra-cerebral organ failure during the early phase after SAH. Methods In this retrospective study, we analyzed data from all 142 adult patients admitted to our university hospital surgical intensive care unit (ICU) with SAH between March 2004 and November 2010. Results The mean patient age was 54 ± 14 years, 62.7 % were female, and the median Hunt and Hess score was 3. The proportions of patients with poor outcome (Glasgow Outcome Score ≤3) were 58.4, 54.2, and 52.1 % at 3, 6, and 12 months, respectively, after the SAH. The ICU and hospital mortality rates were both 12.7 %, and the median lengths of stay in the ICU and the hospital were 16 (IQ 7–25) and 26 (IQ 18–34) days, respectively. In multivariable analysis, older age and greater cumulative fluid balance within the first 7 days in the ICU were independently associated with a greater risk of poor outcome. Conclusion In this cohort of patients, older age and greater cumulative fluid balance were independently associated with a greater risk of poor outcome up to 1 year after the initial insult. Our data suggest that mild hypovolemia may be beneficial in the management of these patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0128-6) contains supplementary material, which is available to authorized users.
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Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients. J Crit Care 2016; 34:46-9. [PMID: 27288609 DOI: 10.1016/j.jcrc.2016.03.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/12/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement. MATERIALS AND METHODS We included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500mL of crystalloids over 15minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV. RESULTS Twenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P=.28). CONCLUSION The individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.
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