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Joseph A, Evrard B, Petit M, Goudelin M, Prat G, Slama M, Charron C, Vignon P, Vieillard-Baron A. Fluid responsiveness in acute respiratory distress syndrome patients: a post hoc analysis of the HEMOPRED study. Intensive Care Med 2024:10.1007/s00134-024-07639-6. [PMID: 39254736 DOI: 10.1007/s00134-024-07639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/24/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE Optimal fluid management in patients with acute respiratory distress syndrome (ARDS) is challenging due to risks associated with both circulatory failure and fluid overload. The performance of dynamic indices to predict fluid responsiveness (FR) in ARDS patients is uncertain. METHODS This post hoc analysis of the HEMOPRED study compared the performance of dynamic indices in mechanically ventilated patients with shock, with and without ARDS, to predict FR, defined as an increase in aortic velocity time integral (VTI) > 10% after passive leg raising (PLR). RESULTS Among 540 patients, 117 (22%) had ARDS and were ventilated with a median tidal volume of 7.6 mL/kg [6.9-8.4] and a median positive end-expiratory pressure of 7 cmH2O [5-9]. FR was observed in 45 ARDS patients (39% vs 44% in non-ARDS patients, p = 0.384). Reliability of dynamic indices to predict FR remained consistent in ARDS patients, though with different thresholds. Collapsibility index of the superior vena cava (ΔSVC) showed the best predictive performance in both ARDS (area under the curve [AUC] = 0.763 [0.659-0.868]) and non-ARDS (AUC = 0.750 [0.698-0.802]) patients. A right to left ventricle end-diastolic area ratio > 0.8 or paradoxical septal motion were strongly linked to the absence of FR (> 80% specificity). FR was not associated with intensive care unit (ICU) mortality (47% vs. 46%, p = 1). However, hypovolemia, defined as an aortic VTI increase > 32% during PLR (median increase in patients with a partial SVC collapse) was independently associated with ICU mortality (odds ratio [OR] = 1.355 [1.077-1.705], p = 0.011), as well as pulse pressure variation (OR = 1.014 [1.001-1.026], p = 0.034). CONCLUSION Performance of dynamic indices to predict FR appears preserved in ARDS patients, albeit with distinct thresholds. Hypovolemia, indicated by a > 32% increase in aortic VTI during PLR, rather than FR, was associated with ICU mortality in this population.
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Affiliation(s)
- Adrien Joseph
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France.
- Inserm U1173, Laboratory of Infection & Inflammation, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France.
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Matthieu Petit
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
| | - Marine Goudelin
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Gwenaël Prat
- Medical Intensive Care Unit, Brest University Hospital, Brest, France
| | - Michel Slama
- Medical Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Cyril Charron
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Antoine Vieillard-Baron
- Medical and Surgical intensive care unit, University Hospital Ambroise Paré, GHU Paris-Saclay, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
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Orso D, Sabbadin M, Bacchetti G, Simeoni G, Bove T. Correlation Between Tissue Doppler Imaging Method (E/e') and Invasive Measurements of Left Ventricular Filling Pressures: A Systematic Review, Meta-Analysis, and Meta-Regression. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00534-2. [PMID: 39218765 DOI: 10.1053/j.jvca.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/21/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Evaluation of pulmonary capillary wedge pressure (PCWP) through right heart catheterization can indirectly provide an estimation of the filling pressure of the left ventricle. Echocardiography can estimate left ventricular compliance using mitral annular tissue Doppler imaging (TDI). The E/e' ratio refers to the correlation between the peak mitral inflow (E-wave) velocity and early diastolic tissue Doppler mitral annular velocity (e'). The main purpose of this systematic review was to establish the correlation between echocardiographic E/e' ratio and PCWP. The correlation between E/e' and left ventricular end-diastolic pressure (LVEDP) was evaluated as a secondary objective. DESIGN A systematic review and meta-analysis of observational studies was conducted. The search was based on Medline (PubMed), Scopus, and Web of Science. SETTING Intensive care unit or cardiac intensive care unit. PARTICIPANTS Adult patients. INTERVENTIONS Any study comparing the left ventricular filling pressure obtained by cardiac catheterization (reference) and echocardiographic evaluation, in particular TDI analysis (intervention), were included. MEASUREMENTS AND MAIN RESULTS The pooled analysis included 94 studies from the initially identified 7,304 records. The correlation was 0.48 (95% CI 0.42-0.54, Q = 420.52, I2 = 84.8%) for PCWP and 0.50 (95% CI 0.38-0.60, Q = 210.91, I2 = 89.1%) for LVEDP. CONCLUSIONS The E/e' ratio moderately correlated with PCWP/LVEDP. The correlation was stable irrespective of the sites where e' was measured, but each site has its own limitations for specific patient subpopulations. The correlation was weak in patients with heart failure with a preserved ejection fraction.
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Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care, ASUFC University Hospital of Udine, Udine, Italy.
| | - Marta Sabbadin
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | | | - Gabriele Simeoni
- Department of Anesthesia and Intensive Care, ASUFC University Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, ASUFC University Hospital of Udine, Udine, Italy; Department of Medicine (DAME), University of Udine, Udine, Italy
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Min JY, Jeon JP, Chung MY, Kim CJ. Use of the cardiac power index to predict fluid responsiveness in the prone position: a proof-of-concept study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844545. [PMID: 39117065 PMCID: PMC11393583 DOI: 10.1016/j.bjane.2024.844545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND The primary aim of this proof-of-concept study was to investigate whether the Cardiac Power Index (CPI) could be a novel alternative method to assess fluid responsiveness in the prone position. METHODS Patients undergoing scheduled elective lumbar spine surgery in the prone position under general anesthesia were enrolled in the criteria of patients aged 19-75 years with American Society of Anesthesiologists (ASA) physical status I-II. The hemodynamic variables were evaluated before and after changes in posture after administering a colloid bolus (5 mL.kg-1) in the prone position. Fluid responsiveness was defined as an increase in the Stroke Volume Index (SVI) ≥ 10%. RESULTS A total of 28 patients were enrolled. In responders, the CPI (median [1/4Q-3/4Q]) decreased to 0.34 [0.28-0.39] W.m-2 (p = 0.035) after the prone position. After following fluid loading, CPI increased to 0.48 [0.37-0.52] W.m-2 (p < 0.008), and decreased SVI (median [1/4Q-3/4Q]) after prone increased from 26.0 [24.5-28.0] mL.m-2 to 33.0 [31.0-37.5] mL.m-2 (p = 0.014). Among non-responders, CPI decreased to 0.43 [0.28-0.53] W.m-2 (p = 0.011), and SVI decreased to 29.0 [23.5-34.8] mL.m-2 (p < 0.009). CPI exhibited predictive capabilities for fluid responsiveness as a receiver operating characteristic curve of 0.78 [95% Confidence Interval, 0.60-0.95; p = 0.025]. CONCLUSION This study suggests the potential of CPI as an alternative method to existing preload indices in assessing fluid responsiveness in clinical scenarios, offering potential benefits for responders and non-responders.
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Affiliation(s)
- Ji Young Min
- The Catholic University of Korea, College of Medicine, Eunpyeong St. Mary's Hospital, Department of Anesthesiology and Pain Medicine, Seoul, Republic of Korea
| | - Joon Pyo Jeon
- The Catholic University of Korea, College of Medicine, Eunpyeong St. Mary's Hospital, Department of Anesthesiology and Pain Medicine, Seoul, Republic of Korea
| | - Mee Young Chung
- The Catholic University of Korea, College of Medicine, Eunpyeong St. Mary's Hospital, Department of Anesthesiology and Pain Medicine, Seoul, Republic of Korea
| | - Chang Jae Kim
- The Catholic University of Korea, College of Medicine, Eunpyeong St. Mary's Hospital, Department of Anesthesiology and Pain Medicine, Seoul, Republic of Korea.
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Gevaerd Martins J, Saad A, Saade G, Pacheco LD. The role of point-of-care ultrasound to monitor response of fluid replacement therapy in pregnancy. Am J Obstet Gynecol 2024:S0002-9378(24)00730-0. [PMID: 38969197 DOI: 10.1016/j.ajog.2024.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/05/2024] [Accepted: 06/15/2024] [Indexed: 07/07/2024]
Abstract
Fluid management in obstetrical care is crucial because of the complex physiological conditions of pregnancy, which complicate clinical manifestations and fluid balance management. This expert review examined the use of point-of-care ultrasound to evaluate and monitor the response to fluid therapy in pregnant patients. Pregnancy induces substantial physiological changes, including increased cardiac output and glomerular filtration rate, decreased systemic vascular resistance, and decreased plasma oncotic pressure. Conditions, such as preeclampsia, further complicate fluid management because of decreased intravascular volume and increased capillary permeability. Traditional methods for assessing fluid volume status, such as physical examination and invasive monitoring, are often unreliable or inappropriate. Point-of-care ultrasound provides a noninvasive, rapid, and reliable means to assess fluid responsiveness, which is essential for managing fluid therapy in pregnant patients. This review details the various point-of-care ultrasound modalities used to measure dynamic changes in fluid status, focusing on the evaluation of the inferior vena cava, lung ultrasound, and left ventricular outflow tract. Inferior vena cava ultrasound in spontaneously breathing patients determines diameter variability, predicts fluid responsiveness, and is feasible even late in pregnancy. Lung ultrasound is crucial for detecting early signs of pulmonary edema before clinical symptoms arise and is more accurate than traditional radiography. The left ventricular outflow tract velocity time integral assesses stroke volume response to fluid challenges, providing a quantifiable measure of cardiac function, which is particularly beneficial in critical care settings where rapid and accurate fluid management is essential. This expert review synthesizes current evidence and practice guidelines, suggesting the integration of point-of-care ultrasound as a fundamental aspect of fluid management in obstetrics. It calls for ongoing research to enhance techniques and validate their use in broader clinical settings, aiming to improve outcomes for pregnant patients and their babies by preventing complications associated with both under- and overresuscitation.
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Affiliation(s)
| | - Antonio Saad
- Department of Obstetrics and Gynecology, Inova Maternal-Fetal Medicine, Fairfax, VA
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Luis D Pacheco
- Departments of Obstetrics and Gynecology and Anesthesiology, The University of Texas Medical Branch, Galveston, TX
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Kouz K, Thiele R, Michard F, Saugel B. Haemodynamic monitoring during noncardiac surgery: past, present, and future. J Clin Monit Comput 2024; 38:565-580. [PMID: 38687416 PMCID: PMC11164815 DOI: 10.1007/s10877-024-01161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.
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Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | | | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg, 20246, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Joseph A, Petit M, Vignon P, Vieillard-Baron A. Fluid responsiveness and venous congestion: unraveling the nuances of fluid status. Crit Care 2024; 28:140. [PMID: 38671461 PMCID: PMC11055218 DOI: 10.1186/s13054-024-04930-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Affiliation(s)
- Adrien Joseph
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, AP-HP, Boulogne-Billancourt, France.
- Inserm U1173, Laboratory of Infection and Inflammation, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France.
| | - Matthieu Petit
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, AP-HP, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC 1435 and Faculty of Medicine, University of Limoges, Limoges, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, AP-HP, Boulogne-Billancourt, France
- Inserm U1018, CESP, University Versailles Saint Quentin - University Paris Saclay, Guyancourt, France
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Tang X, Liang J, Tan D, Chen Q, Zhou C, Yang T, Liu H. Value of carotid corrected flow time or changes value of FTc could be more useful in predicting fluid responsiveness in patients undergoing robot-assisted gynecologic surgery: a prospective observational study. Front Med (Lausanne) 2024; 11:1387433. [PMID: 38638936 PMCID: PMC11024293 DOI: 10.3389/fmed.2024.1387433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Background The aim of this study was to evaluate the ability of point-of-care Doppler ultrasound measurements of carotid corrected flow time and its changes induced by volume expansion to predict fluid responsiveness in patients undergoing robot-assisted gynecological surgery. Methods In this prospective study, carotid corrected flow time was measured using Doppler images of the common carotid artery before and after volume expansion. The stroke volume index at each time point was recorded using noninvasive cardiac output monitoring with MostCare. Of the 52 patients enrolled, 26 responded. Results The areas under the receiver operating characteristic curves of the carotid corrected flow time and changes in carotid corrected flow time induced by volume expansion were 0.82 and 0.67, respectively. Their optimal cut-off values were 357 and 19.5 ms, respectively. Conclusion Carotid corrected flow time was superior to changes in carotid corrected flow time induced by volume expansion for predicting fluid responsiveness in this population.
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Affiliation(s)
- Xixi Tang
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Jingqiu Liang
- Chongqing Cancer Multi-Omics Big Data Application Engineering Research Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Dongling Tan
- Department of Anesthesiology, People’s Hospital of Shizhu, Chongqing, China
| | - Qi Chen
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Chengfu Zhou
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
| | - Tingjun Yang
- Department of Anesthesiology, People’s Hospital of Shizhu, Chongqing, China
| | - Hongliang Liu
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing, China
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Gavelli F, Patrucco F, DE Vita N, Solidoro P, Avanzi GC. Central venous pressure in critically ill patients: do we still need it? Panminerva Med 2024; 66:1-3. [PMID: 38088034 DOI: 10.23736/s0031-0808.23.05082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Francesco Gavelli
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy -
- Emergency Medicine Department, Maggiore della Carità University Hospital, Novara, Italy -
| | - Filippo Patrucco
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Division of Respiratory Diseases, Maggiore della Carità University Hospital, Novara, Italy
| | - Nello DE Vita
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Department of Anesthesiology and Intensive Care, Maggiore della Carità University Hospital, Novara, Italy
| | - Paolo Solidoro
- Unit of Respiratory Diseases, Cardiovascular and Thoracic Department, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Gian C Avanzi
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Emergency Medicine Department, Maggiore della Carità University Hospital, Novara, Italy
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Ochiai R, Terada T, Sakamoto N. Comparative evaluation of stroke volume variation measured by pulse wave transit time and arterial pressure wave. Technol Health Care 2024; 32:651-662. [PMID: 37483029 PMCID: PMC10977375 DOI: 10.3233/thc-220849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/15/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Several monitors have been developed that measure stroke volume (SV) in a beat-to-beat manner. Accordingly, Stroke volume variation (SVV) induced by positive pressure ventilation is widely used to predict fluid responsiveness. OBJECTIVE The purpose of this study was to compare the ability of two different methods to predict fluid responsiveness using SVV, stroke volume variation by esCCO (esSVV) and stroke volume variation by FloTrac/VigileoTM (flSVV). METHODS esSVV, flSVV, and stroke volume index (SVI) by both monitoring devices of 37 adult patients who underwent laparotomy surgery, were measured. Receiver operating characteristic (ROC) analysis was performed. RESULTS The area under the ROC curve (AUC) of esSVV was significantly higher than that of flSVV (p= 0.030). esSVV and flSVV showed cutoff values of 6.1% and 10% respectively, to predict an increase of more than 10% in SVI after fluid challenge. The Youden index for esSVV was higher than flSVV, even with a cutoff value between 6% and 8%. CONCLUSION Since esSVV and flSVV showed significant differences in AUC and cutoff values, the two systems were not comparable in predicting fluid responsiveness. Furthermore, it seems that SVV needs to be personalized to accurately predict fluid responsiveness for each patient.
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Affiliation(s)
| | - Takashi Terada
- Department of Anesthesiology, Japan Community Health Care Organization Mishima General Hospital, Fujikubo, Mishima, Japan
| | - Noriaki Sakamoto
- Department of Anesthesiology, Toho University Omori Medical Centre, Oota, Japan
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Yu ZB, Cui N, Zhang N, Su D, Wu JQ, Xi XM. Prediction of fluid responsiveness for patients in shock using a ventilator disconnection test combined with the pulse contour-derived cardiac index. Technol Health Care 2024; 32:629-638. [PMID: 37522231 DOI: 10.3233/thc-220799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND Finding a simple and reliable method to predict and assess fluid responsiveness has long been of clinical interest. OBJECTIVE To investigate the predictive value of a ventilator disconnection (DV) test combined with the pulse contour-derived cardiac output (PiCCO) index on fluid responsiveness for patients in shock. METHODS Thirty-two patients were chosen for the study. Patients who were in shock, received mechanical ventilation, and met the inclusion criteria were selected. Patients were divided into a fluid-responsive group (14 patients) and fluid-unresponsive group (18 patients) based on whether the increase in cardiac index (Δ CI) was > 10% or not, respectively, following the fluid challenge test. Changes in heart rate, pulse oximeter-measured oxygen saturation, mean arterial pressure (MAP), and CI before and after passive leg raising (PLR), DV, and fluid challenge tests were observed. We used Pearson's correlation coefficient to analyze an increase in the MAP (Δ MAP) and Δ CI before and after the PLR, DV, and fluid challenge tests; the sensitivity and specificity of the Δ MAP and Δ CI in the PLR and DV tests for predicting fluid response were also analyzed by plotting the receiver operating characteristic (ROC) curves. RESULTS CI results in the PLR and DV tests, as well as the fluid challenge test, were significantly higher in the fluid-responsive group compared with before the test (P< 0.05). The Δ CI before and after the PLR, DV, and fluid challenge tests were positively correlated among patients in the fluid-responsive group. The area under the ROC curve for the post-PLR test CI and the post-DV CI for predicting fluid responsiveness was 0.869 (95% confidence interval (CI) [0.735-1.000, P= 0.000]) and 0.937 (95% CI [0.829-1.000, P= 0.000]), respectively, in patients in the fluid-responsive group. The sensitivity and specificity of the post-DV CI for predicting fluid responsiveness in all patients was 100.0% and 88.9%, respectively, using a 5% increase as the cut-off value. CONCLUSION Application of DV, combined with PiCCO, has a high predictive value for fluid responsiveness among patients in shock.
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Affiliation(s)
- Zhan-Biao Yu
- Intensive Care Unit, Fu Xing Hospital, Capital Medical University, Beijing, China
- Intensive Care Unit, Affiliated Hospital of HeBei University, Baoding, Hebei, China
| | - Na Cui
- Intensive Care Unit, Affiliated Hospital of HeBei University, Baoding, Hebei, China
| | - Nan Zhang
- Intensive Care Unit, Affiliated Hospital of HeBei University, Baoding, Hebei, China
| | - Dan Su
- Intensive Care Unit, Affiliated Hospital of HeBei University, Baoding, Hebei, China
| | - Jia-Qian Wu
- Intensive Care Unit, Affiliated Hospital of HeBei University, Baoding, Hebei, China
| | - Xiu-Ming Xi
- Intensive Care Unit, Fu Xing Hospital, Capital Medical University, Beijing, China
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Paranjape VV, Henao-Guerrero N, Menciotti G, Saksena S. Performance of four cardiac output monitoring techniques vs. intermittent pulmonary artery thermodilution during a modified passive leg raise maneuver in isoflurane-anesthetized dogs. Front Vet Sci 2023; 10:1238549. [PMID: 37781276 PMCID: PMC10538972 DOI: 10.3389/fvets.2023.1238549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Objective This study investigated the performance among four cardiac output (CO) monitoring techniques in comparison with the reference method intermittent pulmonary artery thermodilution (iPATD) and their ability to diagnose fluid responsiveness (FR) during a modified passive leg raise (PLRM) maneuver in isoflurane-anesthetized dogs undergoing acute blood volume manipulations. The study also examined the simultaneous effect of performing the PLRM on dynamic variables such as stroke distance variation (SDV), peak velocity variation (PVV), and stroke volume variation (SVV). Study design Prospective, nonrandomized, crossover design. Study animals Six healthy male Beagle dogs. Methods The dogs were anesthetized with propofol and isoflurane and mechanically ventilated under neuromuscular blockade. After instrumentation, they underwent a series of sequential, nonrandomized steps: Step 1: baseline data collection; Step 2: removal of 33 mL kg-1 of circulating blood volume; Step 3: blood re-transfusion; and Step 4: infusion of 20 mL kg-1 colloid solution. Following a 10-min stabilization period after each step, CO measurements were recorded using esophageal Doppler (EDCO), transesophageal echocardiography (TEECO), arterial pressure waveform analysis (APWACO), and electrical cardiometry (ECCO). Additionally, SDV, PVV, and SVV were recorded. Intermittent pulmonary artery thermodilution (iPATDCO) measurements were also recorded before, during, and after the PLRM maneuver. A successful FR diagnosis made using a specific test indicated that CO increased by more than 15% during the PLRM maneuver. Statistical analysis was performed using one-way analysis of variance for repeated measures with post hoc Tukey test, linear regression, Lin's concordance correlation coefficient (ρc), and Bland-Altman analysis. Statistical significance was set at p < 0.05. Results All techniques detected a reduction in CO (p < 0.001) during hemorrhage and an increase in CO after blood re-transfusion and colloid infusion (p < 0.001) compared with baseline. During hemorrhage, CO increases with the PLRM maneuver were as follows: 33% for iPATD (p < 0.001), 19% for EC (p = 0.03), 7% for APWA (p = 0.97), 39% for TEE (p < 0.001), and 17% for ED (p = 0.02). Concurrently, decreases in SVV, SDV, and PVV values (p < 0.001) were also observed. The percentage error for TEE, ED, and EC was less than 30% but exceeded 55% for APWA. While TEECO and ECCO slightly underestimated iPATDCO values, EDCO and APWACO significantly overestimated iPATDCO values. TEE and EC exhibited good and acceptable agreement with iPATD. However, CO measurements using all four techniques and iPATD did not differ before, during, and after PLRM at baseline, blood re-transfusion, and colloid infusion. Conclusion and clinical relevance iPATD, EC, TEE, and ED effectively assessed FR in hypovolemic dogs during the PLRM maneuver, while the performance of APWA was unacceptable and not recommended. SVV, SDV, and PVV could be used to monitor CO changes during PLRM and acute blood volume manipulations, suggesting their potential clinical utility.
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Affiliation(s)
- Vaidehi V. Paranjape
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Natalia Henao-Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Giulio Menciotti
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Siddharth Saksena
- Department of Civil and Environmental Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
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Shields AD, Plante LA, Pacheco LD, Louis JM. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. Am J Obstet Gynecol 2023; 229:B2-B19. [PMID: 37236495 DOI: 10.1016/j.ajog.2023.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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Berger D, Werner Moller P, Bachmann KF. Cardiopulmonary interactions-which monitoring tools to use? Front Physiol 2023; 14:1234915. [PMID: 37621761 PMCID: PMC10445648 DOI: 10.3389/fphys.2023.1234915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/18/2023] [Indexed: 08/26/2023] Open
Abstract
Heart-lung interactions occur due to the mechanical influence of intrathoracic pressure and lung volume changes on cardiac and circulatory function. These interactions manifest as respiratory fluctuations in venous, pulmonary, and arterial pressures, potentially affecting stroke volume. In the context of functional hemodynamic monitoring, pulse or stroke volume variation (pulse pressure variation or stroke volume variability) are commonly employed to assess volume or preload responsiveness. However, correct interpretation of these parameters requires a comprehensive understanding of the physiological factors that determine pulse pressure and stroke volume. These factors include pleural pressure, venous return, pulmonary vessel function, lung mechanics, gas exchange, and specific cardiac factors. A comprehensive knowledge of heart-lung physiology is vital to avoid clinical misjudgments, particularly in cases of right ventricular (RV) failure or diastolic dysfunction. Therefore, when selecting monitoring devices or technologies, these factors must be considered. Invasive arterial pressure measurements of variations in breath-to-breath pressure swings are commonly used to monitor heart-lung interactions. Echocardiography or pulmonary artery catheters are valuable tools for differentiating preload responsiveness from right ventricular failure, while changes in diastolic function should be assessed alongside alterations in airway or pleural pressure, which can be approximated by esophageal pressure. In complex clinical scenarios like ARDS, combined forms of shock or right heart failure, additional information on gas exchange and pulmonary mechanics aids in the interpretation of heart-lung interactions. This review aims to describe monitoring techniques that provide clinicians with an integrative understanding of a patient's condition, enabling accurate assessment and patient care.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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Zhang Y, Ding Y, Zhang J, Huang T, Gao J. Tidal volume challenge-induced hemodynamic changes can predict fluid responsiveness during one-lung ventilation: an observational study. Front Med (Lausanne) 2023; 10:1169912. [PMID: 37636561 PMCID: PMC10447224 DOI: 10.3389/fmed.2023.1169912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Background To evaluate the ability of tidal volume challenge (VTC)-induced hemodynamic changes to predict fluid responsiveness in patients during one-lung ventilation (OLV). Methods 80 patients scheduled for elective thoracoscopic surgery with OLV were enrolled. The inclusion criteria were: age ≥ 18 years, American Society of Anesthesiologists physical status I-III, normal right ventricular function, normal left ventricular systolic function (ejection fraction ≥55%), and normal or slightly impaired diastolic function. The study protocol was implemented 15 min after starting OLV. Simultaneous recordings were performed for hemodynamic variables of diameter of left ventricular outflow tract, velocity time integral (VTI) of aortic valve, and stroke volume (SV), and ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC were calculated at four time points: with VT 5 mL/kg (T1); after VT increased from 5 mL/kg to 8 mL/kg and maintained at this level for 2 min (T2); after VT was adjusted back to 5 mL/kg for 2 min (T3); and after volume expansion (250 mL of 0.9% saline infused over 10-15 min) (T4). Patients were considered as responders to fluid administration if SV increased by ≥10%. Receiver operating characteristic (ROC) curves for percent decrease in SV, VTI, and MAP by VTC were generated to evaluate their ability to discriminate fluid responders from nonresponders. Results Of the 58 patients analyzed, there were 32 responders (55%) and 26 nonresponders (45%). The basic characteristics were comparable between the two groups (p > 0.05). The area under the curve (AUC) for ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC to discriminate responders from nonresponders were 0.81 (95% CI: 0.68-0.90), 0.79 (95% CI: 0.66-0.89), and 0.56 (95% CI: 0.42-0.69). The best threshold for ΔSV-VTC was -16.1% (sensitivity, 78.1%; specificity, 84.6%); the best threshold for ΔVTI-VTC was -14.5% (sensitivity, 78.1%; specificity, 80.8%). Conclusion Tidal volume challenge-induced relative change of stroke volume and velocity time integral can predict fluid responsiveness in patients during one-lung ventilation.Clinical Trial Registration: Chinese Clinical Trial Registry, No: chictr210051310.
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Affiliation(s)
| | | | | | | | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, China
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15
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Selvam V, Shende D, Anand RK, Kashyap L, Ray BR. End-expiratory Occlusion Test and Mini-fluid Challenge Test for Predicting Fluid Responsiveness in Acute Circulatory Failure. J Emerg Trauma Shock 2023; 16:109-115. [PMID: 38025504 PMCID: PMC10661572 DOI: 10.4103/jets.jets_44_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/05/2023] [Accepted: 06/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Predicting which patients with acute circulatory failure will respond to the fluid by an increase in cardiac output is a daily challenge. End-expiratory occlusion test (EEOT) and mini-fluid challenge (MFC) can be used for assessing fluid responsiveness in patients with spontaneous breathing activity, cardiac arrhythmias, low-tidal volume and/or low lung compliance. Methods The objective of the study is to evaluate the value of EEOT and MFC-induced rise in left ventricular outflow tract (LVOT) velocity time integral (VTI) in predicting fluid responsiveness in acute circulatory failure in comparison to the passive leg-raising (PLR) test. Hundred critically ill ventilated and sedated patients with acute circulatory failure were studied. LVOT VTI was measured by transthoracic echocardiography before and after EEOT (interrupting the ventilator at end-expiration over 15 s), and before and after MFC (100 ml of Ringer lactate was infused over 1 min). The variation of LVOT VTI after EEOT and the MFC was calculated from the baseline. Sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) curve of LVOT VTI after EEOT and MFC to predict fluid responsiveness were determined. Results After PLR, stroke volume (SV) increased by ≥12% in 49 patients, who were defined as responders and 34 patients in whom the increase in SV <12% were defined as nonresponders. A cutoff of 9.1% Change in VTI after MFC (ΔVTIMFC) predicted fluid responsiveness with an AUROC of 0.96 (P < 0.001) with sensitivity and specificity of 91.5% and 88.9%, respectively. Change in VTI after EEOT (ΔVTIEEOT) >4.3% predicted fluid responsiveness with sensitivity and specificity 89.4% and 88.9%, respectively, with an AUROC of 0.97 (P < 0.001), but in 17 patients, EEOT was not possible because triggering of the ventilator by the patient's inspiratory effort. Conclusion In conclusion, in mechanically ventilated patients with acute circulatory failure Δ VTIMFC and Δ VTI EEOT accurately predicts fluid responsiveness.
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Affiliation(s)
- Velmurugan Selvam
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
- Department of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Dilip Shende
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar Anand
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Lokesh Kashyap
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bikash Ranjan Ray
- Department of Anesthesia, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Giakoumidakis K, Patelarou A, Chatziefstratiou AA, Zografakis-Sfakianakis M, Fotos NV, Patelarou E. Development and Validation of the CVP Score: A Cross-Sectional Study in Greece. Healthcare (Basel) 2023; 11:healthcare11111543. [PMID: 37297683 DOI: 10.3390/healthcare11111543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Although central venous pressure (CVP) is among the most frequent estimated hemodynamic parameters in the critically ill setting, extremely little is known on how intensive care unit (ICU) nurses use this index in their decision-making process. The purpose of the study was to develop a new questionnaire for accessing how ICU nurses use CVP measurements to address patients' hemodynamics investigating its validity and reliability. A cross-sectional study was conducted among 120 ICU nurses from four ICUs of Greece. Based on a comprehensive literature review and the evaluation by a panel of five experts, a new questionnaire, named "CVP Score", was created, having eight items. The construct validity and the reliability of the questionnaire were examined. Half of the study participants (51.7%) worked at a specialized ICU, and they had a mean [±Standard Deviation (SD)] ICU experience of 13(±7.1) years. The estimated construct validity of the newly developed tool was acceptable, while the internal consistency reliability as measured by Cronbach alpha was excellent (0.901). CVP Score had acceptable test-retest reliability (r = 0.996, p < 0.001) and split-half reliability (0.855). The CVP score is a valid and reliable instrument for measuring how critical care nurses use CVP measurements in their decision-making process.
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Affiliation(s)
- Konstantinos Giakoumidakis
- Department of Nursing, School of Health Sciences, Hellenic Mediterranean University, 71410 Heraklion, Greece
| | - Athina Patelarou
- Department of Nursing, School of Health Sciences, Hellenic Mediterranean University, 71410 Heraklion, Greece
| | | | | | - Nikolaos V Fotos
- Department of Nursing, School of Health Sciences, National & Kapodistrian University of Athens, 15771 Athens, Greece
| | - Evridiki Patelarou
- Department of Nursing, School of Health Sciences, Hellenic Mediterranean University, 71410 Heraklion, Greece
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Horejsek J, Balík M, Kunstýř J, Michálek P, Brožek T, Kopecký P, Fink A, Waldauf P, Pořízka M. Prediction of Fluid Responsiveness Using Combined End-Expiratory and End-Inspiratory Occlusion Tests in Cardiac Surgical Patients. J Clin Med 2023; 12:jcm12072569. [PMID: 37048651 PMCID: PMC10094769 DOI: 10.3390/jcm12072569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
End-expiratory occlusion (EEO) and end-inspiratory occlusion (EIO) tests have been successfully used to predict fluid responsiveness in various settings using calibrated pulse contour analysis and echocardiography. The aim of this study was to test if respiratory occlusion tests predicted fluid responsiveness reliably in cardiac surgical patients with protective ventilation. This single-centre, prospective study, included 57 ventilated patients after elective coronary artery bypass grafting who were indicated for fluid expansion. Baseline echocardiographic measurements were obtained and patients with significant cardiac pathology were excluded. Cardiac index (CI), stroke volume and stroke volume variation were recorded using uncalibrated pulse contour analysis at baseline, after performing EEO and EIO tests and after volume expansion (7 mL/kg of succinylated gelatin). Fluid responsiveness was defined as an increase in cardiac index by 15%. Neither EEO, EIO nor their combination predicted fluid responsiveness reliably in our study. After a combined EEO and EIO, a cut-off point for CI change of 16.7% predicted fluid responsiveness with a sensitivity of 61.8%, specificity of 69.6% and ROC AUC of 0.593. In elective cardiac surgical patients with protective ventilation, respiratory occlusion tests failed to predict fluid responsiveness using uncalibrated pulse contour analysis.
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18
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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: 17] [Impact Index Per Article: 17.0] [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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19
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Elia J, Diwan M, Deshpande R, Brainard JC, Karamchandani K. Perioperative Fluid Management and Volume Assessment. Anesthesiol Clin 2023; 41:191-209. [PMID: 36871999 DOI: 10.1016/j.anclin.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Fluid therapy is an integral component of perioperative care and helps maintain or restore effective circulating blood volume. The principal goal of fluid management is to optimize cardiac preload, maximize stroke volume, and maintain adequate organ perfusion. Accurate assessment of volume status and volume responsiveness is necessary for appropriate and judicious utilization of fluid therapy. To accomplish this, static and dynamic indicators of fluid responsiveness have been widely studied. This review discusses the overarching goals of perioperative fluid management, reviews the physiology and parameters used to assess fluid responsiveness, and provides evidence-based recommendations on intraoperative fluid management.
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Affiliation(s)
- Jennifer Elia
- Department of Anesthesiology, University of California, Irvine School of Medicine, 101 The City Drive South, Building 53-225, Orange, CA 92868, USA.
| | - Murtaza Diwan
- Department of Anesthesiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine, 333Cedars Street, TMP 3, New Haven, CT 06510, USA
| | - Jason C Brainard
- Department of Anesthesiology, University of Colorado, University of Colorado Hospital, 12401 East 17th Avenue, Mail Stop B113, Aurora, CO 80045, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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20
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Carsetti A, Vitali E, Pesaresi L, Antolini R, Casarotta E, Damiani E, Adrario E, Donati A. Anesthetic management of patients with sepsis/septic shock. Front Med (Lausanne) 2023; 10:1150124. [PMID: 37035341 PMCID: PMC10076637 DOI: 10.3389/fmed.2023.1150124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, while septic shock is a subset of sepsis with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg and having a serum lactate level of >2 mmol/L, despite adequate volume resuscitation. Sepsis and septic shock are medical emergencies and time-dependent diseases with a high mortality rate for which early identification, early antibiotic therapy, and early source control are paramount for patient outcomes. The patient may require surgical intervention or an invasive procedure aiming to control the source of infection, and the anesthesiologist has a pivotal role in all phases of patient management. During the preoperative assessment, patients should be aware of all possible organ dysfunctions, and the severity of the disease combined with the patient's physiological reserve should be carefully assessed. All possible efforts should be made to optimize conditions before surgery, especially from a hemodynamic point of view. Anesthetic agents may worsen the hemodynamics of shock patients, and the anesthesiologist must know the properties of each anesthetic agent. All possible efforts should be made to maintain organ perfusion supporting hemodynamics with fluids, vasoactive agents, and inotropes if required.
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Affiliation(s)
- Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- *Correspondence: Andrea Carsetti
| | - Eva Vitali
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia Pesaresi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Riccardo Antolini
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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Messina A, Calabrò L, Pugliese L, Lulja A, Sopuch A, Rosalba D, Morenghi E, Hernandez G, Monnet X, Cecconi M. Fluid challenge in critically ill patients receiving haemodynamic monitoring: a systematic review and comparison of two decades. Crit Care 2022; 26:186. [PMID: 35729632 PMCID: PMC9210670 DOI: 10.1186/s13054-022-04056-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000–2010 and 2011–2021.
Methods
We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold.
Results
We included 124 studies, 32 (25.8%) published in 2000–2010 and 92 (74.2%) in 2011–2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011–2021 compared to the 2000–2010 period.
Conclusions
In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000–2010 decade, in 2011–2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.
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22
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De Backer D, Aissaoui N, Cecconi M, Chew MS, Denault A, Hajjar L, Hernandez G, Messina A, Myatra SN, Ostermann M, Pinsky MR, Teboul JL, Vignon P, Vincent JL, Monnet X. How can assessing hemodynamics help to assess volume status? Intensive Care Med 2022; 48:1482-1494. [PMID: 35945344 PMCID: PMC9363272 DOI: 10.1007/s00134-022-06808-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023]
Abstract
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Nadia Aissaoui
- Assistance publique des hôpitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, médecine interne reanimation, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, 25 rue Leblanc, 75015, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Ludhmila Hajjar
- Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, Pichamuthu K, Jog SA, Divatia JV, Myatra SN. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022; 26:S66-S76. [PMID: 36896359 PMCID: PMC9989872 DOI: 10.5005/jp-journals-10071-24301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
| | | | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sameer Arvind Jog
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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24
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Hamzaoui O, Teboul JL. Central venous pressure (CVP). Intensive Care Med 2022; 48:1498-1500. [PMID: 35953675 DOI: 10.1007/s00134-022-06835-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Olfa Hamzaoui
- Service de Réanimation Polyvalente, Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, 157, Rue de la Porte de Trivaux, 92141, Clamart, France.
| | - Jean-Louis Teboul
- Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Le Kremlin-Bicêtre, France.,INSERM-UMR_S999 LabEx-LERMIT, Hôpital Marie-Lannelongue, 92350, Le Plessis Robinson, France
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25
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Nakano H, Hashimoto H, Mochizuki M, Naraba H, Takahashi Y, Sonoo T, Nakamura K. Evaluation of Intravascular Volume Using the Internal Jugular Vein Cardiac Collapse Index in the Emergency Department: A Preliminary Prospective Observational Study. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1169-1178. [PMID: 35370023 DOI: 10.1016/j.ultrasmedbio.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 01/17/2022] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
A non-invasive method for assessment of intravascular volume for optimal fluid administration is needed. We here conducted a preliminary study to confirm whether cardiac variation in the internal jugular vein (IJV), evaluated by ultrasound, predicts fluid responsiveness in patients in the emergency department. Patients who presented to the emergency department between August 2019 and March 2020 and required infusions were enrolled. We recorded a short-axis video of the IJV, respiratory variability in the inferior vena cava and stroke volume variations using the ClearSight System (Edwards Lifesciences, Irvine, CA, USA) before infusion of 500 mL of crystalloid fluid. Cardiac variations in the cross-sectional area of the IJV were measured by speckle tracking. Among the 148 patients enrolled, 105 were included in the final analysis. Fluid responsiveness did not correlate with the cardiac collapse index (13.6% vs. 16.8%, p = 0.24), but correlated with stroke volume variations (12.5% vs. 15.6%, p = 0.026). Although it is a simple correction, the cardiac collapse index correlated with stroke volume corrected by age (r = 0.25, p = 0.01), body surface area (r = 0.33, p = 0.002) and both (r = 0.35, p = 0.001). Cardiac variations in the IJV did not predict fluid responsiveness in the emergency department, but may reflect stroke volume.
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Affiliation(s)
- Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan.
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
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26
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Baba M, Alsbrook D, Williamson S, Soman S, Ramadan AR. Approach to the Management of Sodium Disorders in the Neuro Critical Care Unit. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Cartotto R, Burmeister DM, Kubasiak JC. Burn Shock and Resuscitation: Review and State of the Science. J Burn Care Res 2022; 43:irac025. [PMID: 35218662 DOI: 10.1093/jbcr/irac025] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 12/31/2022]
Abstract
Burn shock and acute fluid resuscitation continue to spark intense interest and debate among burn clinicians. Following a major burn injury, fluid resuscitation of burn shock is life-saving, but paradoxically can also be a source of increased morbidity and mortality because of the unintended consequence of systemic edema formation. Considerable research over the past two decades has been devoted to understanding the mechanisms of edema formation, and to develop strategies to curb resuscitation fluids and limit edema development. Recognition of burn endotheliopathy - injury to the endothelium's glycocalyx layer- is one of the most important recent developments in our understanding of burn shock pathophysiology. Newer monitoring approaches and resuscitation endpoints, along with alternative resuscitation strategies to crystalloids alone, such as administration of albumin, or plasma, or high dose ascorbic acid, have had mixed results in limiting fluid creep. Clear demonstration of improvements in outcomes with all of these approaches remains elusive. This comprehensive review article on burn shock and acute resuscitation accompanies the American Burn Association's State of the Science meeting held in New Orleans, LA on November 2-3, 2021 and the Proceedings of that conference published in this journal.
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Affiliation(s)
- Robert Cartotto
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Canada
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland and United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas USA
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Kim SJ, Kim SY, Lee HS, Park G, Yoon EJ, Heo S, Koo BN. Ability of dynamic preload indices to predict fluid responsiveness in a high femoral-to-radial arterial pressure gradient: a retrospective study. Anesth Pain Med (Seoul) 2022; 16:360-367. [PMID: 35139617 PMCID: PMC8828628 DOI: 10.17085/apm.21001] [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: 12/31/2020] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Dynamic preload indices may predict fluid responsiveness in end-stage liver disease. However, their usefulness in patients with altered vascular compliance is uncertain. This study is the first to evaluate whether dynamic indices can reliably predict fluid responsiveness in patients undergoing liver transplantation with a high femoral-to-radial arterial pressure gradient (PG). Methods Eighty liver transplant recipients were retrospectively categorized as having a normal (n = 56) or high (n = 24, difference in systolic pressure ≥ 10 mmHg and/or mean pressure ≥ 5 mmHg) femoral-to-radial arterial PG, measured immediately after radial and femoral arterial cannulation. The ability of dynamic preload indices (stroke volume variation, pulse pressure variation [PPV], pleth variability index) to predict fluid responsiveness was assessed before the surgery. Fluid replacement of 500 ml of crystalloid solution was performed over 15 min. Fluid responsiveness was defined as ≥ 15% increase in the stroke volume index. The area under the receiver-operating characteristic curve (AUC) indicated the prediction of fluid responsiveness. Results Fourteen patients in the normal, and eight in the high PG group were fluid responders. The AUCs for PPV in the normal, high PG groups and total patients were 0.702 (95% confidence interval [CI] 0.553–0.851, P = 0.008), 0.633 (95% CI 0.384–0.881, P = 0.295) and 0.667 (95% CI 0.537–0.798, P = 0.012), respectively. No other index predicted fluid responsiveness. Conclusion PPV can be used as a dynamic index of fluid responsiveness in patients with end-stage liver disease but not in patients with altered vascular compliance.
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Affiliation(s)
- Seon Ju Kim
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Goeun Park
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jang Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sungtaik Heo
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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29
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Selvam V, Srinivasan S. Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation. Indian J Crit Care Med 2022; 26:159-160. [PMID: 35712735 PMCID: PMC8857725 DOI: 10.5005/jp-journals-10071-24108] [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
Selvam V, Srinivasan S. Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation. Indian J Crit Care Med 2022;26(2):159-160.
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Affiliation(s)
- Velmurugan Selvam
- Department of Critical Care, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
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30
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Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022; 26:179-184. [PMID: 35712738 PMCID: PMC8857717 DOI: 10.5005/jp-journals-10071-24115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Fluid boluses are used in hemodynamically unstable patients with presumed hypovolemia, to improve tissue perfusion, in the perioperative period. Now less invasive methods, such as pulse pressure variation (PPV) and stroke volume variation (SVV) are increasingly being used. We investigated correlation between carotid and brachial artery velocity time integral (VTI) and compared both with PPV and SVV. Methods We recruited 27 patients undergoing supra-major abdominal surgeries. When indicated (hypotension or increased lactate), a fluid bolus was given after measuring carotid and brachial artery VTI, PPV, and SVV. The change in SV was noted and patients were categorized as responders if the SV increased by >15%. We performed Bland Altman Agreement and calculated best sensitivity and specificity for the parameters. Results Patients were found to be fluid responders on 29 instances. The correlation between PPV, SVV, carotid and brachial artery VTI was poor and the limits of agreement between them were wide. The Area under Curve (AUC) for PPV was 0.69, for SVV was 0.63, while those of Carotid and Brachial artery VTI (TAP and flow) were (0.53 and 0.54 for carotid) and (0.51 and 0.56 for brachial) respectively. Conclusion We found poor agreement and weak correlation between both VTi (TAP and flow) measured at carotid and brachial arteries, suggesting that the readings at brachial vessel cannot be used interchangeably with those at carotid artery. The PPV and SVV were better than these parameters for predicting fluid responsiveness; however, their predictive ability (AUROC), sensitivity and specificity were much lower than previously reported. Further studies in this area are therefore required (CTRI Reg No: CTRI/2017/08/009243). How to cite this article Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022;26(2):179–184.
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Affiliation(s)
- Malini Joshi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Praveen Dhakane
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shilpushp J Bhosale
- Department of Critical Care Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rutuja Phulambrikar
- Department of Community Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Atul P Kulkarni, Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
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31
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Anand R, Chowdhury S, Baidya D, Maitra S, Singh A, Rewari V. Assessment of role of inferior vena cava collapsibility index and variations in carotid artery peak systolic velocity in prediction of post-spinal anaesthesia hypotension in spontaneously breathing patients: An observational study. Indian J Anaesth 2022; 66:100-106. [PMID: 35359469 PMCID: PMC8963237 DOI: 10.4103/ija.ija_828_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/11/2021] [Accepted: 02/06/2022] [Indexed: 11/04/2022] Open
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Bandyopadhyay D, Lai C, Pulido JN, Restrepo-Jaramillo R, Tonelli AR, Humbert M. Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery. Eur Respir Rev 2021; 30:30/162/210166. [PMID: 34937705 DOI: 10.1183/16000617.0166-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/12/2021] [Indexed: 01/02/2023] Open
Abstract
Pulmonary hypertension (PH) confers a significant challenge in perioperative care. It is associated with substantial morbidity and mortality. A considerable amount of information about management of patients with PH has emerged over the past decade. However, there is still a paucity of information to guide perioperative evaluation and management of these patients. Yet, a satisfactory outcome is feasible by focusing on elaborate disease-adapted anaesthetic management of this complex disease with a multidisciplinary approach. The cornerstone of the peri-anaesthetic management of patients with PH is preservation of right ventricular (RV) function with attention on maintaining RV preload, contractility and limiting increase in RV afterload at each stage of the patient's perioperative care. Pre-anaesthetic evaluation, choice of anaesthetic agents, proper fluid management, appropriate ventilation, correction of hypoxia, hypercarbia, acid-base balance and pain control are paramount in this regard. Essentially, the perioperative management of PH patients is intricate and multifaceted. Unfortunately, a comprehensive evidence-based guideline is lacking to navigate us through this complex process. We conducted a literature review on patients with PH with a focus on the perioperative evaluation and suggest management algorithms for these patients during non-cardiac, non-obstetric surgery.
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Affiliation(s)
- Debabrata Bandyopadhyay
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Christopher Lai
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Juan N Pulido
- Dept of Anesthesiology and Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA and US Anesthesia Partners - Washington, Seattle, WA, USA
| | - Ricardo Restrepo-Jaramillo
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Adriano R Tonelli
- Dept of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Marc Humbert
- Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Pace R, Lassola S, Miori S, Cammarota G, Barbariol F, Vetrugno L. Carotid vs aortic velocity time integral and peak velocity to predict fluid responsiveness in mechanically ventilated patients. A comparative study. Minerva Anestesiol 2021; 88:352-360. [PMID: 34761663 DOI: 10.23736/s0375-9393.21.16035-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The carotid artery velocity-time integral (CVTI) and the carotid Doppler peak velocity (cDPV), as well as measures of their variation induced by the respiratory cycle, have been proposed as fast and easy to obtain ultrasound measures for assessing fluid responsiveness in intensive care unit patients. To investigate this possibility, we conducted a prospective observational study in hemodynamically unstable patients under mechanical ventilation. METHODS From May 1 to December 31, 2019, we conducted a prospective observational study involving 50 hemodynamically unstable patients under mechanical ventilation. We obtained a total of 800 Doppler ultrasound measurements from the left common carotid artery and at the level of the aortic annulus in the apical five-chamber view. The two measurements were performed before and after a 7 mL/kg fluid challenge and within the first hour of the onset of hemodynamic instability. The maximum Doppler peak velocity, the minimum Doppler peak velocity, and the maximum and minimum VTI at both the aortic and carotid level were acquired. RESULTS Twenty-eight (56%) patients showed a ≥15% increase in AoVTI after the fluid challenge, and were therefore identified as "fluid responders". All Doppler measurements were always significantly greater (p <0.0001) in fluid responders in relation to both carotid and aortic parameters. Good agreement between the above-mentioned measurements was found: Cohen's kappa coefficient between the carotid and aortic ΔDPV was 0.76 (95% CI 0.58 - 0.94); and between the Carotid and Aortic ΔVTI it was 0.84 (95% CI 0.68 - 0.99). CONCLUSIONS CDPV was found to predict fluid responsiveness in unstable mechanically ventilated patients.
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Affiliation(s)
- Rocco Pace
- Intensive Care Unit, Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS, Trento, Italy -
| | - Sergio Lassola
- Intensive Care Unit, Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS, Trento, Italy
| | - Sara Miori
- Intensive Care Unit, Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS, Trento, Italy
| | | | | | - Luigi Vetrugno
- University-Hospital of Udine, ASFC, Udine, Italy.,Department of Medicine, University of Udine, Udine, Italy
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Courbe A, Perrault-Hébert C, Ion I, Desjardins G, Fortier A, Denault A, Deschamps A, Couture P. Should we use diastolic function parameters to determine preload responsiveness in cardiac surgery? A pilot study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2021; 1:12. [PMID: 37386580 DOI: 10.1186/s44158-021-00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 07/01/2023]
Abstract
BACKGROUND Left ventricular (LV) diastolic function (DF) may play an important role in predicting fluid responsiveness. However, few studies assessed the role of diastolic function in predicting fluid responsiveness. The aim of this pilot study was to assess whether parameters of right and left diastolic function assessed with transesophageal echocardiography, including the mitral E/e' ratio, is associated with fluid responsiveness among patients undergoing elective bypass graft surgery. We also sought to compare other methods of fluid responsiveness assessment, including echocardiographic and hemodynamic parameters, pulse pressure variation, and stroke volume variation (SVV) (arterial pulse contour analysis, Flotrac/Vigileo system). RESULTS We prospectively studied seventy patients undergoing coronary artery bypass grafting (CABG) monitored with a radial arterial catheter, transesophageal echocardiography (TEE), and a pulmonary artery catheter (for cardiac output measurements), before and after the administration of 500 mL of crystalloid over 10 min after the anesthetic induction. Thirteen patients were excluded (total of 57 patients). Fluid responsiveness was defined as an increase in cardiac index of ≥ 15%. There were 21 responders (36.8%) and 36 non-responders (63.2%). No difference in baseline pulsed wave Doppler echocardiographic measurements of any components of the mitral, tricuspid, and pulmonary and hepatic venous flows were found between responders and non-responders. There was no difference in MV tissue Doppler measurements between responders and non-responders, including E/e' ratio (8.7 ± 4.1 vs. 8.5 ± 2.8 in responders vs. non-responders, P = 0.85). SVV was the only independent variable to predict an increase in cardiac index by multivariate analysis (P = 0.0208, OR = 1.196, 95% CI (1.028-1.393)). CONCLUSIONS In this pilot study, we found that no parameters of right and left ventricular diastolic function were associated with fluid responsiveness in patients undergoing CABG. SVV was the most useful parameter to predict fluid responsiveness. TRIAL REGISTRATION ClinicalTrials.gov , NCT02714244 . Registered 21 March 2016-retrospectively registered.
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Affiliation(s)
- Athanase Courbe
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Clotilde Perrault-Hébert
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Iolanda Ion
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Annik Fortier
- Department of Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T 1C8, Canada.
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Orhon Ergun M, Zengin SU, Umuroglu T. Goal-Directed Fluid Management Using Plethysmographic Variability Index in Patients Undergoing Laparoscopic Bariatric Surgery. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2021.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Meliha Orhon Ergun
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Seniyye Ulgen Zengin
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Tumay Umuroglu
- Department of Anesthesiology and Reanimation, Pendik Research and Training Hospital, Marmara University Medical Faculty, Istanbul, Turkey
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Ravi C, Johnson DW. Optimizing Fluid Resuscitation and Preventing Fluid Overload in Patients with Septic Shock. Semin Respir Crit Care Med 2021; 42:698-705. [PMID: 34544187 DOI: 10.1055/s-0041-1733898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravenous fluid administration remains an important component in the care of patients with septic shock. A common error in the treatment of septic shock is the use of excessive fluid in an effort to overcome both hypovolemia and vasoplegia. While fluids are necessary to help correct the intravascular depletion, vasopressors should be concomitantly administered to address vasoplegia. Excessive fluid administration is associated with worse outcomes in septic shock, so great care should be taken when deciding how much fluid to give these vulnerable patients. Simple or strict "recipes" which mandate an exact amount of fluid to administer, even when weight based, are not associated with better outcomes and therefore should be avoided. Determining the correct amount of fluid requires the clinician to repeatedly assess and consider multiple variables, including the fluid deficit, organ dysfunction, tolerance of additional fluid, and overall trajectory of the shock state. Dynamic indices, often involving the interaction between the cardiovascular and respiratory systems, appear to be superior to traditional static indices such as central venous pressure for assessing fluid responsiveness. Point-of-care ultrasound offers the bedside clinician a multitude of applications which are useful in determining fluid administration in septic shock. In summary, prevention of fluid overload in septic shock patients is extremely important, and requires the careful attention of the entire critical care team.
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Affiliation(s)
- Chandni Ravi
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Daniel W Johnson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Hua Z, Xin D, Xiaoting W, Dawei L. High Central Venous Pressure and Right Ventricle Size Are Related to Non-decreased Left Ventricle Stroke Volume After Negative Fluid Balance in Critically Ill Patients: A Single Prospective Observational Study. Front Med (Lausanne) 2021; 8:715099. [PMID: 34532330 PMCID: PMC8438320 DOI: 10.3389/fmed.2021.715099] [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: 05/26/2021] [Accepted: 07/29/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Optimal adjustment of cardiac preload is essential for improving left ventricle stroke volume (LVSV) and tissue perfusion. Changes in LVSV caused by central venous pressure (CVP) are the most important concerns in the treatment of critically ill patients. Objectives: This study aimed to clarify the changes in LVSV after negative fluid balance in patients with elevated CVP, and to elucidate the relationship between the parameters of right ventricle (RV) filling state and LVSV changes. Methods: This prospective cohort study included patients with high central venous pressure (CVP) (≥8 mmHg) within 24 h of ICU admission in the Critical Medicine Department of Peking Union Medical College Hospital. Patients were classified into two groups based on the LVSV changes after negative fluid balance. The cutoff value was 10%. The hemodynamic and echo parameters of the two groups were recorded at baseline and after negative fluid balance. Results: A total of 71 patients included in this study. Forty in VI Group (LVOT VTI increased ≥10%) and 31 in VNI Group (LVOT VTI increased <10%). Of all patients, 56.3% showed increased LVSV after negative fluid balance. In terms of hemodynamic parameters at T0, patients in VI Group had a higher CVP (p < 0.001) and P(v-a)CO2 (p < 0.001) and lower ScVO2 (p < 0.001) relative to VNI Group, regarding the echo parameters at T0, the RVD/LVD ratio (p < 0.001), DIVC end-expiratory (p < 0.001), and ΔLVOT VTI (p < 0.001) were higher, while T0 LVOT VTI (p < 0.001) was lower, in VI Group patients. The multifactor logistic regression analysis suggested that a high CVP and RVD/LVD ratio ≥0.6 were significant associated with LVSV increase after negative fluid balance in critically patients. The AUC of CVP was 0.894. A CVP >10.5 mmHg provided a sensitivity of 87.5% and a specificity of 77.4%. The AUC of CVP combined with the RVD/LVD ratio ≥0.6 was 0.926, which provided a sensitivity of 92.6% and a specificity of 80.4%. Conclusion: High CVP and RVD/LVD ratio ≥0.6 were significant associated with RV stressed in critically patients. Negative fluid balance will not always lead to a decrease, even an increase, in LVSV in these patients.
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Affiliation(s)
- Zhao Hua
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ding Xin
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wang Xiaoting
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liu Dawei
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Ability of short-time low peep challenge to predict fluid responsiveness in mechanically ventilated patients in the intensive care. J Clin Monit Comput 2021; 36:1165-1172. [PMID: 34476670 PMCID: PMC8412862 DOI: 10.1007/s10877-021-00752-7] [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: 02/23/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022]
Abstract
Short-time low PEEP challenge (SLPC, application of additional 5 cmH2O PEEP to patients for 30 s) is a novel functional hemodynamic test presented in the literature. We hypothesized that SLPC could predict fluid responsiveness better than stroke volume variation (SVV) in mechanically ventilated intensive care patients. Heart rate, mean arterial pressure, stroke volume index (SVI) and SVV were recorded before SLPC, during SLPC and before and after 500 mL fluid loading. Patients whose SVI increased more than 15% after the fluid loading were defined as fluid responders. Reciever operating characteristics (ROC) curves were generated to evaluate the abilities of the methods to predict fluid responsiveness. Fifty-five patients completed the study. Twenty-five (46%) of them were responders. Decrease percentage in SVI during SLPC (SVIΔ%–SLPC) was 11.6 ± 5.2% and 4.3 ± 2.2% in responders and non-responders, respectively (p < 0.001). A good correlation was found between SVIΔ%–SLPC and percentage change in SVI after fluid loading (r = 0.728, P < 0.001). Areas under the ROC curves (ROC–AUC) of SVIΔ%–SLPC and SVV were 0.951 (95% CI 0.857–0.991) and 0.747 (95% CI 0.611–0.854), respectively. The ROC–AUC of SVIΔ%–SLPC was significantly higher than that of SVV (p = 0.0045). The best cut-off value of SVIΔ%–SLPC was 7.5% with 90% sensitivity and 96% specificity. The percentage change in SVI during SLPC predicts fluid responsiveness in intensive care patients who are ventilated with low tidal volumes; the sensitivity and specificity values are higher than those of SVV.
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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Marx G, Zacharowski K, Ichai C, Asehnoune K, Černý V, Dembinski R, Ferrer Roca R, Fries D, Molnar Z, Rosenberger P, Sanchez-Sanchez M, Schürholz T, Dehnhardt T, Schmier S, von Kleist E, Brauer U, Simon TP. Efficacy and safety of early target-controlled plasma volume replacement with a balanced gelatine solution versus a balanced electrolyte solution in patients with severe sepsis/septic shock: study protocol, design, and rationale of a prospective, randomized, controlled, double-blind, multicentric, international clinical trial : GENIUS-Gelatine use in ICU and sepsis. Trials 2021; 22:376. [PMID: 34078421 PMCID: PMC8170449 DOI: 10.1186/s13063-021-05311-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sepsis is associated with capillary leakage and vasodilatation and leads to hypotension and tissue hypoperfusion. Early plasma volume replacement is required to achieve haemodynamic stability (HDS) and maintain adequate tissue oxygenation. The right choice of fluids to be used for plasma volume replacement (colloid or crystalloid solutions) is still a matter of debate, and large trials investigating the use of colloid solutions containing gelatine are missing. This study aims to investigate the efficacy and safety of plasma volume replacement using either a combined gelatine-crystalloid regime (1:1 ratio) or a pure crystalloid regime. METHODS This is a prospective, controlled, randomized, double-blind, international, multicentric phase IV study with two parallel groups that is planned to be conducted at European intensive care units (ICUs) in a population of patients with hypovolaemia in severe sepsis/septic shock. A total of 608 eligible patients will be randomly assigned to receive either a gelatine-crystalloid regime (Gelaspan® 4% and Sterofundin® ISO, B. Braun Melsungen AG, in a 1:1 ratio) or a pure crystalloid regime (Sterofundin® ISO) for plasma volume replacement. The primary outcome is defined as the time needed to achieve HDS. Plasma volume replacement will be target-controlled, i.e. fluids will only be administered to volume-responsive patients. Volume responsiveness will be assessed through passive leg raising or fluid challenges. The safety and efficacy of both regimens will be assessed daily for 28 days or until ICU discharge (whichever occurs first) as the secondary outcomes of this study. Follow-up visits/calls will be scheduled on day 28 and day 90. DISCUSSION This study aims to generate evidence regarding which regimen-a gelatine-crystalloid regimen or a pure crystalloid regimen-is more effective in achieving HDS in critically ill patients with hypovolaemia. Study participants in both groups will benefit from the increased safety of target-controlled plasma volume replacement, which prevents fluid administration to already haemodynamically stable patients and reduces the risk of harmful fluid overload. TRIAL REGISTRATION The European clinical trial database EudraCT 2015-000057-20 and the ClinicalTrials.gov Protocol Registration and Results System ClinicalTrials.gov NCT02715466 . Registered on 17 March 2016.
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Affiliation(s)
- Gernot Marx
- Klinik für Operative Intensivmedizin und Intermediate Care, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Kai Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt/Main, Goethe Universität, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Carole Ichai
- Université Côte d'Azur Service de Réanimation Polyvalente, Hôpital Pasteur 2 - CHU de Nice, 30 Voie Romaine, 06000, Nice, France
| | - Karim Asehnoune
- Université de Nantes, CHU - L'Hôtel Dieu, 1, Place Alexis Ricordeau, 44093, Nantes Cedex 1, France
| | - Vladimír Černý
- Krajská zdravotní, a.s., Masarykova nemocnice v Ústí nad Labem, o.z., Sociální péče 3316/12A, 401 13, Ústí nad Labem, Czech Republic
| | - Rolf Dembinski
- Klinik für Intensivmedizin und Notfallmedizin, Klinikum Bremen-Mitte, St. Jürgen-Straße 1, 28177, Bremen, Germany
| | - Ricard Ferrer Roca
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Dietmar Fries
- Allgemeine und Chirurgische Intensivstation, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Zsolt Molnar
- School of Medicine, Institute for Translational Medicine, University of Pécs, 12 Szigeti St, Pécs, 7624, Hungary.,Faculty of Medicine, Department of Anaesthesiology and Intensive Therapy, Poznan University for Medical Sciences, 49 Przybyszewskiego St, 60-355, Poznan, Poland
| | - Peter Rosenberger
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Manuel Sanchez-Sanchez
- Hospital Universitario La Paz, Cantoblanco-Carlos III/Hospital La Paz Institute for Health Research (IdiPAZ), Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Tobias Schürholz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Tamara Dehnhardt
- Medical Scientific Affairs, B. Braun Melsungen AG, Carl-Braun-Straße 1, 34212, Melsungen, Germany
| | - Sonja Schmier
- Medical Scientific Affairs, B. Braun Melsungen AG, Carl-Braun-Straße 1, 34212, Melsungen, Germany
| | - Elke von Kleist
- Medical Scientific Affairs, B. Braun Melsungen AG, Carl-Braun-Straße 1, 34212, Melsungen, Germany
| | - Ute Brauer
- Medical Scientific Affairs, B. Braun Melsungen AG, Carl-Braun-Straße 1, 34212, Melsungen, Germany
| | - Tim-Philipp Simon
- Klinik für Operative Intensivmedizin und Intermediate Care, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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Kim HB, Soh S, Song JW, Kim MY, Kwak YL, Shim JK. Combination of Static Echocardiographic Indices for the Prediction of Fluid Responsiveness in Patients Undergoing Coronary Surgery: A Pilot Study. J Clin Med 2021; 10:jcm10091886. [PMID: 33925449 PMCID: PMC8123780 DOI: 10.3390/jcm10091886] [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: 01/26/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
We investigated the role of echocardiographic indices consisting of left ventricular end-diastolic area (LVEDA) in combination with Doppler-derived surrogates of diastolic compliance and filling (E/E′, E′/S′, E′/A′; early transmitral flow velocity (E), tissue Doppler-derived early (E′) diastolic, late (A′) diastolic, or peak systolic (S′) velocity of the mitral annulus) in predicting fluid responsiveness in off-pump coronary surgery. Hemodynamic and echocardiographic variables were prospectively assessed under general anesthesia before and after a fluid challenge of 6 mL/kg during apnea at atmospheric pressure in 64 patients with LV ejection fraction ≥40%. Forty patients (63%) were fluid responders (≥15% increase in stroke volume index). E/E′ and E′/S′ could predict fluid responsiveness with area under the receiver operating characteristic curve (AUROC) of 0.71 (95% confidence interval [CI], 0.56–0.85; p = 0.006) and 0.68 (95% CI, 0.54–0.82; p = 0.017), respectively. The combination of LVEDA and E/E′ showed incremental predictive ability for fluid responsiveness compared with LVEDA (AUROC, 0.60; p = 0.170) or pulse pressure variation (AUROC, 0.70; p = 0.002), yielding the highest AUROC of 0.78 (95% CI, 0.66–0.90; p < 0.001). The combined index of echocardiographic variables reflecting LV dimension (LVEDA) and diastolic compliance and filling (E/E′) is a potentially useful predictor of fluid responsiveness.
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Affiliation(s)
| | | | | | | | | | - Jae-Kwang Shim
- Correspondence: ; Tel.: +82-2-2228-8500; Fax: +82-2-364-2951
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Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med 2021; 78:1-19. [PMID: 33840511 DOI: 10.1016/j.annemergmed.2021.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/12/2022]
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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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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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[Comments on the updated German S3 guidelines on intravascular volume therapy in adults]. Anaesthesist 2021; 70:413-419. [PMID: 33646330 DOI: 10.1007/s00101-021-00929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
The German S3 guidelines on intravascular volume therapy in adults were updated in September 2020. Based on updated evidence recommendations for the diagnosis of isotonic dehydration and for fluid therapy with crystalloids and colloids in peri-interventional and intensive care medicine were proposed.
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Broyles MG, Subramanyam S, Barker AB, Tolwani AJ. Fluid Responsiveness in the Critically Ill Patient. Adv Chronic Kidney Dis 2021; 28:20-28. [PMID: 34389133 DOI: 10.1053/j.ackd.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/04/2021] [Accepted: 06/13/2021] [Indexed: 12/19/2022]
Abstract
Accurate assessment of intravascular volume status in critically ill patients remains a very challenging task. Recent data have shown adverse outcomes in critically ill patients with either inadequate or overaggressive fluid therapy. Understanding the tools and techniques available for accurate volume assessment is imperative. This article discusses the concept of fluid responsiveness and reviews methods for assessing fluid responsiveness in critically ill patients.
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Henríquez-Camacho C, Miralles-Aguiar F, Bernabeu-Wittel M. Emerging applications of clinical ultrasonography. Rev Clin Esp 2021; 221:45-54. [PMID: 32654759 DOI: 10.1016/j.rce.2020.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 11/26/2022]
Abstract
In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).
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Affiliation(s)
- C Henríquez-Camacho
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, Españan
| | - F Miralles-Aguiar
- Unidad Clínica de Anestesiología y Reanimación, Hospital Universitario Puerta del Mar, Cádiz, España
| | - M Bernabeu-Wittel
- Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Henríquez-Camacho C, Miralles-Aguiar F, Bernabeu-Wittel M. Emerging applications of clinical ultrasonography. Rev Clin Esp 2020; 221:45-54. [PMID: 33998478 DOI: 10.1016/j.rceng.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 10/22/2022]
Abstract
In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).
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Affiliation(s)
- C Henríquez-Camacho
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, Spain
| | - F Miralles-Aguiar
- Unidad Clínica de Anestesiología y Reanimación, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - M Bernabeu-Wittel
- Unidad Clínica de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
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Judson PI, Abhilash KPP, Pichamuthu K, Chandy GM. Evaluation of Carotid Flow Time to Assess Fluid Responsiveness in the Emergency Department. J Med Ultrasound 2020; 29:99-104. [PMID: 34377640 PMCID: PMC8330669 DOI: 10.4103/jmu.jmu_77_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/19/2020] [Accepted: 08/07/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Assessing fluid responsiveness in critically ill patients is challenging. Objective, noninvasive tests that are easy to perform are needed. Doppler measurements of dynamic carotid artery parameters such as carotid blood flow (CBF) and carotid flow time (CFT) are being studied as the potential indicators of volume responsiveness, but the data supporting its use are sparse. Methods: This prospective, observational study was conducted in the adult emergency department from June to September 2018. Patients who were prescribed a bolus of 500 ml of crystalloid for any indication were enrolled. Carotid Doppler was performed before and after a fluid bolus to measure the change in CBF and CFT. The aim of our study was to determine if CFT can be used as a marker of fluid responsiveness. Results: During the 4-month study period, 209 patients were recruited through convenient sampling after obtaining informed written consent. 29.6% of patients presented with a mean arterial pressure (MAP) <65, among whom 58.1% had septic shock. The baseline CBF was 643.0 ± 212.7 ml/min, and it was 583.9 ± 207.1 ml/min and 668 ± 210.8 ml/min in hypotensive and normotensive patients, respectively. Considering a >10% increase in CBF as fluid response, there were 59% responders and 41% nonresponders. The MAP increased by 9.5% in the responders, while there was no significant change in CFT after the fluid bolus. There was no difference in CFT among the responders as compared to the nonresponders. There was no correlation between the change of CBF and CFT (r[207] = 0.013, P = 0.061) after the fluid bolus. Conclusion: Though easy to perform, CFT is probably not a good indicator of fluid responsiveness.
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Affiliation(s)
- P Immanuel Judson
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Kishore Pichamuthu
- Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
| | - Gina Maryann Chandy
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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