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Barthélémy R, Kindermans M, Delval P, Collet M, Gaugain S, Cecconi M, Mebazaa A, Chousterman BG. Accuracy of cumulative volumes of fluid challenge to assess fluid responsiveness in critically ill patients with acute circulatory failure: a pharmacodynamic approach. Br J Anaesth 2021; 128:236-243. [PMID: 34895718 DOI: 10.1016/j.bja.2021.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The relationship between the dose (volume of fluid) and the effect (increase of stroke volume [SV]) has been poorly described. We hypothesised that the analysis of the dynamic response of SV during fluid challenge (FC) helps to determine the optimal volume of FC, along with its diagnostic accuracy parameters for fluid responsiveness. METHODS A prospective observational study was conducted in critically ill patients with circulatory failure. Patients monitored with oesophageal Doppler and assigned to an FC of 500 ml of crystalloid were included. The areas under the curve (AUC) and 95% confidence intervals (CI95) of the receiver operating characteristic curves for cumulative volumes from 50 to 450 ml were determined for fluid responsiveness (SV increase ≥15% from baseline) along with other parameters of diagnostic accuracy. In the pharmacodynamic analysis, dose-effect and dose-response models were constructed, with determination of median and 90% effective dose (ED50 and ED90). RESULTS Forty-five patients were included. The AUC increased with cumulative volumes of FC up to 250 ml (AUC250 0.93 [CI95: 0.85-1.00]), followed by a plateau above 0.95 of AUC. The optimal volume was 250 ml, associated with a specificity of 0.89 [CI95: 0.78-1.00], a sensitivity of 0.92 [CI95: 0.69-1.00], and a threshold of 9.6% increase in SV. The ED50 was 156 [CI95: 136-177] ml and the ED90 was 312 [CI95: 269-352] ml. CONCLUSIONS A volume of FC of 250 ml with a threshold of 9.6% increase in SV showed the highest accuracy in detecting fluid responsiveness in critically ill patients with shock. CLINICAL TRIAL REGISTRATION .
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Affiliation(s)
- Romain Barthélémy
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France.
| | - Manuel Kindermans
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Paul Delval
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Magalie Collet
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Samuel Gaugain
- AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alexandre Mebazaa
- Université de Paris, AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, MASCOT UMRS 942, Inserm, Paris, France
| | - Benjamin G Chousterman
- Université de Paris, AP-HP, Hôpital Lariboisière, Department of Anesthesia and Critical Care, DMU Parabol, MASCOT UMRS 942, Inserm, Paris, France
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Karlsson J, Svedmyr A, Wiegele M, Lönnqvist PA, Wallin M, Hallbäck M. Cardiac Output Assessments in Anesthetized Children: Dynamic Capnography Versus Esophageal Doppler. Anesth Analg 2021; 134:644-652. [PMID: 34304235 DOI: 10.1213/ane.0000000000005679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The objective of this study was to compare esophageal Doppler cardiac output (COEDM) against the reference method effective pulmonary blood flow cardiac output (COEPBF), for agreement of absolute values and ability to detect change in cardiac output (CO) in pediatric surgical patients. Furthermore, the relationship between these 2 methods and noninvasive blood pressure (NIBP) parameters was evaluated. METHODS Fifteen children American Society of Anesthesiology (ASA) I and II (median age, 8 months; median weight, 9 kg) scheduled for surgery were investigated in this prospective observational cohort study. Baseline COEPBF/COEDM/NIBP measurements were made at positive end-expiratory pressure (PEEP) 3 cm H2O. PEEP was increased to 10 cm H2O and COEPBF/COEDM/NIBP was recorded after 1 and 3 minutes. PEEP was then lowered to 3 cm H2O, and all measurements were repeated after 3 minutes. Finally, 20-µg kg-1 intravenous atropine was given with the intent to increase CO, and all measurements were recorded again after 5 minutes. Paired recordings of COEDM and COEPBF were examined for agreement and trending ability, and all parameters were analyzed for their responses to the hemodynamic challenges. RESULTS Bias between COEDM and COEPBF (COEDM - COEPBF) was -17 mL kg-1 min-1 (limits of agreement, -67 to +33 mL kg-1 min-1) with a mean percentage error of 32% (95% confidence interval [CI], 25-37) and a concordance rate of 71% (95% CI, 63-80). The hemodynamic interventions caused by PEEP manipulations resulted in significant decrease in COEPBF absolute numbers (155 mL kg-1 min-1 [95% CI, 151-159] to 127 mL kg-1 min-1 [95% CI, 113-141]) and a corresponding relative decrease of 18% (95% CI, 14-22) 3 minutes after application of PEEP 10. No corresponding decreases were detected by COEDM. Mean arterial pressure showed a relative decrease with 5 (95% CI, 2-8) and 6% (95% CI, 2-10) 1 and 3 minutes after the application of PEEP 10, respectively. Systolic arterial pressure showed a relative decrease of 5% (95% CI, 2-10) 3 minutes after application of PEEP 10. None of the recorded parameters responded to atropine administration except for heart rate that showed a 4% relative increase (95% CI, 1-7, P = .02) 5 minutes after atropine. CONCLUSIONS COEDM was unable to detect the reduction of CO cause by increased PEEP, whereas COEPBF and to a minimal extent NIBP detected these changes in CO. The ability of COEPBF to react to minor reductions in CO, before noticeable changes in NIBP are seen, suggests that COEPBF may be a potentially useful tool for hemodynamic monitoring in mechanically ventilated children.
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Affiliation(s)
- Jacob Karlsson
- From the Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm Sweden
| | - Anders Svedmyr
- From the Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm Sweden
| | - Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Per-Arne Lönnqvist
- From the Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm Sweden
| | - Mats Wallin
- From the Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Jung S, Kim J, Na S, Nam WS, Kim DH. Ability of Carotid Corrected Flow Time to Predict Fluid Responsiveness in Patients Mechanically Ventilated Using Low Tidal Volume after Surgery. J Clin Med 2021; 10:jcm10122676. [PMID: 34204523 PMCID: PMC8234831 DOI: 10.3390/jcm10122676] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 11/16/2022] Open
Abstract
Predicting fluid responsiveness in patients under mechanical ventilation with low tidal volume (VT) is challenging. This study evaluated the ability of carotid corrected flow time (FTc) assessed by ultrasound for predicting the fluid responsiveness during low VT ventilation. Patients under postoperative mechanical ventilation and clinically diagnosed with hypovolemia were enrolled. Carotid FTc and pulse pressure variation (PPV) were measured at VT of 6 and 10 mL/kg predicted body weight (PBW). FTc was calculated using both Bazett’s (FTcB) and Wodey’s (FTcW) formulas. Fluid responsiveness was defined as a ≥15% increase in the stroke volume index assessed by FloTrac/Vigileo monitor after administration of 8 mL/kg of balanced crystalloid. Among 36 patients, 16 (44.4%) were fluid responders. The areas under the receiver operating characteristic curves (AUROCs) for the FTcB at VT of 6 and 10 mL/kg PBW were 0.897 (95% confidence interval [95% CI]: 0.750–0.973) and 0.895 (95% CI: 0.748–0.972), respectively. The AUROCs for the FTcW at VT of 6 and 10 mL/kg PBW were 0.875 (95% CI: 0.722–0.961) and 0.891 (95% CI: 0.744–0.970), respectively. However, PPV at VT of 6 mL/kg PBW (AUROC: 0.714, 95% CI: 0.539–0.852) showed significantly lower accuracy than that of PPV at VT of 10 mL/kg PBW (AUROC: 0.867, 95% CI: 0.712–0.957; p = 0.034). Carotid FTc can predict fluid responsiveness better than PPV during low VT ventilation. However, further studies using automated continuous monitoring system are needed before its clinical use.
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Effect of fluid strategy on stroke volume, cardiac output, and fluid responsiveness in adult patients undergoing major abdominal surgery: a sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial. Br J Anaesth 2021; 126:818-825. [PMID: 33632521 DOI: 10.1016/j.bja.2021.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/18/2020] [Accepted: 01/09/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. METHODS Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. RESULTS Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m-2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min-1 m-2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). CONCLUSIONS The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. CLINICAL TRIAL REGISTRATION ACTRN12615000125527.
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Kobe J, Mishra N, Arya VK, Al-Moustadi W, Nates W, Kumar B. Cardiac output monitoring: Technology and choice. Ann Card Anaesth 2020; 22:6-17. [PMID: 30648673 PMCID: PMC6350438 DOI: 10.4103/aca.aca_41_18] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.
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Affiliation(s)
- Jeff Kobe
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Nitasha Mishra
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra K Arya
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Waiel Al-Moustadi
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Wayne Nates
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bhupesh Kumar
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Hong A, Joachim J, Buxin C, Levé C, Le Gall A, Millasseau S, Mateo J, Civelli V, Serrano J, Mebazaa A, Gayat E, Vallée F. Using velocity-pressure loops in the operating room: a new approach of arterial mechanics for cardiac afterload monitoring under general anesthesia. Am J Physiol Heart Circ Physiol 2019; 317:H1354-H1362. [PMID: 31674813 DOI: 10.1152/ajpheart.00362.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and β-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-risk and high-risk patients. In contrast, Ctot, WR, GALA, and β-angle were strongly influenced by cardiovascular risk factors regardless of the site of measurement along the aorta. The GALA angle was inversely related to aortic compliance, and the β-angle reflected the magnitude of wave reflection in both the ascending and descending aortas (P < 0.001). Under general anesthesia, the VP loop can provide new visual insights into arterial mechanical properties compared with the traditional MAP and CO for the assessment of cardiac afterload. Further studies are necessary to demonstrate the clinical utility of the VP loop in the operating room.NEW & NOTEWORTHY Our team recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta under general anesthesia. However, the evaluation of cardiac afterload at this location is unusual. The present study shows that VP loop parameters can describe the components of cardiac afterload both in the ascending and descending thoracic aorta in the operating room. Aging and cardiovascular risk factors strongly influence VP loop parameters. The VP loop could provide continuous visual additional information on the arterial system than the traditional mean arterial pressure and cardiac output during the general anesthesia.
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Affiliation(s)
- A Hong
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - J Joachim
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - C Buxin
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - C Levé
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - A Le Gall
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Mathematical and Mechanical Modeling with Data Interaction in Simulations for Medicine, Inria, Université Paris-Saclay, Palaiseau, France.,Solid Mechanics Laboratory, Ecole Polytechnique, Centre National de la Recherche Scientifique, Palaiseau, France
| | - S Millasseau
- Pulse Wave Consulting, Saint-Leu-La-Forêt, France
| | - J Mateo
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - V Civelli
- Department of Neuroradiology, Lariboisière Hospital, Paris, France
| | - J Serrano
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France
| | - A Mebazaa
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - E Gayat
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France
| | - F Vallée
- Department of Anesthesiology and Intensive Care, Lariboisière-Saint Louis Hospitals, Paris, France.,Inserm, UMRS-942, Paris Diderot University, Paris, France.,Mathematical and Mechanical Modeling with Data Interaction in Simulations for Medicine, Inria, Université Paris-Saclay, Palaiseau, France.,Solid Mechanics Laboratory, Ecole Polytechnique, Centre National de la Recherche Scientifique, Palaiseau, France
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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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Villavicencio C, Leache J, Marin J, Oliva I, Rodriguez A, Bodí M, Soni NJ. Basic critical care echocardiography training of intensivists allows reproducible and reliable measurements of cardiac output. Ultrasound J 2019; 11:5. [PMID: 31359188 PMCID: PMC6638616 DOI: 10.1186/s13089-019-0120-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although pulmonary artery catheters (PACs) have been the reference standard for calculating cardiac output, echocardiographic estimation of cardiac output (CO) by cardiologists has shown high accuracy compared to PAC measurements. A few studies have assessed the accuracy of echocardiographic estimation of CO in critically ill patients by intensivists with basic training. The aim of this study was to evaluate the accuracy of CO measurements by intensivists with basic training using pulsed-wave Doppler ultrasound vs. PACs in critically ill patients. METHODS Critically ill patients who required hemodynamic monitoring with a PAC were eligible for the study. Three different intensivists with basic critical care echocardiography training obtained three measurements of CO on each patient. The maximum of three separate left-ventricular outflow tract diameter measurements and the mean of three LVOT velocity time integral measurements were used. The inter-observer reliability and correlation of CO measured by PACs vs. critical care echocardiography were assessed. RESULTS A total of 20 patients were included. Data were analyzed comparing the measurements of CO by PAC vs. echocardiography. The inter-observer reliability for measuring CO by echocardiography was good based on a coefficient of intraclass correlation of 0.6 (95% CI 0.48-0.86, p < 0.001). Bias and limits of agreement between the two techniques were acceptable (0.64 ± 1.18 L/min, 95% limits of agreement of - 1.73 to 3.01 L/min). In patients with CO < 6.5 L/min, the agreement between CO measured by PAC vs. echocardiography improved (0.13 ± 0.89 L/min; 95% limits of agreement of - 1.64 to 2.22 L/min). The mean percentage of error between the two methods was 17%. CONCLUSIONS Critical care echocardiography performed at the bedside by intensivists with basic critical care echocardiography training is an accurate and reproducible technique to measure cardiac output in critically ill patients.
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Affiliation(s)
- Christian Villavicencio
- Critical Care Department, Joan XXIII-University Hospital, Mallafre Guasch 4, 43007, Tarragona, Spain.
| | - Julen Leache
- Critical Care Department, Joan XXIII-University Hospital, Mallafre Guasch 4, 43007, Tarragona, Spain
| | - Judith Marin
- Critical Care Department, Hospital del Mar-Research Group in Critical Illness (GREPAC), Institut Hospital del Mar d'investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Iban Oliva
- Critical Care Department, Joan XXIII-University Hospital, Mallafre Guasch 4, 43007, Tarragona, Spain
| | - Alejandro Rodriguez
- Critical Care Department, Joan XXIII-University Hospital, Mallafre Guasch 4, 43007, Tarragona, Spain
| | - María Bodí
- Critical Care Department, Joan XXIII-University Hospital, Mallafre Guasch 4, 43007, Tarragona, Spain
| | - Nilam J Soni
- Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.,Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.,Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
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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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Cheng YW, Xu F, Li J. Identification of volume parameters monitored with a noninvasive ultrasonic cardiac output monitor for predicting fluid responsiveness in children after congenital heart disease surgery. Medicine (Baltimore) 2018; 97:e12289. [PMID: 30278500 PMCID: PMC6181535 DOI: 10.1097/md.0000000000012289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 08/16/2018] [Indexed: 01/23/2023] Open
Abstract
No previous study has used an ultrasonic cardiac output monitor (USCOM) to assess volume parameters, such as stroke volume variation (SVV), in order to predict the volume status and fluid responsivenes in children after congenital heart disease (CHD) surgery. The present prospective trial aimed to investigate the ability of SVV and corrected flow time (FTc), which were assessed with a USCOM, for predicting fluid responsiveness in children after CHD surgery.The study included 60 children who underwent elective CHD surgery. Data were collected after elective CHD surgery. After arrival at PICU, the continuous invasive blood pressure was monitored. Once the blood pressure (BP) decreased to the minimum value, 6% hydroxyethyl starch (130/0.4) was administered (10 mL/kg) over 30 minutes for volume expansion (VE). The USCOM was used to monitor the heart rate, central venous pressure, stroke volume index (SVI), cardiac index, SVV, FTc of the children before and after VE. Additionally, the SVI change (ΔSVI) was calculated, and the inotropic score (IS) was determined. Children with a ΔSVI ≥15% were considered responders, while the others were considered nonresponders. The children were also divided into IS ≤10 and IS >10 groups.Of the 60 children, 32 were responders and 28 were nonresponders. We found that only SVV was significantly correlated with ΔSVI (r = 0.42, P < .01). SVV could predict fluid responsiveness after surgery (area under the curve [AUC]: 0.776, P < .01), and the optimal threshold was 17.04% (sensitivity, 84.4%; specificity, 60.7%). Additionally, the SVV AUC was higher in the IS >10 group than in the IS ≤10 group (0.81 vs 0.73).SVV measured with a USCOM can be used to predict fluid responsiveness after CHD surgery in children. Additionally, the accuracy of SVV for predicting fluid responsiveness might be higher among patients with an IS >10 than among those with an IS ≤10.
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Affiliation(s)
- Yu-wei Cheng
- Department of Emergency of Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Feng Xu
- Department of PICU of Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Jing Li
- Department of PICU of Children's Hospital of Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- Key Laboratory of Pediatrics in Chongqing
- Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
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Kim DH, Shin S, Kim JY, Kim SH, Jo M, Choi YS. Pulse pressure variation and pleth variability index as predictors of fluid responsiveness in patients undergoing spinal surgery in the prone position. Ther Clin Risk Manag 2018; 14:1175-1183. [PMID: 30013353 PMCID: PMC6038863 DOI: 10.2147/tcrm.s170395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study investigated the ability of pulse pressure variation (PPV) and pleth variability index (PVI) to predict fluid responsiveness of patients undergoing spinal surgery in the prone position. Patients and methods A total of 53 patients undergoing posterior lumbar spinal fusion in the prone position on a Jackson table were studied. PPV, PVI, and hemodynamic and respiratory variables were measured both before and after the administration of 6 mL/kg colloid in both the supine and prone positions. Fluid responsiveness was defined as a 15% or greater increase in stroke volume index, as assessed by esophageal Doppler monitor after fluid loading. Results In the supine position, 40 patients were responders. The areas under the receiver operating characteristic (ROC) curves for PPV and PVI were 0.783 [95% CI 0.648–0.884, P<0.001] and 0.814 (95% CI 0.684–0.908, P<0.001), respectively. The optimal cut-off values of PPV and PVI were 10% (sensitivity 75%, specificity 62%) and 8% (sensitivity 78%, specificity 77%), respectively. In the prone position, 27 patients were responders. The areas under the ROC curves for PPV and PVI were 0.781 (95% CI 0.646–0.883, P<0.001) and 0.756 (95% CI 0.618–0.863, P<0.001), respectively. The optimal cut-off values of PPV and PVI were 7% (sensitivity 82%, specificity 62%) and 8% (sensitivity 67%, specificity 69%), respectively. Conclusion Both PPV and PVI were able to predict fluid responsiveness; their predictive abilities were maintained in the prone position.
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Affiliation(s)
- Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Minju Jo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
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Le Dorze M, Huché F, Coelembier C, Rabuel C, Payen D. Impact of fluid challenge increase in cardiac output on the relationship between systemic and cerebral hemodynamics in severe sepsis compared to brain injury and controls. Ann Intensive Care 2018; 8:74. [PMID: 29956057 PMCID: PMC6023801 DOI: 10.1186/s13613-018-0419-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022] Open
Abstract
Background Cognitive dysfunction and delirium after ICU are frequent and may partially result from brain ischemia episodes. We hypothesized that systemic inflammation (severe sepsis or septic shock) modifies the control of brain circulation and the relation between systemic and cerebral hemodynamic after a positive response to fluid challenge (FC). Methods Three groups of patients were studied if they increased stroke volume (SV) > 10% after 250 or 500 ml of crystalloids: control group: patients free of comorbidity anesthetized for orthopedic surgery; sepsis group: patients with severe sepsis or septic shock (classic definition); brain injury (BI) group: trauma brain jury or hemorrhagic stroke with no detectable systemic inflammation. The measurements before and after FC were mean arterial blood pressure (MAP) (radial catheter); SV and cardiac output (CO; transesophageal Doppler); bilateral middle cerebral artery (MCAv) velocity with peak systolic (PSV) and end diastolic (EDV) values (transcranial Doppler); end-tidal CO2. The role of MAP increase was investigated by an arbitrarily threshold increase of 5%, called responder in CO and MAP (RR). The remaining patients were call responders in CO and non-responders in MAP (RnR). Nonparametric tests were used for statistical analysis. Results Among the 86 screened patients, 66 have completed the protocol: 17 in control group; 38 in sepsis group; and 11 in BI group. All patients increased SV > 10% after FC. Only the sepsis group increased MAP [+ 12 (2–25%), p < 0.05] with a significant increase in PSV and EDV [(17 (3–30)% and 17 (12–42)%, respectively (p < 0.05)], which did not change in the two other groups. The septic RR or RnR had similar variations in MCAv after FC. The baseline MAP < or > baseline median MAP had similar MCAv. Conclusions After a FC-induced increase in SV, MCAv (PSV and EDV) increased only in septic group, mostly independently from MAP increase and from baseline MAP level. Cerebral perfusion becomes passively dependent on systemic blood flow, suggesting a modification of the control of cerebrovascular tone in sepsis-induced systemic inflammation. This information has been considered in the clinical management of septic patients. Electronic supplementary material The online version of this article (10.1186/s13613-018-0419-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Florian Huché
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Clément Coelembier
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Christophe Rabuel
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France. .,UMR INSERM 1160, University Paris 7 Denis Diderot, Paris, France.
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Vinayagam D, Thilaganathan B, Stirrup O, Mantovani E, Khalil A. Maternal hemodynamics in normal pregnancy: reference ranges and role of maternal characteristics. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:665-671. [PMID: 28437601 DOI: 10.1002/uog.17504] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 03/31/2017] [Accepted: 04/12/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The main aim of this study was to construct reference ranges of maternal central hemodynamic parameters during pregnancy. The second aim was to determine the maternal and pregnancy characteristics that influence these hemodynamic parameters. METHODS This was a prospective cohort study of low-risk pregnant women attending for routine antenatal care at St George's Hospital, London, UK. Exclusion criteria included any medical disorder present at the time of study recruitment, or development of hypertension or intrauterine fetal growth restriction following study recruitment. Stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR) were obtained using non-invasive cardiac output monitoring (USCOM-1A®). USCOM-1A utilizes a non-imaging probe in the suprasternal notch to obtain velocity-time integrals of transaortic blood flow at the left ventricular outflow tract. Once the distribution of the data with respect to gestational age had been determined, maternal characteristics were added to the model to test whether they provided a significant improvement in the prediction of the median value. RESULTS The study included 627 women with a singleton pregnancy. The estimated median CO was constant for a maternal age above 32 years, but was around 0.5 L/min higher for women aged ≤ 25 years (P < 0.001). Maternal weight (P < 0.001) and height (P < 0.001) significantly affected CO values and there was a significant interaction (P = 0.002) between them. In women with a height of less than 1.60 m, there was no association between median CO and weight; however, in those with a height exceeding 1.60 m, an increase in weight was associated with an increase in CO. SV was primarily associated with height (P < 0.001), although some positive association with weight (P < 0.001) could also be observed within the normal body-mass-index range. Greater height (P < 0.001) was associated with lower median values of SVR, with an estimated difference of around 120 dynes × s/cm5 between 1.60 m and 1.80 m. Advancing maternal age was associated with higher median SVR, with an estimated difference of around 50 dynes × s/cm5 between 25 and 35 years. Smokers had a lower SVR by 73.5 (95% CI, 8.6-138.4) dynes × s/cm5 . CONCLUSION Maternal hemodynamics are influenced significantly by maternal age, height and weight. We provide USCOM-1A-specific reference ranges and a calculator for SV, CO and SVR in uncomplicated pregnancies that correct for maternal age, height and weight. This should enable clinical application and comparison in both uncomplicated and pathological pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Vinayagam
- Fetal Medicine Unit, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St. George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - O Stirrup
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - E Mantovani
- Fetal Medicine Unit, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Fetal Medicine Unit, St. George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Applications of Noninvasive Hemodynamic Monitoring in Obstetric Management. Clin Obstet Gynecol 2018; 60:375-383. [PMID: 28426506 DOI: 10.1097/grf.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Clinicians managing obstetric patients are dependent on valid hemodynamic measurements to guide care. Heart rate and noninvasive blood pressure guide most current care. New hemodynamic monitors are being used to report research findings and are being investigated by clinicians for their value to supplement standard monitoring. These include arterial pulse contour analysis, Doppler velocimetry, and bioimpedance among others. This chapter serves to present these new devices with a critical review of their advantages and limitations, and most importantly the validity of their measurements.
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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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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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Hossein-Nejad H, Mohammadinejad P, Zeinoddini A, Seyedhosseini Davarani S, Banaie M. A new modality for the estimation of corrected flow time via electrocardiography as an alternative to Doppler ultrasonography. Ann Noninvasive Electrocardiol 2017; 23. [PMID: 28432709 DOI: 10.1111/anec.12456] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Evaluation of corrected flow time (FTc) via ultrasonography is one of the suggested modalities for the assessment of intravascular volume status. This study aimed to compare the results of FTc of carotid artery measured via ultrasonography, as a measure of mechanical outcome of the cardiac cycle, with the results of FTc estimation from a new modified formula via electrocardiography (ECG), as a measure of electrical function of the cardiac cycle. METHODS Healthy volunteers were evaluated before and after a passive leg raising (PLR) maneuver. FTc was measured concurrently before and after PLR via a modified method from ECG and via ultrasonography of the carotid artery. RESULTS A total number of 98 healthy volunteers (51 women and 47 men) with a mean age of 30.69 ± 6.28 years were included. There was a significant correlation between FTc measured by ultrasonography and estimated by ECG both before PLR and after PLR (r = .878, p < .0001 and r = .797, p < .0001, respectively). Changes in FTc were slightly higher in measurements by ultrasonography compared to estimations by ECG (22.33 ± 17.15 ms0.5 vs. 15.86 ± 14.25 ms0.5 , p = .001). CONCLUSION Estimation of FTc via ECG is potentially an effective and feasible method for the assessment of volume status at the clinical settings. Further investigations should determine the significance of differences that may be observed between ultrasonography and ECG in patients with either dehydration or volume overload and in the need of real-time volume status assessment.
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18
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Reply to: phenylephrine and cardiac output. Eur J Anaesthesiol 2017; 34:316. [PMID: 28375980 DOI: 10.1097/eja.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Johnson A, Ahrens T. Stroke volume optimization: the new hemodynamic algorithm. Crit Care Nurse 2016; 35:11-27. [PMID: 25639574 DOI: 10.4037/ccn2015427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Critical care practices have evolved to rely more on physical assessments for monitoring cardiac output and evaluating fluid volume status because these assessments are less invasive and more convenient to use than is a pulmonary artery catheter. Despite this trend, level of consciousness, central venous pressure, urine output, heart rate, and blood pressure remain assessments that are slow to be changed, potentially misleading, and often manifested as late indications of decreased cardiac output. The hemodynamic optimization strategy called stroke volume optimization might provide a proactive guide for clinicians to optimize a patient's status before late indications of a worsening condition occur. The evidence supporting use of the stroke volume optimization algorithm to treat hypovolemia is increasing. Many of the cardiac output monitor technologies today measure stroke volume, as well as the parameters that comprise stroke volume: preload, afterload, and contractility.
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Affiliation(s)
- Alexander Johnson
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri.
| | - Thomas Ahrens
- Alexander Johnson is a clinical nurse specialist, Central DuPage Hospital, Cadence Health System-Northwestern Medicine, Winfield, Illinois.Thomas Ahrens is a research scientist, Barnes-Jewish Hospital, St Louis, Missouri
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Rimehaug AE, Skogvoll E, Aadahl P, Lyng O, Nordhaug DO, Løvstakken L, Kirkeby-Garstad I. Minimally invasive beat-by-beat monitoring of cardiac power in normal hearts and during acute ventricular dysfunction. Physiol Rep 2016; 4:4/19/e12989. [PMID: 27702881 PMCID: PMC5064141 DOI: 10.14814/phy2.12989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022] Open
Abstract
Cardiac power, the product of aortic flow and blood pressure, appears to be a fundamental cardiovascular parameter. The simplified version named cardiac power output (CPO), calculated as the product of cardiac output (CO) in L/min and mean arterial pressure (MAP) in mmHg divided by 451, has shown great ability to predict outcome in a broad spectrum of cardiac disease. Beat‐by‐beat evaluation of cardiac power (PWR) therefore appears to be a possibly valuable addition when monitoring circulatory unstable patients, providing parameters of overall cardiovascular function. We have developed a minimally invasive system for cardiac power measurement, and aimed in this study to compare this system to an invasive method (ttPWR). Seven male anesthetized farm pigs were included. A laptop with in‐house software gathered audio from Doppler signals of aortic flow and blood pressure from the patient monitor to continuously calculate and display a minimally invasive cardiac power trace (uPWR). The time integral per cardiac cycle (uPWR‐integral) represents cardiac work, and was compared to the invasive counterpart (ttPWR‐integral). Signals were obtained at baseline, during mechanically manipulated preload and afterload, before and after induced global ischemic left ventricular dysfunction. We found that the uPWR‐integral overestimated compared to the ttPWR‐integral by about 10% (P < 0.001) in both normal hearts and during ventricular dysfunction. Bland–Altman limits of agreement were at +0.060 and −0.054 J, without increasing spread over the range. In conclusion we find that the minimally invasive system follows its invasive counterpart, and is ready for clinical research of cardiac power parameters.
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Affiliation(s)
- Audun E Rimehaug
- Department of Anaesthesiology and Intensive care, Trondheim University Hospital, Trondheim, Norway Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway Circulation research group Trondheim (CIRCUT), Trondheim, Norway
| | - Eirik Skogvoll
- Department of Anaesthesiology and Intensive care, Trondheim University Hospital, Trondheim, Norway Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway Circulation research group Trondheim (CIRCUT), Trondheim, Norway
| | - Petter Aadahl
- Department of Anaesthesiology and Intensive care, Trondheim University Hospital, Trondheim, Norway Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway Circulation research group Trondheim (CIRCUT), Trondheim, Norway
| | - Oddveig Lyng
- Unit of Comparative Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dag O Nordhaug
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway Department of Thoracic Surgery, Trondheim University Hospital, Trondheim, Norway
| | - Lasse Løvstakken
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Anaesthesiology and Intensive care, Trondheim University Hospital, Trondheim, Norway Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway Circulation research group Trondheim (CIRCUT), Trondheim, Norway
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Peachey T, Tang A, Baker EC, Pott J, Freund Y, Harris T. The assessment of circulating volume using inferior vena cava collapse index and carotid Doppler velocity time integral in healthy volunteers: a pilot study. Scand J Trauma Resusc Emerg Med 2016; 24:108. [PMID: 27590048 PMCID: PMC5010685 DOI: 10.1186/s13049-016-0298-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/22/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Assessment of circulating volume and the requirement for fluid replacement are fundamental to resuscitation but remain largely empirical. Passive leg raise (PLR) may determine fluid responders while avoiding potential fluid overload. We hypothesised that inferior vena cava collapse index (IVCCI) and carotid artery blood flow would change predictably in response to PLR, potentially providing a non-invasive tool to assess circulating volume and identifying fluid responsive patients. METHODS We conducted a prospective proof of concept pilot study on fasted healthy volunteers. One operator measured IVC diameter during quiet respiration and sniff, and carotid artery flow. Stroke volume (SV) was also measured using suprasternal Doppler. Our primary endpoint was change in IVCCI after PLR. We also studied changes in IVCCI after "sniff", and correlation between carotid artery flow and SV. RESULTS Passive leg raise was associated with significant reduction in the mean inferior vena cava collapsibility index from 0.24 to 0.17 (p < 0.01). Mean stroke volume increased from 56.0 to 69.2 mL (p < 0.01). There was no significant change in common carotid artery blood flow. Changes in physiology consequent upon passive leg raise normalised rapidly. DISCUSSION Passive leg raise is associated with a decrease of IVCCI and increase in stroke volume. However, the wide range of values observed suggests that factors other than circulating volume predominate in determining the proportion of collapse with respiration. CONCLUSION In contrast to other studies, we did not find that carotid blood flow increased with passive leg raise. Rapid normalisation of post-PLR physiology may account for this.
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Affiliation(s)
- Tom Peachey
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
| | - Andrew Tang
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
| | - Elinor C. Baker
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
| | - Jason Pott
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
| | - Yonathan Freund
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
- Sorbonne université, UPMC univ Paris-06, Paris, France
| | - Tim Harris
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, London, E1 1BB UK
- Emergency Department, Whipps Cross University Hospital, Barts Health NHS Trust, London, UK
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Hossein-Nejad H, Mohammadinejad P, Lessan-Pezeshki M, Davarani SS, Banaie M. Carotid artery corrected flow time measurement via bedside ultrasonography in monitoring volume status. J Crit Care 2015; 30:1199-203. [DOI: 10.1016/j.jcrc.2015.08.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/30/2015] [Accepted: 08/20/2015] [Indexed: 11/25/2022]
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Transesophageal Doppler reliably tracks changes in cardiac output in comparison with intermittent pulmonary artery thermodilution in cardiac surgery patients. J Clin Monit Comput 2015; 31:135-142. [PMID: 26578096 DOI: 10.1007/s10877-015-9806-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
In this study a comparison of cardiac output (CO) measurements obtained with CardioQ transesophageal Doppler (TED) and pulmonary artery catheter (PAC) thermodilution (TD) technique was done in a systematic set-up, with induced changes in preload, afterload and heart rate. Twenty-five patients completed the study. Each patient were placed in the following successive positions: (1) supine, (2) head-down tilt, (3) head-up tilt, (4) supine, (5) supine with phenylephrine administration, (6) pace heart rate 80 beats per minute (bpm), (7) pace heart rate 110 bpm. The agreement of compared data was investigated by Bland-Altman plots, and to assess trending ability a four quadrants plot and a polar plot were constructed. Both methods showed an acceptable precision 6.4 % (PAC TD) and 12.8 % (TED). In comparison with PAC TD, the TED was associated with a mean bias in supine position of -0.30 l min-1 (95 % CI -0.88; 0.27), wide limits of agreement, a percentage error of 69.5 %, and a trending ability with a concordance rate of 92 %, angular bias of 1.1° and a radial sector size of 40.0° corresponding to an acceptable trending ability. In comparison with PAC TD, the CardioQ TED showed a low mean bias, wide limits of agreement and a larger percentage error than should be expected from the precision of the two methods. However, an acceptable trending ability was found. Thus, the CardioQ TED should not replace CO measurements done by PAC TD, but could be a valuable tool in guiding therapy.
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Li H, Critchley LAH, Zhang J. Does using two Doppler cardiac output monitors in tandem provide a reliable trend line of changes for validation studies? J Clin Monit Comput 2015; 30:559-67. [PMID: 26315476 DOI: 10.1007/s10877-015-9753-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 08/10/2015] [Indexed: 11/29/2022]
Abstract
The demise of the pulmonary artery catheter as a gold standard in cardiac output measurement has created the need for new standard. Doppler cardiac output can be measured suprasternally (USCOM) and via the oesophagus (CardioQ). Use in tandem they may provide a reliable trend line of cardiac output changes against which new technologies can be assessed. Data from three similar clinical studies was pooled. Simultaneous USCOM and CardioQ readings, 13 (7-27), were performed every 15-30 min intraoperatively. Within individual patient regression analysis was performed. Data was normalized, CardioQ against USCOM, to eliminate the systematic error component following calibration. Bland-Altman and trend, concordance and polar analysis, were performed on the grouped data. Cardiac output was indexed (CI) to BSA. Data from 53 patients, aged 59 (26-81) years, scheduled for major surgery were included. Within-individual mean (SD) CI was 3.4 (0.6) L min(-1) m(-2). Correlation was good to excellent in 83 % of cases, R(2) > 0.80, and reasonable in 96 %, R(2) > 0.60. Percentage error was 38 %, and decreased to 14 % with normalization. The estimated 95 % precision for a single Doppler reading was ±10 %. Concordance rate was 96.6 % (confidence intervals 94.7-99.5 %) and above the >92 % threshold for good trending ability. Polar analysis also confirmed good trending ability. The regression line between Doppler methods was offset with a slope of 0.9, thus CardioQ CI readings increased relative to USCOM. Both Doppler methods trended cardiac output reliably. Used in tandem they provide a new standard to assess cardiac output trending.
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Affiliation(s)
- Huang Li
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China
| | - Lester A H Critchley
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR
| | - Jie Zhang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR.
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Hemodynamic assessment in the contemporary intensive care unit: a review of circulatory monitoring devices. Crit Care Clin 2015; 30:413-45. [PMID: 24996604 DOI: 10.1016/j.ccc.2014.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The assessment of the circulating volume and efficiency of tissue perfusion is necessary in the management of critically ill patients. The controversy surrounding pulmonary artery catheterization has led to a new wave of minimally invasive hemodynamic monitoring technologies, including echocardiographic and Doppler imaging, pulse wave analysis, and bioimpedance. This article reviews the principles, advantages, and limitations of these technologies and the clinical contexts in which they may be clinically useful.
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Lorne E, Dupont H, Mahjoub Y. Reply from the authors: In a perfect world, we would have used a perfect method for cardiac output monitoring. Br J Anaesth 2015; 115:323-4. [DOI: 10.1093/bja/aev244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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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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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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Canfrán S, Cediel R, Sández I, Caro-Vadillo A, Gómez de Segura IA. Evaluation of an oesophageal Doppler device for monitoring cardiac output in anaesthetised healthy normotensive dogs. J Small Anim Pract 2015; 56:450-5. [DOI: 10.1111/jsap.12362] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/02/2015] [Accepted: 03/09/2015] [Indexed: 12/26/2022]
Affiliation(s)
- S. Canfrán
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - R. Cediel
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - I. Sández
- Itinerant Anaesthesiology Service; Sinergia Veterinaria Madrid Spain
| | - A. Caro-Vadillo
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - I. A. Gómez de Segura
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
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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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Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2014; 62:169-81. [PMID: 25391734 DOI: 10.1007/s12630-014-0265-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy. PRINCIPAL FINDINGS The focus of many devices used for advanced hemodynamic monitoring is on providing measurements of cardiac output, while other, more recent, devices include estimates of fluid responsiveness based on dynamic indices that better predict an individual's response to a fluid bolus. Currently available technologies include the pulmonary artery catheter, esophageal Doppler, arterial waveform analysis, photoplethysmography, venous oxygen saturation, as well as bioimpedance and bioreactance. The underlying mechanistic principles for each device are presented as well as their performance in clinical trials relevant for goal-directed therapy in ERAS. CONCLUSIONS The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.
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Affiliation(s)
- Robert H Thiele
- Technology in Anesthesia & Critical Care Group, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, Departments of Anesthesiology and Biomedical Engineering, University of Virginia School of Medicine, P.O. Box 800710-0710, Charlottesville, VA, 22908-0710, USA,
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Huang L, Critchley LAH. An assessment of two Doppler-Based Monitors to Track Cardiac Output Changes in Anaesthetised Patients Undergoing Major Surgery. Anaesth Intensive Care 2014; 42:631-9. [PMID: 25233178 DOI: 10.1177/0310057x1404200514] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally-invasive cardiac output (CO) monitoring to follow changes in CO would be helpful in anaesthesia practice. Two Doppler systems marketed for this purpose include the CardioQ (Deltex Medical Group, Chichester, United Kingdom), which uses an oesophageal probe, and the USCOM (USCOM Ltd., Sydney, NSW, Australia), which uses a hand-held probe. The aim of the study was to assess the ability of these two methods to track CO during major surgery and to determine their relationship. Twenty patients, age 58 (26 to 81) years, (m/f) 15/5, requiring abdominal surgery were studied. The surgical procedures lasted between 128 and 408 minutes and a total of 285 data pairs (8 to 22 per case) were collected. Time plots showed good tracking ability across a wide range of CO in most patients. Correlation between the two devices was excellent in 14 patients (R2 >0.85), good in another four (R2 >0.64) and poor in two. Regression line data supported the hypothesis that CardioQ under-reads at low CO and over-reads at high CO in respect to the USCOM. However, the precision between the two CO readings was poor with wide limits of agreement and a percentage error of ± 37%. These findings indicate that these devices individually track changes in CO in many patients but cannot be relied upon to provide the same values.
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Affiliation(s)
- L. Huang
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China and Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - L. A. H. Critchley
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Lorne E, Mahjoub Y, Diouf M, Sleghem J, Buchalet C, Guinot PG, Petiot S, Kessavane A, Dehedin B, Dupont H. Accuracy of impedance cardiography for evaluating trends in cardiac output: a comparison with oesophageal Doppler. Br J Anaesth 2014; 113:596-602. [PMID: 24871872 DOI: 10.1093/bja/aeu136] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Impedance cardiography (ICG) enables continuous, beat-by-beat, non-invasive, operator-independent, and inexpensive cardiac output (CO) monitoring. We compared CO values and variations obtained by ICG (Niccomo™, Medis) and oesophageal Doppler monitoring (ODM) (CardioQ™, Deltex Medical) in surgical patients. METHODS This prospective, observational, single-centre study included 32 subjects undergoing surgery with general anaesthesia. CO was measured simultaneously with ICG and ODM before and after events likely to modify CO (vasopressor administration and volume expansion). One hundred and twenty pairs of CO measurements and 94 pairs of CO variation measurements were recorded. RESULTS The CO variations measured by ICG correlated with those measured by ODM [r=0.88 (0.82-0.94), P<0.001]. Trending ability was good for a four-quadrant plot analysis with exclusion of the central zone (<10%) [95% confidence interval (CI) for concordance (0.86; 1.00)]. Moderate to good trending ability was observed with a polar plot analysis (angular bias: -7.2°; 95% CI -12.3°; -2.5°; with radial limits of agreement -38°; 24°). After excluding subjects with chronic obstructive pulmonary disease, a Bland-Altman plot showed a mean bias of 0.47 litre min(-1), limits of agreements between -1.24 and 2.11 litre min(-1), and a percentage error of 35%. CONCLUSION ICG appears to be a reliable method for the non-invasive monitoring of CO in patients undergoing general surgery.
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Affiliation(s)
- E Lorne
- Department of Anesthesiology and Critical Care Medicine and INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Y Mahjoub
- Department of Anesthesiology and Critical Care Medicine and INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - M Diouf
- Biostatistics Department, Amiens University Medical Center, Amiens, France
| | - J Sleghem
- Department of Anesthesiology and Critical Care Medicine and
| | - C Buchalet
- Department of Anesthesiology and Critical Care Medicine and
| | - P-G Guinot
- Department of Anesthesiology and Critical Care Medicine and
| | - S Petiot
- Department of Anesthesiology and Critical Care Medicine and
| | - A Kessavane
- Department of Anesthesiology and Critical Care Medicine and
| | - B Dehedin
- Department of Anesthesiology and Critical Care Medicine and
| | - H Dupont
- Department of Anesthesiology and Critical Care Medicine and INSERM U1088, Jules Verne University of Picardy, Amiens, France
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Critchley LAH, Huang L, Zhang J. Continuous Cardiac Output Monitoring: What Do Validation Studies Tell Us? CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0062-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Staelens A, Tomsin K, Grieten L, Oben J, Mesens T, Spaanderman M, Jacquemyn Y, Gyselaers W. Non-invasive assessment of gestational hemodynamics: benefits and limitations of impedance cardiography versus other techniques. Expert Rev Med Devices 2014; 10:765-79. [DOI: 10.1586/17434440.2013.853466] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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A comparison of noninvasive bioreactance with oesophageal Doppler estimation of stroke volume during open abdominal surgery: an observational study. Eur J Anaesthesiol 2013; 30:501-8. [PMID: 23549128 DOI: 10.1097/eja.0b013e3283603250] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT The anaesthetist must maintain tissue perfusion by ensuring optimal perioperative fluid balance. This can be achieved using less invasive cardiac output monitors such as oesophageal Doppler monitoring (ODM). Other less invasive cardiac output monitors using bio-impedence technology (noninvasive cardiac output monitoring, NICOM) may have a role in monitoring the circulation and informing fluid management decisions. OBJECTIVE To compare estimates of stroke volume from ODM with those from NICOM, a noninvasive monitor using bioreactance, a modification of transthoracic bio-impedence. DESIGN An observational study. SETTING Manchester Royal Infirmary, UK. Data collected in 2011 and 2012. PARTICIPANTS Twenty-two patients scheduled for major, open abdominal surgery. Reasons for noninclusion: atrial fibrillation; heart failure; oesophageal disease; lack of capacity; and known sensitivity to colloid. INTERVENTION All patients had oesophageal Doppler cardiac output monitoring as a standard element of anaesthesia care. We placed NICOM Bioreactance electrodes and recorded stroke volume estimates from both devices. Fluid challenges were given by the anaesthetist and the haemodynamic responses were recorded. MAIN OUTCOME MEASURE Stroke volume during surgery. The Bland-Altman method was used to compare bias and limits of agreement for stroke volume and cardiac output. Fluid responders were defined as patients who increased stroke volume by at least 10% after fluid loading. The precision of each device was calculated during periods of haemodynamic stability. RESULTS We made 788 acceptable measurements of cardiac output. The bias was -6.9 ml and the limits of agreement were -22.9 to 36.8 ml. The percentage error was 57%. Average precision for both the ODM and NICOM were similar, 8.5% (SD 5.4%) and 8.7% (SD 3.2%). The concordance for the stroke volume change following fluid challenge was 90.5%. Both devices produced unacceptable readings with electrical diathermy. CONCLUSION Simultaneous stroke volume estimations made by noninvasive Bioreactance (NICOM) and oesophageal Doppler showed bias and limits of agreement that are not clinically acceptable. The measurements made by these two devices cannot be regarded as interchangeable.
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Schena E, Cecchini S, Saccomandi P, Leuzzi M, Silvestri S. An algorithm to improve the estimation accuracy of a non-invasive method for cardiac output measurement based on prolonged expiration. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:1823-6. [PMID: 24110064 DOI: 10.1109/embc.2013.6609877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac output (CO) monitoring is important in the hemodynamic management of critically ill patients. In a previous study, a novel non-invasive technique for CO monitoring based on prolonged expiration was proposed. The novel method showed good agreement with thermodilution on stable mechanically ventilated patients; unstable patients were excluded. The aim of this study is to improve the outcome of the above mentioned method on hemodynamic unstable patients, requiring vasoactive medications, and showing marked cardiogenic oscillations on waveforms related to expired gases. This prospective study has been carried out on three cardiac surgery patients; eighteen CO measurements were performed on each patient, and these values were compared with data obtained by thermodilution. The designed and tested algorithm allowed to reach a good agreement between CO measured by our method and by thermodilution (e.g., the mean percentage differences were 4%, 11% and 3%). Even though further validation is necessary, the results are quite promising and the adopted solution appears to allow the suitability of the prolonged expiration method also on unstable patients.
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Romagnoli S. Circulatory failure: Exploring macro- and micro-circulation. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Julien F, Hilly J, Sallah TB, Skhiri A, Michelet D, Brasher C, Varin L, Nivoche Y, Dahmani S. Plethysmographic variability index (PVI) accuracy in predicting fluid responsiveness in anesthetized children. Paediatr Anaesth 2013; 23:536-46. [PMID: 23521073 DOI: 10.1111/pan.12139] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Plethysmographic Variability Index (PVI) has been shown to accurately predict responsiveness to fluid loads in adults. The goal of this study was to evaluate PVI accuracy when predicting fluid responsiveness during noncardiac surgery in children. MATERIAL AND METHODS Children aged 2-10 years scheduled for noncardiac surgery under general anesthesia were included. PVI was assessed concomitantly with stroke volume index (SVI). A response to fluid load was defined by an SVI increase of more than 15%. A 10 ml·kg(-1) normal saline intravenous fluid challenge was administered before surgical incision and after anesthetic induction. After incision, fluid challenges were administered when SVI values decreased by more than 15% or where judged necessary by the anesthesiologist. Statistical analyses include receiving operator characteristics (ROC) analysis and the determination of gray zone method with an error tolerance of 10%. RESULTS Fifty-four patients were included, 97 fluid challenges administered and 45 responses recorded. Area under the curve of ROC curves was 0.85 [0.77-0.93] and 0.8 [0.7-0.89] for baseline PVI and SVI values, respectively. Corresponding gray zone limits were [10-17%] and [22-31 ml·m(-2)], respectively. PVI values exhibited different gray zone limits for pre-incision and postincision fluid challenges, whereas SVI values were comparable. PVI value percentages in the gray zone were 34% overall and 44% for challenges performed after surgical incision. DISCUSSION This study found both PVI and prechallenge SVI to be accurate when used to predict fluid load response during anesthetized noncardiac surgery in children. However, a third of recorded PVI values were inconclusive.
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Affiliation(s)
- Florence Julien
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France
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Yang SY, Shim JK, Song Y, Seo SJ, Kwak YL. Validation of pulse pressure variation and corrected flow time as predictors of fluid responsiveness in patients in the prone position. Br J Anaesth 2013; 110:713-20. [DOI: 10.1093/bja/aes475] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Durand P, Bailly Salin J, Roulleau P. Monitoring hémodynamique non invasif chez l’enfant. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0656-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kalantari K, Chang JN, Ronco C, Rosner MH. Assessment of intravascular volume status and volume responsiveness in critically ill patients. Kidney Int 2013; 83:1017-28. [PMID: 23302716 DOI: 10.1038/ki.2012.424] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Accurate assessment of a patient's volume status, as well as whether they will respond to a fluid challenge with an increase in cardiac output, is a critical task in the care of critically ill patients. Despite this, most decisions regarding fluid therapy are made either empirically or with limited and poor data. Given recent data highlighting the negative impact of either inadequate or overaggressive fluid therapy, understanding the tools and techniques available for accurate volume assessment is critical. This review highlights both static and dynamic methods that can be utilized to help in the assessment of volume status.
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Affiliation(s)
- Kambiz Kalantari
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Nordström J, Hällsjö-Sander C, Shore R, Björne H. Stroke volume optimization in elective bowel surgery: a comparison between pulse power wave analysis (LiDCOrapid) and oesophageal Doppler (CardioQ). Br J Anaesth 2012; 110:374-80. [PMID: 23171725 DOI: 10.1093/bja/aes399] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Goal-directed fluid therapy improves outcome in major surgery. We evaluated a new device (LiDCOrapid) against our standard oesophageal Doppler method (ODM) for stroke volume (SV) optimization during colorectal surgery. METHODS This was an observational study in 20 patients undergoing major colorectal surgery within a fast-track protocol. We compared SV values measured simultaneously by LiDCOrapid and ODM before and after 86 fluid challenges. We also evaluated the LiDCOrapid dynamic indices SV variation (SVV) and pulse pressure variation (PPV) as predictors for volume responsiveness, defined as an increase in SV ≥ 10% after 200 ml of colloid. RESULTS SV increased ≥ 10% after 27 out of 86 fluid challenges. For 172 paired SV values, the overall correlation was r=0.39, and bias (limits of agreement) -28 (-91-35) ml, percentage error 70%. The ability of LiDCOrapid to track changes in SV was weak with a concordance rate of 80%, and a sensitivity and specificity of 48% and 81%, respectively, to detect a positive fluid challenge. The area under the curve values (with 95% confidence intervals) for SVV and PPV were 0.72 (0.60-0.83) and 0.66 (0.52-0.79), respectively, indicating low predictive capacity in these setting. CONCLUSIONS LiDCOrapid and ODM devices are not interchangeable. We cannot recommend that the LiDCOrapid replace the standard Doppler method until further device-specific outcome studies on volume optimization are available. The dynamic indices SVV and PPV add little value to a fluid optimization protocol, and should not replace SV measurements with a validated technique.
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Affiliation(s)
- J Nordström
- Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Guinot PG, de Broca B, Abou Arab O, Diouf M, Badoux L, Bernard E, Lorne E, Dupont H. Ability of stroke volume variation measured by oesophageal Doppler monitoring to predict fluid responsiveness during surgery. Br J Anaesth 2012; 110:28-33. [PMID: 22918700 DOI: 10.1093/bja/aes301] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The objective of this study was to test whether non-invasive assessment of respiratory stroke volume variation (ΔrespSV) by oesophageal Doppler monitoring (ODM) can predict fluid responsiveness during surgery in a mixed population. The predictive value of ΔrespSV was evaluated using a grey zone approach. METHODS Ninety patients monitored using ODM who required i.v. fluids to expand their circulating volume during surgery under general anaesthesia were studied. Patients with a preoperative arrhythmia, right ventricular failure, frequent ectopic beats, or breathing spontaneously were excluded. Haemodynamic variables and oesophageal Doppler indices [peak velocity (PV), stroke volume (SV), corrected flow time (FTc), cardiac output (CO), ΔrespSV, and respiratory variation of PV (ΔrespPV)] were measured before and after fluid expansion. Responders were defined by a >15% increase in SV after infusion of 500 ml crystalloid solution. RESULTS SV was increased by ≥15% after 500 ml crystalloid infusion in 53 (59%) of the 90 patients. ΔrespSV predicted fluid responsiveness with an area under the receiver-operating characteristic (AUC) curve of 0.91 [95% confidence interval (95% CI): 0.85-0.97, P<0.0001]. The optimal ΔrespSV cut-off was 14.4% (95% CI: 14.3-14.5%). The grey zone approach identified 12 patients (14%) with a range of ΔrespSV values between 14% and 15%. FTc was not predictive of fluid responsiveness (AUC 0.49, 95% CI: 0.37-0.62, P=0.84). CONCLUSIONS ΔrespSV predicted fluid responsiveness accurately during surgery over a ΔrespSV range between 14% and 15%. In contrast, FTc did not predict fluid responsiveness.
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Affiliation(s)
- P-G Guinot
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens 80054, France.
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Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth 2012; 27:121-34. [PMID: 22609340 DOI: 10.1053/j.jvca.2012.03.022] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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