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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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2
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Papaioannou V, Papaioannou T. Rethinking Fluid Responsiveness during Septic Shock: Ameliorate Accuracy of Noninvasive Cardiac Output Measurements through Evaluation of Arterial Biomechanical Properties. J Pers Med 2024; 14:70. [PMID: 38248770 PMCID: PMC10817669 DOI: 10.3390/jpm14010070] [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: 10/22/2023] [Revised: 12/28/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Beat-to-beat estimates of cardiac output from the direct measure of peripheral arterial blood pressure rely on the assumption that changes in the waveform morphology are related to changes in blood flow and vasomotor tone. However, in septic shock patients, profound changes in vascular tone occur that are not uniform across the entire arterial bed. In such cases, cardiac output estimates might be inaccurate, leading to unreliable evaluation of fluid responsiveness. Pulse wave velocity is the gold-standard method for assessing different arterial biomechanical properties. Such methods might be able to guide, personalize and optimize the management of septic patients.
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Affiliation(s)
- Vasileios Papaioannou
- Intensive Care Unit, Alexandroupolis University Hospital, Democritus University of Thrace, Dragana, 68100 Alexandroupolis, Greece
| | - Theodoros Papaioannou
- Biomedical Engineering and Cardiovascular Mechanics Unit, 1st Department of Cardiology, Hippokration University Hospital, Medical School of the National and Kapodistrian University of Athens, 11527 Athens, Greece;
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Asllanaj B, Benge E, Bae J, McWhorter Y. Fluid management in septic patients with pulmonary hypertension, review of the literature. Front Cardiovasc Med 2023; 10:1096871. [PMID: 36937900 PMCID: PMC10017881 DOI: 10.3389/fcvm.2023.1096871] [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: 11/12/2022] [Accepted: 02/07/2023] [Indexed: 03/06/2023] Open
Abstract
The management of sepsis in patients with pulmonary hypertension (PH) is challenging due to significant conflicting goals of management and complex hemodynamics. As PH progresses, the ability of right heart to perfuse lungs at a normal central venous pressure (CVP) is impaired. Elevated pulmonary vascular pressure, due to pulmonary vasoconstriction and vascular remodeling, opposes blood flow through lungs thus limiting the ability of right ventricle (RV) to increase cardiac output (CO) and maintain adequate oxygen delivery to tissue. In sepsis without PH, avoidance of volume depletion with intravascular volume replacement, followed by vasopressor therapy if hypoperfusion persists, remains the cornerstone of therapy. Intravenous fluid (IVF) resuscitation based on individualized hemodynamic assessment can help improve the prognosis of critically ill patients. This is accomplished by optimizing CO by maintaining adequate preload, afterload and contractility. Particular challenges in patients with PH include RV failure as a result of pressure and volume overload, gas exchange abnormalities, and managing IVF and diuretic use. Suggested approaches to remedy these difficulties include early recognition of symptoms associated with pressure and volume overload, intravascular volume management strategies and serial lab monitoring to assess electrolytes and renal function.
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Affiliation(s)
- Blerina Asllanaj
- Department of Internal Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
| | - Elizabeth Benge
- Department of Internal Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
| | - Jieun Bae
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, United States
| | - Yi McWhorter
- Department of Critical Care Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
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Suriani I, van Houte J, de Boer EC, van Knippenberg L, Manzari S, Mischi M, Bouwman RA. Carotid Doppler ultrasound for non-invasive haemodynamic monitoring: a narrative review. Physiol Meas 2023; 43. [PMID: 36179705 DOI: 10.1088/1361-6579/ac96cb] [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: 06/02/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
Objective.Accurate haemodynamic monitoring is the cornerstone in the management of critically ill patients. It guides the optimization of tissue and organ perfusion in order to prevent multiple organ failure. In the past decades, carotid Doppler ultrasound (CDU) has been explored as a non-invasive alternative for long-established invasive haemodynamic monitoring techniques. Considering the large heterogeneity in reported studies, we conducted a review of the literature to clarify the current status of CDU as a haemodynamic monitoring tool.Approach.In this article, firstly an overview is given of the equipment and workflow required to perform a CDU exam in clinical practice, the limitations and technical challenges potentially faced by the CDU sonographer, and the cerebrovascular mechanisms that may influence CDU measurement outcomes. The following chapter describes alternative techniques for non-invasive haemodynamic monitoring, detailing advantages and limitations compared to CDU. Next, a comprehensive review of the literature regarding the use of CDU for haemodynamic monitoring is presented. Furthermore, feasibility aspects, training requirements and technical developments of CDU are addressed.Main results.Based on the outcomes of these studies, we assess the applicability of CDU-derived parameters within three clinical domains (cardiac output, volume status, and fluid responsiveness), and amongst different patient groups. Finally, recommendations are provided to improve the quality and standardization of future research and clinical practice in this field.Significance.Although CDU is not yet interchangeable with invasive 'gold standard' cardiac output monitoring, the present work shows that certain CDU-derived parameters prove promising in the context of functional haemodynamic monitoring.
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Affiliation(s)
- Irene Suriani
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Joris van Houte
- Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Esmée C de Boer
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Luuk van Knippenberg
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Sabina Manzari
- Philips Research High Tech Campus 34, 5656 AE Eindhoven, The Netherlands
| | - Massimo Mischi
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands.,Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
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Couture EJ, Laferrière-Langlois P, Denault A. New Developments in Continuous Hemodynamic Monitoring of the Critically Ill Patient. Can J Cardiol 2023; 39:432-443. [PMID: 36669685 DOI: 10.1016/j.cjca.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
Hemodynamic monitoring is a cornerstone in the assessment of patients with circulatory shock. Timely recognition of hemodynamic compromise and proper optimisation is essential to ensure adequate tissue perfusion and maintain renal, hepatic, abdominal, and cerebral functions. Hemodynamic monitoring has significantly evolved since the first inception of the pulmonary artery catheter more than 50 years ago. Bedside echocardiography, when combined with noninvasive and minimally invasive technologies, provides tools to monitor and quantify the cardiac output to promptly react and improve hemodynamic management in an acute care setting. Commonly used technologies include noninvasive pulse-wave analysis, pulse-wave transit time, thoracic bioimpedance and bioreactance, esophageal Doppler, minimally invasive pulse-wave analysis, transpulmonary thermodilution, and pulmonary artery catheter. These monitoring strategies are reviewed here, along with detailed analysis of their operating mode, particularities, and limitations. The use of artificial intelligence to enhance performance and effectiveness of hemodynamic monitoring is reviewed to apprehend future possibilities.
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Affiliation(s)
- Etienne J Couture
- Departments of Anaesthesiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada.
| | - Pascal Laferrière-Langlois
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, Université de Montréal, Montréal, Québec, Canada
| | - André Denault
- Department of Anaesthesiology, Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
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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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Carotid artery velocity time integral and corrected flow time measured by a wearable Doppler ultrasound detect stroke volume rise from simulated hemorrhage to transfusion. BMC Res Notes 2022; 15:7. [PMID: 35012624 PMCID: PMC8750810 DOI: 10.1186/s13104-021-05896-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Objective Doppler ultrasonography of the common carotid artery is used to infer stroke volume change and a wearable Doppler ultrasound has been designed to improve this workflow. Previously, in a human model of hemorrhage and resuscitation comprising approximately 50,000 cardiac cycles, we found a strong, linear correlation between changing stroke volume, and measures from the carotid Doppler signal, however, optimal Doppler thresholds for detecting a 10% stroke volume change were not reported. In this Research Note, we present these thresholds, their sensitivities, specificities and areas under their receiver operator curves (AUROC). Results Augmentation of carotid artery maximum velocity time integral and corrected flowtime by 18% and 4%, respectively, accurately captured 10% stroke volume rise. The sensitivity and specificity for these thresholds were identical at 89% and 100%. These data are similar to previous investigations in healthy volunteers monitored by the wearable ultrasound.
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Kenny JÉS, Clarke G, Myers M, Elfarnawany M, Eibl AM, Eibl JK, Nalla B, Atoui R. A Wireless Wearable Doppler Ultrasound Detects Changing Stroke Volume: Proof-of-Principle Comparison with Trans-Esophageal Echocardiography during Coronary Bypass Surgery. Bioengineering (Basel) 2021; 8:203. [PMID: 34940356 PMCID: PMC8698882 DOI: 10.3390/bioengineering8120203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A novel, wireless, ultrasound biosensor that adheres to the neck and measures real-time Doppler of the carotid artery may be a useful functional hemodynamic monitor. A unique experimental set-up during elective coronary artery bypass surgery is described as a means to compare the wearable Doppler to trans-esophageal echocardiography (TEE). METHODS A total of two representative patients were studied at baseline and during Trendelenburg position. Carotid Doppler spectra from the wearable ultrasound and TEE were synchronously captured. Areas under the receiver operator curve (AUROC) were performed to assess the accuracy of changing common carotid artery velocity time integral (ccVTI∆) at detecting a clinically significant change in stroke volume (SV∆). RESULTS Synchronously measuring and comparing Doppler spectra from the wearable ultrasound and TEE is feasible during Trendelenburg positioning. In two representative cardiac surgical patients, the ccVTI∆ accurately detected a clinically significant SV∆ with AUROCs of 0.89, 0.91, and 0.95 when single-beat, 3-consecutive beat and 10-consecutive beat averages were assessed, respectively. CONCLUSION In this proof-of-principle research communication, a wearable Doppler ultrasound system is successfully compared to TEE. Preliminary data suggests that the diagnostic accuracy of carotid Doppler ultrasonography at detecting clinically significant SV∆ is enhanced by averaging more cardiac cycles.
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Affiliation(s)
- Jon-Émile Stuart Kenny
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
| | - Geoffrey Clarke
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
| | - Matt Myers
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
| | - Mai Elfarnawany
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
| | - Andrew M. Eibl
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
| | - Joseph K. Eibl
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Flosonics Medical, 325 Front Street, Toronto, ON M5V 2Y1, Canada; (M.M.); (M.E.)
- Northern Ontario School of Medicine, Sudbury, ON P3E 2C6, Canada
| | - Bhanu Nalla
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Northern Ontario School of Medicine, Sudbury, ON P3E 2C6, Canada
| | - Rony Atoui
- Health Sciences North Research Institute, Sudbury, ON P3E 2H2, Canada; (G.C.); (A.M.E.); (J.K.E.); (B.N.); (R.A.)
- Northern Ontario School of Medicine, Sudbury, ON P3E 2C6, Canada
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Kenny JÉS, Munding CE, Eibl JK, Eibl AM, Long BF, Boyes A, Yin J, Verrecchia P, Parrotta M, Gatzke R, Magnin PA, Burns PN, Foster FS, Demore CEM. A novel, hands-free ultrasound patch for continuous monitoring of quantitative Doppler in the carotid artery. Sci Rep 2021; 11:7780. [PMID: 33833288 PMCID: PMC8032670 DOI: 10.1038/s41598-021-87116-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 03/22/2021] [Indexed: 12/19/2022] Open
Abstract
Quantitative Doppler ultrasound of the carotid artery has been proposed as an instantaneous surrogate for monitoring rapid changes in left ventricular output. Tracking immediate changes in the arterial Doppler spectrogram has value in acute care settings such as the emergency department, operating room and critical care units. We report a novel, hands-free, continuous-wave Doppler ultrasound patch that adheres to the neck and tracks Doppler blood flow metrics in the common carotid artery using an automated algorithm. String and blood-mimicking test objects demonstrated that changes in velocity were accurately measured using both manually and automatically traced Doppler velocity waveforms. In a small usability study with 22 volunteer users (17 clinical, 5 lay), all users were able to locate the carotid Doppler signal on a volunteer subject, and, in a subsequent survey, agreed that the device was easy to use. To illustrate potential clinical applications of the device, the Doppler ultrasound patch was used on a healthy volunteer undergoing a passive leg raise (PLR) as well as on a congestive heart failure patient at resting baseline. The wearable carotid Doppler patch holds promise because of its ease-of-use, velocity measurement accuracy, and ability to continuously record Doppler spectrograms over many cardiac and respiratory cycles.
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Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute and the Northern Ontario School of Medicine, Sudbury, ON, Canada.
- Flosonics Medical, Sudbury, ON, Canada.
| | | | - Joseph K Eibl
- Health Sciences North Research Institute and the Northern Ontario School of Medicine, Sudbury, ON, Canada
- Flosonics Medical, Sudbury, ON, Canada
| | | | - Bradley F Long
- Health Sciences North Research Institute and the Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Aaron Boyes
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Jianhua Yin
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | | | | | | | | | - Peter N Burns
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - F Stuart Foster
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Christine E M Demore
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada.
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
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Kenny JÉS. Functional Hemodynamic Monitoring With a Wireless Ultrasound Patch. J Cardiothorac Vasc Anesth 2021; 35:1509-1515. [PMID: 33597088 DOI: 10.1053/j.jvca.2021.01.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
In this Emerging Technology Review, a novel, wireless, wearable Doppler ultrasound patch is described as a tool for resuscitation. The device is designed, foremost, as a functional hemodynamic monitor-a simple, fast, and consistent method for measuring hemodynamic change with preload variation. More generally, functional hemodynamic monitoring is a paradigm that helps predict stroke volume response to additional intravenous volume. Because Doppler ultrasound of the left ventricular outflow tract noninvasively measures stroke volume in realtime, it increasingly is deployed for this purpose. Nevertheless, Doppler ultrasound in this manner is cumbersome, especially when repeat assessments are needed. Accordingly, peripheral arteries have been studied and various measures from the common carotid artery Doppler signal act as windows to the left ventricle. Yet, handheld Doppler ultrasound of a peripheral artery is susceptible to human measurement error and statistical limitations from inadequate beat sample size. Therefore, a wearable Doppler ultrasound capable of continuous assessment minimizes measurement inconsistencies and smooths inherent physiologic variation by sampling many more cardiac cycles. Reaffirming clinical studies, the ultrasound patch tracks immediate SV change with excellent accuracy in healthy volunteers when cardiac preload is altered by various maneuvers. The wearable ultrasound also follows jugular venous Doppler, which qualitatively trends right atrial pressure. With further clinical research and the application of artificial intelligence, the monitoring modalities with this new technology are manifold.
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Kenny JÉS, Barjaktarevic I. Timing and Measurement Variability Are Critical When Using Carotid Doppler to Infer Hemodynamics. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:3485-3486. [PMID: 32988668 DOI: 10.1016/j.ultrasmedbio.2020.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Jon-Émile S Kenny
- Health Sciences North Research Institute, Sudbury, ON, Canada; Flosonics Medical, Sudbury, ON, Canada.
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Rozental O, Thalappillil R, White RS, Tam CW. To Swan or Not to Swan: Indications, Alternatives, and Future Directions. J Cardiothorac Vasc Anesth 2020; 35:600-615. [PMID: 32859489 DOI: 10.1053/j.jvca.2020.07.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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Volumetric and End-Tidal Capnography for the Detection of Cardiac Output Changes in Mechanically Ventilated Patients Early after Open Heart Surgery. Crit Care Res Pract 2019; 2019:6393649. [PMID: 31281675 PMCID: PMC6589280 DOI: 10.1155/2019/6393649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/13/2019] [Accepted: 05/03/2019] [Indexed: 11/17/2022] Open
Abstract
Background Exhaled carbon dioxide (CO2) reflects cardiac output (CO) provided stable ventilation and metabolism. Detecting CO changes may help distinguish hypovolemia or cardiac dysfunction from other causes of haemodynamic instability. We investigated whether CO2 measured as end-tidal concentration (EtCO2) and eliminated volume per breath (VtCO2) reflect sudden changes in cardiac output (CO). Methods We measured changes in CO, VtCO2, and EtCO2 during right ventricular pacing and passive leg raise in 33 ventilated patients after open heart surgery. CO was measured with oesophageal Doppler. Results During right ventricular pacing, CO was reduced by 21% (CI 18–24; p < 0.001), VtCO2 by 11% (CI 7.9–13; p < 0.001), and EtCO2 by 4.9% (CI 3.6–6.1; p < 0.001). During passive leg raise, CO increased by 21% (CI 17–24; p < 0.001), VtCO2 by 10% (CI 7.8–12; p < 0.001), and EtCO2 by 4.2% (CI 3.2–5.1; p < 0.001). Changes in VtCO2 were significantly larger than changes in EtCO2 (ventricular pacing: 11% vs. 4.9% (p < 0.001); passive leg raise: 10% vs. 4.2% (p < 0.001)). Relative changes in CO correlated with changes in VtCO2 (ρ=0.53; p=0.002) and EtCO2 (ρ=0.47; p=0.006) only during reductions in CO. When dichotomising CO changes at 15%, only EtCO2 detected a CO change as judged by area under the receiver operating characteristic curve. Conclusion VtCO2 and EtCO2 reflected reductions in cardiac output, although correlations were modest. The changes in VtCO2 were larger than the changes in EtCO2, but only EtCO2 detected CO reduction as judged by receiver operating characteristic curves. The predictive ability of EtCO2 in this setting was fair. This trial is registered with NCT02070861.
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Long E, Babl FE, Oakley E, Hopper S, Sheridan B, Duke T. Does fluid bolus therapy increase blood pressure in children with sepsis? Emerg Med Australas 2019; 32:54-60. [DOI: 10.1111/1742-6723.13336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/25/2019] [Accepted: 05/26/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Elliot Long
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Franz E Babl
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Ed Oakley
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Sandy Hopper
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Bennett Sheridan
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne Victoria Australia
- Department of CardiologyThe Royal Children's Hospital Melbourne Victoria Australia
| | - Trevor Duke
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne Victoria Australia
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15
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Monitoring haemodynamic response to fluid-challenge in ICU: comparison of pressure recording analytical method and oesophageal Doppler: A prospective observational study. Eur J Anaesthesiol 2019; 36:135-143. [PMID: 30624291 DOI: 10.1097/eja.0000000000000924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The ability of the pressure recording analytical method (PRAM) in tracking change in cardiac output (ΔCO) after a fluid challenge in ICU needs to be evaluated with the most contemporary comparison methods recommended by experts. OBJECTIVE Our objective was to report the trending ability of PRAM in tracking ΔCO after a fluid challenge in ICU and to compare this with oesophageal Doppler monitoring (ODM). DESIGN Prospective, observational study. SETTING Hôpital Lariboisière and Hôpital Européen George Pompidou, Paris, France, from April 2016 to December 2017. PATIENTS Critically ill patients admitted to ICU with monitoring of CO monitored by ODM and invasive arterial pressure. INTERVENTION ΔCO after fluid challenge was simultaneously registered with ODM and PRAM connected to the arterial line. MAIN OUTCOME MEASURE Polar statistics (mean angular bias, radial limits of agreement and polar concordance rate) and clinical concordance evaluation (error grid and clinical concordance rate). Predictors of bias were determined. RESULTS Sixty-eight fluid challenge were administered in 49 patients. At the time of fluid challenge, almost all were mechanically ventilated (99%), with 85% receiving norepinephrine. Admission diagnosis was septic shock in 70% of patients. Patients had a Sequential Organ Failure Assessment score of 10 [7 to 12] and a median Simplified Acute Physiology Score II of 61 [49 to 69]. Relative ΔCO bias was 7.8° (6.3°) with radial limits of agreement of ±41.7°, polar concordance rate 80% and clinical concordance rate 74%. ΔCO bias was associated with baseline bias (P = 0.007). Baseline bias was associated with radial location of the arterial line (P = 0.03). CONCLUSION When compared with ODM, PRAM has insufficient performance to track ΔCO induced by fluid challenge in ICU patients. Baseline bias is an independent predictor of trending bias. TRIAL REGISTRATION IRB 00010254-2016-033.
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16
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Weil G, Motamed C, Eghiaian A, Monnet X, Suria S. Comparison of Proaqt/Pulsioflex® and oesophageal Doppler for intraoperative haemodynamic monitoring during intermediate-risk abdominal surgery. Anaesth Crit Care Pain Med 2019; 38:153-159. [DOI: 10.1016/j.accpm.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
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17
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Esophageal Doppler Can Predict Fluid Responsiveness Through End-Expiratory and End-Inspiratory Occlusion Tests. Crit Care Med 2019; 47:e96-e102. [DOI: 10.1097/ccm.0000000000003522] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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18
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Messina A, Colombo D, Barra FL, Cammarota G, De Mattei G, Longhini F, Romagnoli S, DellaCorte F, De Backer D, Cecconi M, Navalesi P. Sigh maneuver to enhance assessment of fluid responsiveness during pressure support ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:31. [PMID: 30691523 PMCID: PMC6350369 DOI: 10.1186/s13054-018-2294-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022]
Abstract
Background Assessment of fluid responsiveness is problematic in intensive care unit (ICU) patients, in particular for those undergoing modes of partial support, such as pressure support ventilation (PSV). We propose a new test, based on application of a ventilator-generated sigh, to predict fluid responsiveness in ICU patients undergoing PSV. Methods This was a prospective bi-centric interventional study conducted in two general ICUs. In 40 critically ill patients with a stable ventilatory PSV pattern and requiring volume expansion (VE), we assessed the variations in arterial systolic pressure (SAP), pulse pressure (PP) and stroke volume index (SVI) consequent to random application of 4-s sighs at three different inspiratory pressures. A radial arterial signal was directed to the MOSTCARE™ pulse contour hemodynamic monitoring system for hemodynamic measurements. Data obtained during sigh tests were recorded beat by beat, while all the hemodynamic parameters were averaged over 30 s for the remaining period of the study protocol. VE consisted of 500 mL of crystalloids over 10 min. A patient was considered a responder if a VE-induced increase in cardiac index (CI) ≥ 15% was observed. Results The slopes for SAP, SVI and PP of were all significantly different between responders and non-responders (p < 0.0001, p = 0.0004 and p < 0.0001, respectively). The AUC of the slope of SAP (0.99; sensitivity 100.0% (79.4–100.0%) and specificity 95.8% (78.8–99.9%) was significantly greater than the AUC for PP (0.91) and SVI (0.83) (p = 0.04 and 0.009, respectively). The SAP slope best threshold value of the ROC curve was − 4.4° from baseline. The only parameter found to be independently associated with fluid responsiveness among those included in the logistic regression was the slope for SAP (p = 0.009; odds ratio 0.27 (95% confidence interval (CI95) 0.10–0.70)). The effects produced by the sigh at 35 cmH20 (Sigh35) are significantly different between responders and non-responders. For a 35% reduction in PP from baseline, the AUC was 0.91 (CI95 0.82–0.99), with sensitivity 75.0% and specificity 91.6%. Conclusions In a selected ICU population undergoing PSV, analysis of the slope for SAP after the application of three successive sighs and the nadir of PP after Sigh35 reliably predict fluid responsiveness. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12615001232527. Registered on 10 November 2015. Electronic supplementary material The online version of this article (10.1186/s13054-018-2294-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy.
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | - Federico Lorenzo Barra
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | - Giacomo De Mattei
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Medicine, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco DellaCorte
- Anesthesia and Intensive Care Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | | | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas, Humanitas University, Via Alessandro Manzoni, 56, Rozzano, 20089, Milan, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care Medicine, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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19
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Evaluation of cardiac output variations with the peripheral pulse pressure to mean arterial pressure ratio. J Clin Monit Comput 2018; 33:581-587. [PMID: 30361823 DOI: 10.1007/s10877-018-0210-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Abstract
Cardiac output (CO) optimisation during surgery reduces post-operative morbidity. Various methods based on pulse pressure analysis have been developed to overcome difficulties to measure accurate CO variations in standard anaesthetic settings. Several of these methods include, among other parameters, the ratio of pulse pressure to mean arterial pressure (PP/MAP). The aim of this study was to evaluate whether the ratio of radial pulse pressure to mean arterial pressure (ΔPPrad/MAP) could track CO variations (ΔCO) induced by various therapeutic interventions such as fluid infusions and vasopressors boluses [phenylephrine (PE), norepinephrine (NA) or ephedrine (EP)] in the operating room. Trans-oesophageal Doppler signal and pressure waveforms were recorded in patients undergoing neurosurgery. CO and PPrad/MAP were recorded before and after fluid challenges, PE, NA and EP bolus infusions as medically required during their anaesthesia. One hundred and three patients (mean age: 52 ± 12 years old, 38 men) have been included with a total of 636 sets of measurement. During fluids challenges (n = 188), a positive correlation was found between ΔPPrad/MAP and ΔCO (r = 0.22, p = 0.003). After PE (n = 256) and NA (n = 121) boluses, ΔPPrad/MAP positively tracked ΔCO (r = 0.53 and 0.41 respectively, p < 0.001). By contrast, there was no relation between ΔPPrad/MAP and ΔCO after EP boluses (r = 0.10, p = 0.39). ΔPPrad/MAP tracked ΔCO variations during PE and NA vasopressor challenges. However, after positive fluid challenge or EP boluses, ΔPPrad/MAP was not as performant to track ΔCO which could make the use of this ratio difficult in current clinical practice.
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20
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Suparschi V, Le Bihan E, Toussaint A, Saptefrat D, Ben Abdallah H, Gloulou F, Aouati F, Gauss T, Paugam-Burtz C. Noninvasive assessment of Cardiac Index using impedance cardiography during liver transplantation surgery: a comparison with pulmonary artery thermodilution. Minerva Anestesiol 2018; 85:28-33. [PMID: 29745622 DOI: 10.23736/s0375-9393.18.12391-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Liver transplantation (LT) is a high-risk surgery associated with significant hemodynamic changes requiring advanced hemodynamic monitoring. Pulmonary Artery Catheter (PAC) is still considered as a gold-standard for Cardiac Index (CI) measurement during LT despite association with an increased risk of complications. Noninvasive impedance cardiography (ICG) could be an interesting alternative tool for CI monitoring. The aim of this study was to compare the precision and trending ability of ICG versus PAC methods during LT. METHODS Patients undergoing LT were prospectively included. CI was measured with PAC and ICG at 4 time points (T1: before surgical incision, T2: during anhepatic phase, T3: after portal reperfusion, T4: during wound closure). Bias and percentage error (PE) between CI measured with PAC and ICG were analyzed with the Bland-Altman method for repeated measurements. Trending ability was studied with 4-quadrant and polar plots and correlation coefficient. RESULTS We included 43 patients with 156 measures. Mean bias was -0.95 L.min-1.m-2, SD±1.07, limits of agreement -3.73 to 1.83 L.min-1.m-2 and PE 58%. There was a significant increase in bias during LT (P<0.001). Assessment of trending ability displayed a concordance rate of 72% on the 4-quadrant plot and a mean angular bias of -8.4° (SD±28°) and radial limits of agreement ±55° on the polar plot. CONCLUSIONS CI measurements using ICG exhibited a low precision and a poor trending ability when compared to thermodilution method during LT. Consequently, ICG is not an adequate hemodynamic tool to monitor CI during LT.
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Affiliation(s)
- Vlad Suparschi
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France -
| | - Eric Le Bihan
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Amélie Toussaint
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Diana Saptefrat
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Heykel Ben Abdallah
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Faouzi Gloulou
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Farida Aouati
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Tobias Gauss
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France
| | - Catherine Paugam-Burtz
- Department of Anesthesia and Critical Care, Beaujon Hospital, Paris Nord-Val de Seine University Hospitals, Clichy, France.,Denis Diderot University, PRES Sorbonne Paris Cité, Paris, France.,Inserm UMR-S1149, Center for Research on Inflammation, Paris, France
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21
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22
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De la Puente-Diaz de Leon V, de Jesus Jaramillo-Rocha V, Teboul JL, Garcia-Miranda S, Martinez-Guerra BA, Dominguez-Cherit G. Changes in Radial Artery Pulse Pressure During a Fluid Challenge Cannot Assess Fluid Responsiveness in Patients With Septic Shock. J Intensive Care Med 2017; 35:149-153. [PMID: 28931367 DOI: 10.1177/0885066617732291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Arterial blood pressure is the most common variable used to assess the response to a fluid challenge in routine clinical practice. The aim of this study was to evaluate the accuracy of the change in the radial artery pulse pressure (rPP) to detect the change in cardiac output after a fluid challenge in patients with septic shock. METHODS Prospective observational study including 35 patients with septic shock in which rPP and cardiac output were measured before and after a fluid challenge with 400 mL of crystalloid solution. Cardiac output was measured with intermittent thermodilution technique using a pulmonary artery catheter. Patients were divided between responders (increase >15% of cardiac output after fluid challenge) and nonresponders. The area under the receiver operating characteristic curve (AUROC), Pearson correlation coefficient and paired Student t test were used in statistical analysis. RESULTS Forty-three percent of the patients were fluid responders. The change in rPP could not neither discriminate between responders and nonresponders (AUROC = 0.52; [95% confidence interval: 0.31-0.72] P = .8) nor correlate (r = .21, P = .1) with the change in cardiac output after the fluid challenge. CONCLUSIONS The change in rPP neither discriminated between fluid responders and nonresponders nor correlated with the change in cardiac output after a fluid challenge. The change in rPP cannot serve as a surrogate of the change in cardiac output to assess the response to a fluid challenge in patients with septic shock.
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Affiliation(s)
- Victor De la Puente-Diaz de Leon
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | | | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicetre University Hospital, University Paris-Sud, Le Kremlin-Bicetre, Paris, France
| | - Sofia Garcia-Miranda
- Department of Internal Medicine, Fundacion Clinica Medica Sur, Puente de Piedra, Mexico City, Mexico
| | - Bernardo A Martinez-Guerra
- Department of Internal Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | - Guillermo Dominguez-Cherit
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
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23
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017. [DOI: https://doi.org/10.1177/0885066617709434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia
- Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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24
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017; 33:227-240. [PMID: 28506136 DOI: 10.1177/0885066617709434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- 1 Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia.,2 Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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25
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The dynamic arterial elastance: a call for a cautious interpretation. Intensive Care Med 2017; 43:1438-1439. [DOI: 10.1007/s00134-017-4836-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2017] [Indexed: 11/25/2022]
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26
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Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 518] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
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27
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Roshdy A. Suprasternal Doppler as a haemodynamic tool in emergency care. Emerg Med Australas 2017; 29:476. [PMID: 28455879 DOI: 10.1111/1742-6723.12799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Ashraf Roshdy
- Critical Care Department, Alexandria University, Alexandria, Egypt.,General Intensive Care Unit, Broomfield Hospital, Mid Essex NHS Trust, Chelmsford, UK
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28
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Accuracy of Cardiac Output by Nine Different Pulse Contour Algorithms in Cardiac Surgery Patients: A Comparison with Transpulmonary Thermodilution. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3468015. [PMID: 28116294 PMCID: PMC5225324 DOI: 10.1155/2016/3468015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/09/2016] [Accepted: 11/22/2016] [Indexed: 11/24/2022]
Abstract
Objective. Today, there exist several different pulse contour algorithms for calculation of cardiac output (CO). The aim of the present study was to compare the accuracy of nine different pulse contour algorithms with transpulmonary thermodilution before and after cardiopulmonary bypass (CPB). Methods. Thirty patients scheduled for elective coronary surgery were studied before and after CPB. A passive leg raising maneuver was also performed. Measurements included CO obtained by transpulmonary thermodilution (COTPTD) and by nine pulse contour algorithms (COX1–9). Calibration of pulse contour algorithms was performed by esophageal Doppler ultrasound after induction of anesthesia and 15 min after CPB. Correlations, Bland-Altman analysis, four-quadrant, and polar analysis were also calculated. Results. There was only a poor correlation between COTPTD and COX1–9 during passive leg raising and in the period before and after CPB. Percentage error exceeded the required 30% limit. Four-quadrant and polar analysis revealed poor trending ability for most algorithms before and after CPB. The Liljestrand-Zander algorithm revealed the best reliability. Conclusions. Estimation of CO by nine different pulse contour algorithms revealed poor accuracy compared with transpulmonary thermodilution. Furthermore, the less-invasive algorithms showed an insufficient capability for trending hemodynamic changes before and after CPB. The Liljestrand-Zander algorithm demonstrated the highest reliability. This trial is registered with NCT02438228 (ClinicalTrials.gov).
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29
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Teboul JL, Saugel B, Cecconi M, De Backer D, Hofer CK, Monnet X, Perel A, Pinsky MR, Reuter DA, Rhodes A, Squara P, Vincent JL, Scheeren TW. Less invasive hemodynamic monitoring in critically ill patients. Intensive Care Med 2016; 42:1350-9. [DOI: 10.1007/s00134-016-4375-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 04/28/2016] [Indexed: 11/28/2022]
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Abstract
Aggressive fluid resuscitation to achieve a central venous pressure (CVP) greater than 8 mm Hg has been promoted as the standard of care, in the management of patients with severe sepsis and septic shock. However recent clinical trials have demonstrated that this approach does not improve the outcome of patients with severe sepsis and septic shock. Pathophysiologically, sepsis is characterized by vasoplegia with loss of arterial tone, venodilation with sequestration of blood in the unstressed blood compartment and changes in ventricular function with reduced compliance and reduced preload responsiveness. These data suggest that sepsis is primarily not a volume-depleted state and recent evidence demonstrates that most septic patients are poorly responsive to fluids. Furthermore, almost all of the administered fluid is sequestered in the tissues, resulting in severe oedema in vital organs and, thereby, increasing the risk of organ dysfunction. These data suggest that a physiologic, haemodynamically guided conservative approach to fluid therapy in patients with sepsis would be prudent and would likely reduce the morbidity and improve the outcome of this disease.
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Affiliation(s)
- P Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA 23507, USA
| | - R Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
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31
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Marik P. Fluid therapy in 2015 and beyond: the mini-fluid challenge and mini-fluid bolus approach. Br J Anaesth 2015; 115:347-9. [DOI: 10.1093/bja/aev169] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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32
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Alvarado-Sánchez JI. Prueba de elevación de piernas pasiva. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: https://doi.org/10.1016/j.rca.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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33
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Alvarado-Sánchez JI. The passive leg raising test (PLR). COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2015.03.005] [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] Open
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Hamzaoui O, Monnet X, Teboul JL. Evolving concepts of hemodynamic monitoring for critically ill patients. Indian J Crit Care Med 2015; 19:220-6. [PMID: 25878430 PMCID: PMC4397629 DOI: 10.4103/0972-5229.154556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The last decades have been characterized by a continuous evolution of hemodynamic monitoring techniques from intermittent toward continuous and real-time measurements and from an invasive towards a less invasive approach. The latter approach uses ultrasounds and pulse contour analysis techniques that have been developed over the last 15 years. During the same period, the concept of prediction of fluid responsiveness has also been developed and dynamic indices such as pulse pressure variation, stroke volume variation, and the real-time response of cardiac output to passive leg raising or to end-expiration occlusion, can be easily obtained and displayed with the minimally invasive techniques. In this article, we review the main hemodynamic monitoring devices currently available with their respective advantages and drawbacks. We also present the current viewpoint on how to choose a hemodynamic monitoring device in the most severely ill patients and especially in patients with circulatory shock.
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Affiliation(s)
- Olfa Hamzaoui
- Intensive Care Unit, Antoine Beclere Hospital, Clamart, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
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Caillard A, Gayat E, Tantot A, Dubreuil G, M'Bakulu E, Madadaki C, Bart F, Bresson D, Froelich S, Mebazaa A, Vallée F. Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis. Br J Anaesth 2015; 114:893-900. [PMID: 25735709 DOI: 10.1093/bja/aev001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2014] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Maintaining adequate organ perfusion during high-risk surgery requires continuous monitoring of cardiac output to optimise haemodynamics. Oesophageal Doppler Cardiac Output monitoring (DCO) is commonly used in this context, but has some limitations. Recently, the cardiac output estimated by pulse pressure analysis- (PPCO) was developed. This study evaluated the agreement of cardiac output variations estimated with 9 non-commercial algorithms of PPCO compared with those obtained with DCO. METHODS High-risk patients undergoing neurosurgery were monitored with invasive blood pressure and DCO. For each patient, 9 PPCO algorithms and DCO were recorded before and at the peak effect for every haemodynamic challenge. RESULTS Sixty-two subjects were enrolled; 284 events were recorded, including 134 volume expansions and 150 vasopressor boluses. Among the 9 algorithms tested, the Liljestrand-Zander model led to the smallest bias (0.03 litre min(-1) [-1.31, +1.38] (0.21 litre min(-1) [-1.13; 1.54] after volume expansion and -0.13 litre min(-1) [-1.41, 1.15] after vasopressor use). The corresponding percentage of the concordance was 91% (86% after volume expansion and 94% after vasopressor use). The other algorithms, especially those using the Winkessel concept and the area under the pressure wave, were profoundly affected by the vasopressor. CONCLUSIONS Among the 9 PPCO algorithms examined, the Liljestrand-Zander model demonstrated the least bias and best limits of agreement, especially after vasopressor use. Using this particular algorithm in association with DCO calibration could represent a valuable option for continuous cardiac output monitoring of high risk patients. CLINICAL TRIAL REGISTRATION Comité d'éthique de la Société de Réanimation de Langue Française No. 11-356.
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Affiliation(s)
- A Caillard
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France INSERM UMR-942, Paris, France
| | - E Gayat
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France INSERM UMR-942, Paris, France
| | - A Tantot
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France INSERM UMR-942, Paris, France
| | - G Dubreuil
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France
| | - E M'Bakulu
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France
| | - C Madadaki
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France
| | - F Bart
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France
| | - D Bresson
- University Paris Diderot, Paris, France Department of Neurosurgery, Hôpitaux Universitaires St-Louis-Lariboisière, Paris, France
| | - S Froelich
- University Paris Diderot, Paris, France Department of Neurosurgery, Hôpitaux Universitaires St-Louis-Lariboisière, Paris, France
| | - A Mebazaa
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France INSERM UMR-942, Paris, France
| | - F Vallée
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires St-Louis-Lariboisière-Fernand Widal, Paris, France University Paris Diderot, Paris, France
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Monnet X, Teboul JL. End-expiratory occlusion test: please use the appropriate tools! Br J Anaesth 2015; 114:166-7. [PMID: 25500404 DOI: 10.1093/bja/aeu430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Høiseth LØ, Hoff IE, Hagen OA, Landsverk SA, Kirkebøen KA. Agreement between stroke volume measured by oesophageal Doppler and uncalibrated pulse contour analysis during fluid loads in severe aortic stenosis. J Clin Monit Comput 2015; 29:435-41. [PMID: 25638514 DOI: 10.1007/s10877-015-9666-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 01/27/2015] [Indexed: 11/24/2022]
Abstract
The purpose of this analysis was to study agreement and trending of stroke volume measured by oesophageal Doppler and 3rd generation Vigileo during fluid loads in patients with severe aortic stenosis. Observational study in 32 patients (30 analyzed) scheduled for aortic valve replacement due to severe aortic stenosis. After induction of anesthesia and before start of surgery, hemodynamic registrations for 1 min were obtained before and after a fluid load. Agreement between stroke volume measured by oesophageal Doppler (SVOD) and Vigileo (SVVig) was evaluated in Bland-Altman plot and trending in four-quadrant and polar plots. Bias ± limits of agreement (LOA) between SVOD and SVVig was 24 ± 37 ml (percentage error 45%). Concordance of the two methods from before to after a fluid load was 100%. Angular bias ± LOA was 12° ± 28°. Absolute values of SVOD and SVVig agreed poorly, but changes were highly concordant during fluid loads in aortic stenosis patients. The angular agreement indicated acceptable trending. The two measurement methods are not interchangeable in patients with aortic stenosis.
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Guinot PG, Godart J, de Broca B, Bernard E, Lorne E, Dupont H. Clinical practice. Br J Anaesth 2014; 114:167-8. [PMID: 25500405 DOI: 10.1093/bja/aeu431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795-815. [PMID: 25392034 PMCID: PMC4239778 DOI: 10.1007/s00134-014-3525-z] [Citation(s) in RCA: 972] [Impact Index Per Article: 97.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. METHODS The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. RESULTS Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. CONCLUSIONS This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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Affiliation(s)
- Maurizio Cecconi
- Anaesthesia and Intensive Care, St George's Hospital and Medical School, SW17 0QT, London, UK,
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García MIM, Romero MG, Cano AG, Aya HD, Rhodes A, Grounds RM, Cecconi M. Dynamic arterial elastance as a predictor of arterial pressure response to fluid administration: a validation study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:626. [PMID: 25407570 PMCID: PMC4271484 DOI: 10.1186/s13054-014-0626-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 10/28/2014] [Indexed: 12/19/2022]
Abstract
Introduction Functional assessment of arterial load by dynamic arterial elastance (Eadyn), defined as the ratio between pulse pressure variation (PPV) and stroke volume variation (SVV), has recently been shown to predict the arterial pressure response to volume expansion (VE) in hypotensive, preload-dependent patients. However, because both SVV and PPV were obtained from pulse pressure analysis, a mathematical coupling factor could not be excluded. We therefore designed this study to confirm whether Eadyn, obtained from two independent signals, allows the prediction of arterial pressure response to VE in fluid-responsive patients. Methods We analyzed the response of arterial pressure to an intravenous infusion of 500 ml of normal saline in 53 mechanically ventilated patients with acute circulatory failure and preserved preload dependence. Eadyn was calculated as the simultaneous ratio between PPV (obtained from an arterial line) and SVV (obtained by esophageal Doppler imaging). A total of 80 fluid challenges were performed (median, 1.5 per patient; interquartile range, 1 to 2). Patients were classified according to the increase in mean arterial pressure (MAP) after fluid administration in pressure responders (≥10%) and non-responders. Results Thirty-three fluid challenges (41.2%) significantly increased MAP. At baseline, Eadyn was higher in pressure responders (1.04 ± 0.28 versus 0.60 ± 0.14; P <0.0001). Preinfusion Eadyn was related to changes in MAP after fluid administration (R2 = 0.60; P <0.0001). At baseline, Eadyn predicted the arterial pressure increase to volume expansion (area under the receiver operating characteristic curve, 0.94; 95% confidence interval (CI): 0.86 to 0.98; P <0.0001). A preinfusion Eadyn value ≥0.73 (gray zone: 0.72 to 0.88) discriminated pressure responder patients with a sensitivity of 90.9% (95% CI: 75.6 to 98.1%) and a specificity of 91.5% (95% CI: 79.6 to 97.6%). Conclusions Functional assessment of arterial load by Eadyn, obtained from two independent signals, enabled the prediction of arterial pressure response to fluid administration in mechanically ventilated, preload-dependent patients with acute circulatory failure. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0626-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manuel Ignacio Monge García
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain. .,Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Manuel Gracia Romero
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain.
| | - Anselmo Gil Cano
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain.
| | - Hollmann D Aya
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Robert Michael Grounds
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Maurizio Cecconi
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
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Abstract
Sepsis is among the most common reasons for admission to ICUs throughout the world, and it is believed to be the third most common cause of death in the United States. The pathogenetic mechanism and physiologic changes associated with sepsis are exceedingly complex, but our understanding is evolving rapidly. The major pathophysiologic changes in patients with septic shock include vasoplegic shock (distributive shock), myocardial depression, altered microvascular flow, and a diffuse endothelial injury. These pathophysiologic changes play a central role in the management of sepsis. The early management of patients with severe sepsis and septic shock centers on the administration of antibiotics, IV fluids, and vasoactive agents, followed by source control. However, the specific approach to the resuscitation of patients with septic shock remains highly controversial. This review provides a practical and physiologic-based approach to the early management of sepsis and explores the controversies surrounding the management of this complex condition.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
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Colquhoun DA, Roche AM. Oesophageal Doppler cardiac output monitoring: a longstanding tool with evolving indications and applications. Best Pract Res Clin Anaesthesiol 2014; 28:353-62. [PMID: 25480766 DOI: 10.1016/j.bpa.2014.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/17/2014] [Accepted: 09/23/2014] [Indexed: 01/08/2023]
Abstract
Much work has been done over the years to assess cardiac output and better grasp haemodynamic profiles of patients in critical care and during major surgery. Pulmonary artery catheterization has long been considered as the standard of care, especially in critical care environments, however this dogma has been challenged over the last 10-15 years. This has led to a greater focus on alternate, lesser invasive technologies. This review focuses on the scientific and clinical outcomes basis of oesophageal Doppler monitoring. The science underpinning Doppler shift assessment of velocity stretches back over 100 years, whereas the clinical applicability, and specifically clinical outcomes improvement can be attributed to the last 20 years. Oesophageal Doppler monitoring (ODM), and its associated protocol-guided fluid administration, has been shown to reduce complications, length of stay, and overall healthcare cost when incorporated into perioperative fluid management algorithms. However, more recent advances in enhanced recovery after surgery programs have led to similar improvements, leading the clinician to consider the role of Oesophageal Doppler Monitor to be more focused in high-risk surgery and/or the high-risk patient.
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Affiliation(s)
- Douglas A Colquhoun
- Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, VA, USA.
| | - Anthony M Roche
- University of Washington, Harborview Medical Center, Seattle, WA, USA.
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Marik PE. Response. Chest 2014; 146:e143-4. [DOI: 10.1378/chest.14-1460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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HØISETH LØ, HOFF IE, HAGEN OA, LANDSVERK SA, KIRKEBØEN KA. Dynamic variables and fluid responsiveness in patients for aortic stenosis surgery. Acta Anaesthesiol Scand 2014; 58:826-34. [PMID: 24773498 DOI: 10.1111/aas.12328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Aortic stenosis is the most common valvular disease in developed countries, but it carries an increased mortality during non-cardiac surgery underscoring the importance of adequate hemodynamic management. Further, haemodynamic management of patients immediately after surgery for aortic stenosis can be challenging. Prediction of fluid responsiveness using dynamic variables has not been sufficiently studied in patients for aortic stenosis surgery. METHODS Observational study evaluating fluid responsiveness on 32 (31 analysed) patients scheduled for aortic valve replacement due to aortic stenosis on mechanical ventilation before and after valve replacement. Increase in stroke volume (oesophagus Doppler) ≥ 15% to a fluid challenge defined fluid responders. RESULTS Before surgery (31 fluid loads performed in 31 patients), areas under receiver operating characteristics curves (95% confidence intervals) were stroke volume variation (from arterial pulse contour analysis) 0.77 (0.58-0.90), pulse pressure variation 0.75 (0.54-0.90) and Pleth variability index 0.51 (0.31-0.69). After aortic valve replacement (31 fluid loads performed in 23 patients) the values were stroke volume variation 0.90 (0.74-0.98), pulse pressure variation 0.95 (0.80-1.0) and Pleth variability index 0.72 (0.52-0.87). CONCLUSIONS The arterial pressure-based variables had moderate predictive values before valve replacement, but it predicted fluid responsiveness well postoperatively. Pleth variability index did not predict fluid responsiveness preoperatively, and it had a moderate predictive value postoperatively. These results indicate that arterial pressure-based dynamic variables have limited potential to guide fluid therapy in patients with aortic stenosis. Their ability to guide fluid therapy after aortic valve replacement seems better.
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Affiliation(s)
- L. Ø. HØISETH
- Faculty of Medicine; University of Oslo; Oslo Norway
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
| | - I. E. HOFF
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
- Norwegian Air Ambulance Foundation; Drøbak Norway
| | - O. A. HAGEN
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
| | - S. A. LANDSVERK
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
| | - K. A. KIRKEBØEN
- Faculty of Medicine; University of Oslo; Oslo Norway
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
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Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care 2014; 4:21. [PMID: 25110606 PMCID: PMC4122823 DOI: 10.1186/s13613-014-0021-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/27/2014] [Indexed: 12/18/2022] Open
Abstract
Current teaching and guidelines suggest that aggressive fluid resuscitation is the best initial approach to the patient with hemodynamic instability. The source of this wisdom is difficult to discern, however, Early Goal Directed therapy (EGDT) as championed by Rivers et al. and the Surviving Sepsis Campaign Guidelines appears to have established this as the irrefutable truth. However, over the last decade it has become clear that aggressive fluid resuscitation leading to fluid overload is associated with increased morbidity and mortality across a diverse group of patients, including patients with severe sepsis as well as elective surgical and trauma patients and those with pancreatitis. Excessive fluid administration results in increased interstitial fluid in vital organs leading to impaired renal, hepatic and cardiac function. Increased extra-vascular lung water (EVLW) is particularly lethal, leading to iatrogenic salt water drowning. EGDT and the Surviving Sepsis Campaign Guidelines recommend targeting a central venous pressure (CVP) > 8 mmHg. A CVP > 8 mmHg has been demonstrated to decrease microcirculatory flow, as well as renal blood flow and is associated with an increased risk of renal failure and death. Normal saline (0.9% salt solution) as compared to balanced electrolyte solutions is associated with a greater risk of acute kidney injury and death. This paper reviews the adverse effects of large volume resuscitation, a high CVP and the excessive use of normal saline.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk 23507, VA, USA
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WILKMAN E, KUITUNEN A, PETTILÄ V, VARPULA M. Fluid responsiveness predicted by elevation of PEEP in patients with septic shock. Acta Anaesthesiol Scand 2014; 58:27-35. [PMID: 24341692 DOI: 10.1111/aas.12229] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The assessment of whether a patient is fluid responsive can be difficult in clinical practice. Invasive filling pressures are inadequate indicators of preload and fluid responsiveness in critically ill patients. Dynamic indices may be unreliable in clinical practice because of arrhythmias or spontaneous breathing efforts. Elevation of positive end-expiratory pressure (PEEP) causes cardiorespiratory interactions, which may produce signs of hypovolaemia. Our aim was to assess whether haemodynamic changes during a short elevation of PEEP would predict fluid responsiveness in patients with septic shock. METHODS We performed a prospective observational study in 20 patients with septic shock on mechanical ventilation. We assessed the following changes in haemodynamic variables during a temporary elevation of PEEP from 10 cm H2O to 20 cm H2O during an end-expiratory pause: mean arterial pressure (MAP), systolic arterial pressure, pulse pressure, central venous pressure, pulmonary artery occlusion pressure, left ventricular end diastolic area and aortic velocity-time integral. We defined fluid responsiveness as an increase in cardiac output of 15% to a subsequent fluid challenge. RESULTS Decrease in MAP related to elevation of PEEP predicted fluid responsiveness (P = 0.003). The best cut-off value of ΔMAP for clinical use was -8%, with a negative predictive value for fluid responsiveness of 100%. CONCLUSION In patients with septic shock, the absence of decrease in MAP during an elevation of PEEP may be used to identify patients who will not increase their cardiac output in response to fluid challenge.
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Affiliation(s)
- E. WILKMAN
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
| | - A. KUITUNEN
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Intensive Care Unit; Department of Intensive Care; Tampere University Hospital; Tampere Finland
| | - V. PETTILÄ
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Department of Clinical Sciences; University of Helsinki; Helsinki Finland
| | - M. VARPULA
- Intensive Care Unit; Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki Finland
- Department of Internal Medicine; Heart and Lung Center, Division of Cardiology; Helsinki University Central Hospital; Helsinki Finland
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Monnet X, Robert JM, Jozwiak M, Richard C, Teboul JL. Assessment of changes in left ventricular systolic function with oesophageal Doppler. Br J Anaesth 2013; 111:743-9. [DOI: 10.1093/bja/aet212] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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50
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Thiele RH, Bartels K, Esper S, Ikeda K, Gan TJ. Real-time Doppler-based arterial vascular impedance and peripheral pressure-flow loops: a pilot study. J Cardiothorac Vasc Anesth 2013; 28:36-41. [PMID: 24075638 DOI: 10.1053/j.jvca.2013.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Arterial pressure-flow loops and vascular impedance provide additional data that could be used to assess the hemodynamic effects of therapeutic interventions in anesthetized patients. To evaluate the utility of such an approach, the authors sought to design a device that combines flow waveforms from an esophageal Doppler probe and pressure waveforms from a peripheral artery to produce real-time pressure-flow loops and estimates of arterial vascular impedance. DESIGN Prospective, cohort study. SETTING Single center, university-based teaching hospital. PARTICIPANTS Patients undergoing surgery in whom the attending anesthesiologist had opted to place an esophageal Doppler probe and a peripheral arterial catheter for hemodynamic monitoring. INTERVENTIONS This was a non-interventional study designed to record pressure-flow loops and arterial vascular impedance intraoperatively using a novel, noninvasive device. MEASUREMENTS AND MAIN RESULTS Pressure-flow loops and arterial vascular impedance were measured noninvasively using radial artery pressure and descending thoracic aorta flow waveforms in real time. CONCLUSIONS Real-time arterial vascular impedance and peripheral pressure-volume loops can be determined using available monitoring devices. Technical feasibility of this technology in patients is a crucial first step to permit meaningful evaluation of the clinical value of this approach for accurate determination of complex hemodynamic indices and, eventually, improvement of outcomes.
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Affiliation(s)
- Robert H Thiele
- Technology in Anesthesia and Critical Care Group, University of Virginia, Charlottesville, VA.
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO
| | - Stephen Esper
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Keita Ikeda
- Department of Anesthesiology, Duke University, Durham, NC
| | - Tong-Joo Gan
- Department of Anesthesiology, Duke University, Durham, NC
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