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Longino A, Martin K, Leyba K, Siegel G, Thai TN, Riscinti M, Douglas IS, Gill E, Burke J. Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion. Chest 2024; 165:590-600. [PMID: 37813180 DOI: 10.1016/j.chest.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/24/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. RESEARCH QUESTION Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? STUDY DESIGN AND METHODS We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and < 7 mm Hg. RESULTS Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (β = 4.8; 95% CI, 2.6-7.1; P < .01) and 3 (β = 11; 95% CI, 8.9-14; P < .01) and RAP, VExUS grade of 2 (β = 6.8; 95% CI, 0.16-13; P = .045) and 3 (β = 15; 95% CI, 7.3-22; P < .01) and mean pulmonary artery pressure, and VExUS grade of 2 (β = 7.0; 95% CI, 3.9-10; P < .01) and 3 (β = 13; 95% CI, 9.5-17; P < .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10 mm Hg were 0.9 (95% CI, 0.83-0.97), 0.77 (95% CI, 0.68-0.88), and 0.65 (95% CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP < 7 mm Hg were 0.79 (95% CI, 0.70-0.87), 0.74 (95% CI, 0.64-0.84), and 0.62 (95% CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P = .025). INTERPRETATION Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO.
| | - Katie Martin
- University of Colorado School of Medicine, University of Colorado, Aurora, CO
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Theresa N Thai
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Matthew Riscinti
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO
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Kharat A, Tallaa F, Lepage MA, Trinh E, Suri RS, Mavrakanas TA. Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review. Can J Kidney Health Dis 2023; 10:20543581231217853. [PMID: 38148768 PMCID: PMC10750529 DOI: 10.1177/20543581231217853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/22/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose of review Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. Sources of information We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. Methods From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Key findings Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. Limitations The included studies were heterogeneous and of relatively limited quality.
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Affiliation(s)
- Aileen Kharat
- Division of Respirology, Geneva University Hospitals, Switzerland
| | - Faissal Tallaa
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Marc-Antoine Lepage
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Emilie Trinh
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Rita S. Suri
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Thomas A. Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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Magin JC, Wrobel JR, An X, Acton J, Doyal A, Jia S, Krakowski JC, Schoenherr J, Serrano R, Flynn D, McLean D, Grant SA. Venous Excess Ultrasound (VExUS Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study. POCUS J 2023; 8:223-229. [PMID: 38099161 PMCID: PMC10721303 DOI: 10.24908/pocus.v8i2.16792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Objectives: Perioperative fluid administration impacts the rate of complications following surgery. VExUS grading system is a standardized point of care ultrasound (POCUS)-based, comprehensive method to assess volume status. VExUS could serve as a tool to guide fluid management, if validated perioperatively. The primary aim was to assess the success rate of obtaining required windows for VExUS grading , as well as the feasibility within a perioperative setting among noncardiac surgery. Further, this study describes the incidence of perioperative venous congestion and associations with 30-day postoperative complications. Methods: This observational study was conducted in non-critically ill adults undergoing noncardiac surgery. Patients were scanned preoperatively, in the post anesthesia care unit (PACU), and 24 hours postoperatively for venous congestion. Researchers retrospectively captured 30-day complications for multivariate analyses. Results: The cohort included 69 participants. Ninety-one percent of scans over all timepoints were successfully completed. Pre-operatively, 57 (83%) scans were Grade 0, and 11 (16%) were Grade 1. Venous congestion was observed in 29 (44%) patients in the PACU (n=66). 22 (33%) patients were Grade 1, while 7 (11%) were Grade 2. At 24 hours (n=63), 31 patients (49%) had venous congestion: 20 (32%) Grade 1 and 11 (17%) Grade 2. Of the pre-operative Grade 0, 28 (50%) had at least one postoperative scan with venous congestion. No patients were Grade 3 at any timepoint. The 30-day complication rate was 32% (n=22). Eleven (16%) patients developed acute kidney injury (AKI). There was no statistically significant association between VExUS grading and all-cause complications or AKI. Conclusion: This study demonstrates that perioperative VExUS scoring is a feasible tool among a variety of noncardiac surgeries. We highlight that venous congestion is common and increases postoperatively within non-ICU populations. Larger studies are needed to assess the relationship between VExUS grading and postoperative complications.
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Affiliation(s)
- Justin C Magin
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Jacob R Wrobel
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Xinming An
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jacob Acton
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Alexander Doyal
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Shawn Jia
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - James C Krakowski
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jay Schoenherr
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Ricardo Serrano
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - David Flynn
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Duncan McLean
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Stuart A Grant
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
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Spiliotaki E, Saranteas T, Moschovaki N, Panagouli K, Pistioli E, Kitsinelis V, Briasoulis P, Papadimos T. Inferior vena cava ultrasonography in the assessment of intravascular volume status and fluid responsiveness in the emergency department and intensive care unit: A critical analysis review. J Clin Ultrasound 2022; 50:733-744. [PMID: 35302241 DOI: 10.1002/jcu.23194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Abstract
Rapid evaluation of intravascular volume status is vital; either excessive or limited fluid administration may result in adverse patient outcomes. In this narrative review, critical analysis of pertinent diagnostic accuracy studies is developed to delineate the role of inferior vena cava ultrasound measurements in the assessment of both intravascular volume status and fluid responsiveness in the emergency department and intensive care unit. In addition, limitations, and technical considerations of inferior vena cava ultrasound measurements as well as directions for future research are thoroughly discussed.
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Affiliation(s)
- Eleni Spiliotaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodosios Saranteas
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nefeli Moschovaki
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Panagouli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathia Pistioli
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Kitsinelis
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Briasoulis
- Department of Anesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Papadimos
- Department of Anesthesia, Division of critical care, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Abstract
Volume status assessment is a critical but challenging clinical skill and is especially important for the management of patients in the emergency department, intensive care unit, and dialysis unit where accurate intravascular assessment is necessary to guide appropriate fluid management. Assessment of volume status is subjective and can vary from provider to provider, posing clinical dilemmas. Traditional non-invasive methods of volume assessment include assessment of skin turgor, axillary sweat, peripheral edema, pulmonary crackles, orthostatic vital signs, and jugular venous distension. Invasive assessments of volume status include direct measurement of central venous pressure and pulmonary artery pressures. Each of these has their own limitations, challenges, and pitfalls and were often validated based on small cohorts with questionable comparators. In the past 30 years, the increased availability, progressive miniaturization, and falling price of ultrasound devices has made point of care ultrasound (POCUS) widely available. Emerging evidence base and increased uptake across multiple subspecialities has facilitated the adoption of this technology. POCUS is now widely available, relatively inexpensive, free of ionizing radiation, and can help providers make medical decisions with more precision. POCUS is not intended to replace the physical exam, but rather to complement clinical assessment, guiding providers to give thorough and accurate clinical care to their patients. We should be mindful of the nascent literature supporting the use of POCUS and other limitations as uptake increases among providers and be wary not to use POCUS to substitute clinical judgement, but integrate ultrasonographic findings carefully with history and clinical examination.
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Affiliation(s)
- David Kearney
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
| | - Nathaniel Reisinger
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
| | - Sadichhya Lohani
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
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Veitla V, Bhasin B. Focused Cardiac Assessment in Kidney Care. POCUS J 2022; 7:45-50. [PMID: 36896102 PMCID: PMC9994304 DOI: 10.24908/pocus.v7ikidney.14996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Point of care ultrasonography (POCUS) is considered to be a very useful and informative extension of the bedside physical exam. The information obtained from POCUS allows for real time assessment for expedited decision making to improve efficiency in patient care and management. Many programs across the country are now incorporating POCUS into their training schedules to allow their residents, fellows, and faculty to gain competence in the techniques and varied clinical uses of POCUS [1-3]. In nephrology, POCUS has been used at the bedside for access planning, dialysis catheter placement, and to guide kidney biopsies to mention a few applications [4]. There is a wide scope for POCUS in nephrology in addition to kidney and bladder assessment. This includes focused cardiac ultrasound to evaluate the heart for structural and functional abnormalities and lung ultrasound as well. These bedside ultrasound assessments help with point of care management decisions pertaining to volume assessment in acute and chronic kidney disease, adjustment of ultrafiltration goals in dialysis patients, and evaluation of hypotension and dyspnea.
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Affiliation(s)
- Vineet Veitla
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
| | - Bhavna Bhasin
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
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Abstract
Volume overload is widespread in the hemodialysis (HD) patients, which is closely related to cardiovascular complications, hospitalization rates, hospitalization costs, and mortality. Meanwhile it is an important independent prognostic risk factor. Some new technologies for volume assessment have made some progress and are gradually applied in clinical practice, such as blood volume monitoring, lung ultrasound examination, bioelectrical impedance analysis, and corrected flow time. The new technologies can provide clinicians more objective and efficient methods for assessing the volume status of the HD patients, which is beneficial to the HD patients because they can achieve an ideal volume balance and improve the prognosis.
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Affiliation(s)
| | | | - 虹 刘
- 刘虹,, ORCID: 0000-0001-6358-7898
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8
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Homar V, Švab I, Lainščak M. Optimisation of Heart Failure Management in Nursing Homes Using Point-of-Care Ultrasonography: Harmonious Trial Rationale and Design. Zdr Varst 2020; 59:128-36. [PMID: 32952713 DOI: 10.2478/sjph-2020-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Heart failure is common in the nursing home population and presents many diagnostic and therapeutic challenges. Point-of-care ultrasonography is a bedside method that can be used to assess volume status more reliably than clinical examination. This trial was conceived to test whether point-of-care ultrasonography-guided management improves heart failure outcomes among nursing home residents. Methods Nursing home residents with heart failure will be enrolled in a multi-centre, prospective, randomised controlled trial. Residents will first be screened for heart failure. Patients with heart failure will be randomised in 1:1 fashion into two groups. Nursing home physicians will adjust diuretic therapy according to volume status for six months. Point-of-care ultrasonography will be used in the test group and clinical examination in the control group. The primary endpoint will be heart failure deterioration, defined as a composite of any of the following four events: the need for an intravenous diuretic application, the need for an emergency service intervention, the need for unplanned hospitalisation for non-injury causes, or death from whatever cause. Expected results The expected prevalence of heart failure among nursing home residents is above 10%. Point-of-care ultrasonography-guided heart failure management will reduce the number of deteriorations of heart failure in the nursing home population. Conclusion This study will explore the usefulness of point-of-care ultrasonography for heart failure management in the nursing home population.
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Nixon G, Blattner K, Finnie W, Lawrenson R, Kerse N. Use of point-of-care ultrasound for the assessment of intravascular volume in five rural New Zealand hospitals. Can J Rural Med 2020; 24:109-114. [PMID: 31552867 DOI: 10.4103/cjrm.cjrm_26_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Measuring the diameter of the inferior vena cava (IVC) or the height of the jugular venous pressure (JVP) with point-of-care ultrasound (POCUS) is a practical alternative method for estimating a patient's intravascular volume in the rural setting. This study aims to determine whether or not POCUS of the IVC or JVP generates additional useful clinical information over and above routine physical examination in this context. Methods Twenty generalist physicians, working in five New Zealand rural hospitals, recorded their estimation of a patient's intravascular volume based on physical examination and then again after performing POCUS of the IVC or JVP, using a visual scale from 1 to 11. Results Data were available for 150 assessments. There was an only moderate agreement between the pre- and post-test findings (Spearman's correlation coefficient = 0.46). In 28% (42/150) of cases, the difference was four or more points on the scale, and therefore, had the potential to be clinically significant. Conclusion In the rural context, POCUS provides new information that frequently alters the clinician's estimation of a patient's intravascular volume.
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Affiliation(s)
- Garry Nixon
- Department of GP and Rural Health, University of Otago, Dunedin, New Zealand
| | - Katharina Blattner
- Department of GP and Rural Health, University of Otago, Dunedin, New Zealand
| | - Wendy Finnie
- Medical Research Centre, University of Waikato and Waikato District Health Board, Hamilton, New Zealand
| | - Ross Lawrenson
- Medical Research Centre, University of Waikato and Waikato District Health Board, Hamilton, New Zealand
| | - Ngaire Kerse
- School of Population Health, University of Auckland, Auckland, New Zealand
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Ross DW, Abbasi MM, Jhaveri KD, Sachdeva M, Miller I, Barnett R, Narasimhan M, Mayo P, Merzkani M, Mathew AT. Lung ultrasonography in end-stage renal disease: moving from evidence to practice-a narrative review. Clin Kidney J 2017; 11:172-178. [PMID: 29644056 PMCID: PMC5887421 DOI: 10.1093/ckj/sfx107] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 08/21/2017] [Indexed: 01/29/2023] Open
Abstract
Traditionally, point of care ultrasonography in nephrology has been used for renal biopsies and dialysis line placement. However, there is an emerging literature supporting the value of point of care lung ultrasonography in the assessment of volume status for dialysis patients. We conducted a review and identified 12 studies that examined the utility of lung ultrasonography in assessing volume status in patients with end-stage renal disease. We conclude that lung ultrasonography can be used to determine volume status in chronic dialysis patients by identifying lung congestion using the B-line score. Incorporating this technique into practice may have significant diagnostic and prognostic value for this high-risk population, as it provides the nephrologist with a useful bedside technique to assess extravascular lung water. Developing competence in lung ultrasonography is straightforward. The nephrology community should consider adding this useful tool into fellowship training, paralleling its broader use in other internal medicine specialties.
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Affiliation(s)
- Daniel W Ross
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Mohammed M Abbasi
- Division of Pulmonary and Critical Care, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kenar D Jhaveri
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Mala Sachdeva
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Ilene Miller
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Richard Barnett
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Division of Pulmonary/Critical Care, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Mangala Narasimhan
- Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Division of Pulmonary/Critical Care, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Paul Mayo
- Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Division of Pulmonary/Critical Care, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Massini Merzkani
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
| | - Anna T Mathew
- Division of Nephrology, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA.,Department of Internal Medicine, North Shore University Hospital and Long Island Jewish Medical Center and Hofstra Northwell School of Medicine, Great Neck, NY, USA
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de Witt B, Joshi R, Meislin H, Mosier JM. Optimizing oxygen delivery in the critically ill: assessment of volume responsiveness in the septic patient. J Emerg Med 2014; 47:608-15. [PMID: 25088530 DOI: 10.1016/j.jemermed.2014.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 06/10/2014] [Accepted: 06/29/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Assessing volume responsiveness, defined as an increase in cardiac index after infusion of fluids, is important when caring for critically ill patients in septic shock, as both under- and over-resuscitation can worsen outcomes. This review article describes the currently available methods of assessing volume responsiveness for critically ill patients in the emergency department, with a focus on patients in septic shock. OBJECTIVE The single-pump model of the circulation utilizing cardiac-filling pressures is reviewed in detail. Additionally, the dual-pump model evaluating cardiopulmonary interactions both invasively and noninvasively will be described. DISCUSSION Cardiac filling pressures (central venous pressure and pulmonary artery occlusion pressure) have poor performance characteristics when used to predict volume responsiveness. Cardiopulmonary interaction assessments (inferior vena cava distensibility/collapsibility, systolic pressure variation, pulse pressure variation, stroke volume variation, and aortic flow velocities) have superior test characteristics when measured either invasively or noninvasively. CONCLUSION Cardiac filling pressures may be misleading if used to determine volume responsiveness. Assessment of cardiopulmonary interactions has superior performance characteristics, and should be preferentially used for septic shock patients in the emergency department.
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Affiliation(s)
- Benjamin de Witt
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - Raj Joshi
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
| | - Harvey Meislin
- Arizona Emergency Medicine Research Center, Tucson, Arizona
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona; Department of Internal Medicine, Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona, Tucson, Arizona
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