Volume Status Research Articles

Competencies for proficiency in basic point-of-care ultrasound in anesthesiology: national expert recommendations using Delphi methodology.

Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency. We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada's National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement. We initially identified and circulated (Round 1) 74 competencies across 19 clinical domains (e.g., basics of ultrasound [equipment, nomenclature, clinical governance, physics]; cardiac [left ventricle, right ventricle, valve assessment, pericardial effusion, intravascular volume status] and lung ultrasound anatomy, image acquisition, and image interpretation; and clinical applications [monitoring and serial assessments, persistent hypotension, respiratory distress, cardiac arrest]). After three Delphi rounds (and 100% response rate maintained), panellists ultimately agreed upon 75 competencies. Through national expert consensus, this study identified POCUS competencies suitable for curriculum development and assessment in perioperative anesthesiology. Next steps include designing and piloting a POCUS curriculum and assessment tool(s) based upon these nationally defined competencies.

Importance of Renal Graft Reperfusion Thermoregulation in Living Donor Kidney Transplant Patients: Gasometrical and Hemodynamical Study

INTRODUCTION: Hypothermia, defined as a decrease in core body temperature below 36°C, has a notable influence on hemodynamic variables during anesthesia, which is of great interest in perioperative medicine. Temperature regulation is crucial in anesthetic management because hypothermia can significantly impact the patient's cardiovascular functioning. Accidental (uncontrolled) hypothermia during anesthetic and surgical procedures carries considerable risks such as: Increases the incidence of surgical site infections, prolongs the effects of drugs administered during anesthesia, and disrupts normal coagulation, potentially increasing the risk of bleeding. For these reasons, body temperature regulation is a critical aspect to monitor and control during anesthesia. MATERIAL AND METHODS: A descriptive, observational, single-center, and retrospective study was carried out in patients undergoing a related living donor kidney transplant between June 2022-2023 at the Juarez Hospital in Mexico. All data were collected from the demographic sheets, laboratories and trans anesthetic sheets of the patient's file. The data was integrated into an Excel database and statistical processing was performed in SPSS or STATSm software. The statistical analysis was tested for normality according to Kolmogorov-Smirnov with Lilliefors correction, where it was found that the population has a normal or non-normal distribution. The Mann-Whitney U test was performed to compare the difference of the means between the two groups. A correlation was made with Kendall´s Tau coefficient; All statistical analyzes were performed with a value of p&lt;0.05, considering these significantly. RESULTS: Of the 65 transplanted patients between Jun 2023 and June 2024 only 28 have appropriate inclusion criteria. Of the remaining 28, 16 were female (57.14%) and 12 were male (42.8%) with an average age of recipients of 30.2430.46 ±11.45 years with a weight of 58.23 ±10.47 kg, height 154.20 ±15.32 cm. Gasometrical and Hemodynamic Values upon Reperfusion with a Forced Air Turbine. The gasometrical variables before reperfusion were: Venous pH 7.41±0.05 (p=0.046); Arterial pH 7.40±0.04 (p=0.015); Venous Oxygen Saturation 68.2±9.74% (p = 0.039). Hemodynamic variables before reperfusion were: IC 3.67±1.77 lt/min/m2 (p=0.001); Stroke Volume 79.5±39.6 ml/beat (p=0.022), Oxygen Extraction 25.1±9.95% (p=0.001) and Myocardial Efficiency 0.28±0.06 (p=0.024); The gasometrical variables after reperfusion were: Venous pH 7.40±0.03; Arterial pH 7.380±0.04; Venous Oxygen Saturation 60.03±4.37%; The hemodynamic variables after reperfusion were: IC 2.88±0.48 liter/min/m2; Stroke Volume 65.4±16.01 ml/beat; Oxygen Extraction Rate 36.9±4.31% (p = 0.039) and Myocardial Efficiency 0.32±0.06 Gasometrical and Hemodynamic Values upon Reperfusion without Forced Air Turbine. The gasometrical variables before reperfusion were: Venous pH 7.32±0.04 (p=0.012); Arterial pH 7.30±0.04 (p=0.019); Venous Oxygen Saturation 64.7±8.27% (p = 0.026). Hemodynamic variables before reperfusion were Cardiac Index 3.28±1.66 lt/min/m2 (p=0.006); Stroke Volume 72.39±45.44 ml/beat (p=0.029); Oxygen Extraction 29.11±9.65% (p=0.001) and Myocardial Efficiency 0.268±0.08 (p=0.022). The gasometrical variables after reperfusion were: Venous pH 7.33±0.04; Arterial pH 7.320±0.05; Venous Oxygen Saturation 58.593±5.41%. The hemodynamic variables after reperfusion were: Cardiac Index 2.75±0.69 liter/min/m2, Stroke Volume 59.05±18.81 ml/beat, Oxygen Extraction Rate 38.47±6.17% and Myocardial Efficiency 0.31±0.05. CONCLUSIONS: Understanding the behavior of blood gas and hemodynamic variables upon reperfusion in transplant patients is essential for adequate kidney graft survival. In these patients, the use of a hot forced air turbine improves the conditions under which said reperfusion is performed, impacting not only at the blood gas level (venous pH, arterial pH and venous oxygen saturation) but also at the hemodynamic level (cardiac index, stroke volume, myocardial efficiency The limitations of the study are heterogeneity of the etiologies of CKD, sample size, and volume status prior to the procedure. To date the published works are consistent with the literature.

Laser interstitial thermal therapy for recurrent glioblastomas: a systematic review and meta-analysis.

We aim to investigate the efficacy and safety of laser interstitial thermal therapy (LITT) in treating recurrent glioblastomas (rGBMs). A comprehensive search was conducted in four databases to identify studies published between January 2001 and June 2022 that reported prognosis information of rGBM patients treated with LITT as the primary therapy. The primary outcomes of interest were progression-free survival (PFS) and overall survival (OS) at 6 and 12 months after LITT intervention. Adverse events and complications were also evaluated. Eight eligible non-comparative studies comprising 128 patients were included in the analysis. Seven studies involving 120 patients provided data for the analysis of PFS. The pooled PFS rate at 6 months after LITT was 25% (95% CI 15-37%, I2 = 53%), and at 12 months, it was 9% (95% CI 4-15%, I2 = 24%). OS analysis was performed on 54 patients from six studies, with an OS rate of 92% (95% CI 84-100%, I2 = 0%) at 6 months and 42% (95% CI 13-73%, I2 = 67%) at 12 months after LITT. LITT demonstrates a favorable safety profile with low complication rates and promising tumor control and overall survival rates in patients with rGBMs. Tumor volume and performance status are important factors that may influence the effectiveness of LITT in selected patients. Additionally, the combination of LITT with immune-based therapy holds promise. Further well-designed clinical trials are needed to expand the application of LITT in glioma treatment.

Acute kidney injury and point-of-care ultrasound in liver cirrhosis: redefining hepatorenal syndrome.

Acute kidney injury (AKI) in patients with cirrhosis is a diagnostic challenge due to multiple and sometimes overlapping possible etiologies. Many times, diagnosis cannot be made based on case history, physical examination or laboratory data, especially when the nephrologist is faced with AKI with a hemodynamic basis, such as hepatorenal syndrome. In addition, the guidelines still include generalized recommendations regarding withdrawal of diuretics and plasma volume expansion with albumin for 48 h, which may be ineffective and counterproductive and may have iatrogenic effects, such as fluid overload and acute cardiogenic pulmonary edema. For this reason, the use of new tools, such as hemodynamic point-of-care ultrasound (PoCUS), allows us to phenotype volume status more accurately and ultimately guide medical treatment in a noninvasive, rapid and individualized manner.

Correlation of Caval Index and Central Venous Pressure in Non-ventilated Critically ill Patients

Background: Determination of intravascular volume status can sometimes be challenging part of critically ill patient’s management in ICU. Invasive haemodynamic monitoring of central venous pressure is a useful guide in directing early resuscitative efforts and assist in reducing the morbidity and mortality of ICU patients with severe sepsis/septic shock. Obtaining invasive hemodynamic monitoring can lead to complications and time consuming. Sonographic measurement of the inferior vena cava (IVC) diameter and IVC collapsibility, termed the caval index is a non-invasive method of estimating the fluid status in critically ill patients. The study was designed to see the correlation between caval index and central venous pressure (CVP) in non-ventilated critically ill patients. Objectives: The aim of the study was to evaluate the correlation of caval index and central venous pressure in non-ventilated critically ill patients. Methods: It was a hospital based descriptive type of cross-sectional study, carried out in the ICU at the Department of Anaesthesia, Analgesia, Palliative &amp; Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka from the period of May 2017 to October 2018. A total number of 86 patients were enrolled in this study. Study subjects were patients (age &gt;18 years) with critically-ill non-ventilated and whom central venous catheter inserted for CVP monitoring. Central venous pressure was measured first by CVP manometer. Then IVC diameter and caval index were measured with curvilinear probe of the Sonosite ultrasound device. The correlation of CVP and CI was calculated. Statistical analyses of the results were obtained by using window-based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-24). Results: In this study, according to CVP 33.7% (29) of patients were hypovolemic with mean (±SD) CVP 5.3±1.2 cm H20, euvolemic were 38.3% (33) with mean (±SD) CVP 10.6±1.7 cm H20 and hypervolemic were 27.9% (24) with mean±SD CVP 16.1±1.5 cm H20. Mean caval index (CI) (%) mean (±SD) was found 57.1±7.23 in hypovolemic patients, 39.5±2.65 in euvolemic &amp; hypervolemic patients. So, the result shows &gt;50 % CI is associated with CVP &lt; 8 mm of Hg and &lt; 50% CI is associated with CVP &gt; 8 mm of Hg. Pearsons correlation coefficient test used to assess the strength and nature of correlation between two variables. There was a statistically significant correlation between the mean CVP and the caval index (p &lt; 0.001). So findings revealed that there is an inverse relationship between the caval index and CVP. Conclusion: The caval index had acceptable correlation with CVP at the level of IVC entry into the right atrium. It was concluded that there is an inverse relationship of CVP with the caval index. Bangladesh Crit Care J March 2024; 12 (1): 29-34

A patient diagnosed with new-onset type 1 diabetes and Addison's disease at initial presentation.

A previously healthy 17-year-old female presented to the emergency department with complaints of vomiting, shortness of breath, and tachycardia. She was found to have an elevated blood glucose and was admitted for presumed new onset type 1 diabetes mellitus (T1DM). During the admission, she was noted to have frequent episodes of hypoglycemia despite conservative insulin dosing and high urine output with glucosuria, which seemed out of proportion to her glucose levels and fluid status. She also had persistent hyponatremia despite normalization of blood glucose. Further work-up was initiated to investigate alternative or additional diagnoses to explain these atypical findings. Adrenocorticotropic hormone (ACTH) level was elevated, consistent with the diagnosis of Addison's disease, which led to the subsequent diagnosis of autoimmune polyglandular syndrome type II (APS-2). This is one of the first reports in the literature of concurrent diagnosis of T1DM and Addison's disease at initial presentation and demonstrates the importance of not anchoring to one diagnosis. This case shows the importance of considering multiple diagnoses and investigating atypical signs and symptoms. This case highlights the importance of a thorough history including review of systems. Hyponatremia and recurrent hypoglycemia in a person with type 1 diabetes should raise suspicion for adrenal insufficiency. This case makes us consider the screening for Addison's disease in a person with new onset type 1 diabetes in addition to autoimmune thyroid disease and celiac disease. People with an autoimmune disease should be monitored for other autoimmune diseases in the future.

The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians.

During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.

Fluid therapy in ICU – A review

The most common indications of fluid resuscitation in critical care settings are severe hypovolemia, sepsis, trauma, burns, and perioperative fluid loss. Evaluation of intravascular volume status and the ability for identifying patients who might profit from volume expansion is vital. Traditional markers such as central venous pressure and pulmonary capillary wedge pressure have poor predictive value for fluid responsiveness. Dynamic indices such as pulse pressure variation, stroke volume variation, tidal volume challenge, and passive leg raise test are recommended to predict fluid responsiveness over static markers. The next perplexing part of fluid therapy is the choice of fluid resuscitation. The simplest answer is to provide crystalloids and avoid synthetic colloids (hydroxyethyl startch, gelatin, and dextran). Among the colloids, albumin has a role in certain clinical conditions in critical care settings. Between normal saline and buffered solutions, buffered solutions have the advantage of reducing acid–base disturbances, and chloride burden, and are likely to prevent renal failure. However, the advantage of buffered solutions did not consistently show up in large randomized controlled trials. Although administering fluids is a common therapeutic approach in critical care settings, administering fluids excessively has been linked to fatal outcomes. The resuscitation, optimization, stabilization, and evacuation concept describes the use of a dynamic fluid strategy to optimize benefits and prevent the negative effects of fluid overload. After receiving a patient in an emergency room or intensive care unit with hemodynamic instability, the first thing that comes to mind is whether or not the patient would benefit from fluid administration. How to predict fluid responsiveness? What type of fluids should be administered? When to stop administering fluids and start evacuation are vital questions confronted in day-to-day practice. In this article, we would like to discuss these issues and provide recommendations for current practices.

The Utility of Echocardiography in Estimating Fluid Responsiveness.

Assessing the volume status in critically ill patients is the key to maintain the stability of the hemodynamics; however, it can be challenging to view the complexity of cases and the diversity of shock etiology. Multiple noninvasive means have been used to study the effectiveness of volume resuscitation, but none of them have been used as gold standard. We aim to illustrate the most used techniques: left ventricular outflow tract velocity time integral versus inferior vena cava compressibility index, and highlight their limitations and strengths. These tools are both operator-dependent and might be affected by several factors including ventilator settings.

Prognostic implications of volume status assessed by blood volume analysis in ambulatory heart failure

The prognostic implications of intravascular volume status assessed by blood volume analysis (BVA) in ambulatory heart failure (HF) remain uncertain. The incremental benefits of assessing volume status, beyond the well-established filling pressures, in predicting HF outcomes are unknown.

Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients.

By using inferior vena cava (IVC) measurements, clinicians can detect fluid status and responsiveness and find out the etiology of hypotension, acute heart failure, and sepsis easier. Pocket-sized ultrasound devices (PSUD) may take this advantage a few steps further by their lower costs, user-friendly interface, and easily applicable structure.In this study, we aimed to determine the diagnostic value of a PSUD compared with a standard ultrasound device (SD) for the measurement of IVC diameter (IVCD) and its respiratory variability. We measured the inspiratory, expiratory diameters of IVC, and calculated the inferior vena cava collapsibility index (IVCCI). We investigated 42 intensive care unit (ICU) patients. There was no difference in inspiratory (PSUD: 1.34 ± 0.67 cm; SD: 1.35 ± 0.68 cm) and expiratory (PSUD: 1.98 ± 0.53 cm; SD: 2.01 ± 0.49 cm) IVCD among measurements with PSUD and SD (p > 0.05). There was also no difference between IVCCI's measured with PSUD (39 ± 20%) and SD (39 ± 20%) (p > 0.05). The Bland-Altman analysis revealed that the width of 95% limits of agreement were similar for both devices. There was a good inter-device agreement among PSUD and SD for measurements of IVCD, and there was no difference between IVCCI's measured using both ultrasound devices. We support that the idea of a PSUD is as reliable as a SD for IVC measurements. Inci K, Gürsel G. Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients. Indian J Crit Care Med 2024;28(4):369-374.

Office or home versus 24-h blood pressure measurement in stable kidney transplant recipients.

The aim of this study was to quantify hypertension control and evaluate concordance between all commonly available blood pressure (BP) modalities in kidney transplant recipients (KTRs). For this prospective cross-sectional study, 89 stable KTRs were recruited at the Charité Transplant Outpatient Clinic. For each study participant office [manual office BP (MOBP) and automated office BP (AOBP)], 7-day home (HBPM) and 24-hour ambulatory BP (24h-ABPM) measurements were performed. 80 of the 89 patients recruited had sufficient BP recordings. The mean BP for MOBP, AOBP, HBPM and 24h-ABPM was 129/73, 126/71, 131/85 and 130/81mmHg, respectively. Uncontrolled hypertension, as defined by 24h-ABPM (mean ≥130/80mmHg), was present in 53 (66%) patients. MOBP, AOBP and HBPM classified 19 (24%), 22 (28%) and 41 (51%) patients, respectively, as 'uncontrolled hypertensive'. The Bland-Altman plot showed good agreement between systolic MOBP, AOBP, HBPM and daytime-ABPM (mean bias: -1±13mmHg, -4±13mmHg, 1±10mmHg, respectively). Uncontrolled night-time hypertension was present in 74 (93%) KTRs, with 71 (89%) patients showing a non-physiological dipping pattern. Moderate positive correlation between daytime-ABPM/HBPM and night-time-ABPM (Pearson correlation coefficients: 0.62-0.73), followed by MOBP/AOBP (Pearson correlation coefficients: 0.49-0.59) was noted. Estimated eGFR and proteinuria displayed weak correlation with 24h-, daytime- and night-time-ABPM (absolute values of Pearson correlation coefficients: 0.04-0.41). No robust association with either 24h-, daytime- or night-time-ABPM was observed for volume status exams. Masked hypertension is highly prevalent in KTRs, especially due to high rates of uncontrolled night-time hypertension. HBPM shows the narrowest limits of agreement with daytime-ABPM. Daytime-ABPM and HBPM show the highest, albeit clinically insufficient, correlation with night-time-ABPM. Systematic integration of 24h-ABPM into clinical practice, as proposed by the 2023 ESH guidelines for the management of arterial hypertension, should not be withheld for the KTR population. Clinical trials evaluating the treatment of hypertension in KTRs are urgently needed.

Monitoring the venous circulation: novel techniques and applications.

Venous pressure is an often-unrecognized cause of patient morbidity. However, bedside assessment of PV is challenging. We review the clinical significance of venous pressure measurement, existing techniques, and introduce the Venous Excess Ultrasound (VExUS) Score as a novel approach using doppler ultrasound to assess venous pressure. Studies show clear associations between elevated venous pressure and adverse outcomes in critically ill patients. Current venous pressure measurement techniques include physical examination, right heart catheterization (RHC), two-dimensional ultrasound, and a variety of labor-intensive research-focused physiological maneuvers. Each of these techniques have specific shortcomings, limiting their clinical utility. To address these gaps, Beaubien-Souligny et al. introduced the VExUS Score, a novel doppler ultrasound-based method that integrates IVC diameter with doppler measurements of the hepatic, portal, and renal veins to generate a venous congestion assesment. Studies show strong correlations between VExUS score and RHC measurements, and well as an association between VExUS score and improvement in cardiorenal acute kidney injury, diuretic response, and fluid status shifts. However, studies in noncardiac populations have been small, heterogenous, and inconclusive. Early studies evaluating the use of doppler ultrasound to assess venous congestion show promise, but further research is needed in diverse patient populations and clinical settings.

Incidence and development of validated mortality prediction model among asphyxiated neonates admitted to neonatal intensive care unit at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Northwest Ethiopia, 2021: retrospective follow-up study

IntroductionPerinatal asphyxia is failure to maintain normal breathing at birth. World Health Organization indicates that perinatal asphyxia is the third major cause of neonatal mortality in developing countries accounting for 23% of neonatal deaths every year. At global and national level efforts have done to reduce neonatal mortality, however fatalities from asphyxia remains high in Ethiopia (24%). And there are no sufficient studies to show incidence and prediction of mortality among asphyxiated neonates. Developing validated risk prediction model is one of the crucial strategies to improve neonatal outcomes with asphyxia. Therefore, this study will help to screen asphyxiated neonate at high-risk for mortality during admission by easily accessible predictors. This study aimed to determine the incidence and develop validated Mortality Prediction model among asphyxiated neonates admitted to the Neonatal Intensive Care Unit at Felege-Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia.MethodRetrospective follow-up study was conducted at Felege-Hiwot Comprehensive Specialized Hospital from September 1, 2017, to March 31, 2021. Simple random sampling was used to select 774 neonates, and 738 were reviewed. Since was data Secondary, it was collected by checklist. After the description of the data by table and graph, Univariable with p-value < 0.25, and stepwise multivariable analysis with p-value < 0.05 were done to develop final reduced prediction model by likelihood ratio test. To improve clinical utility, we developed a simplified risk score to classify asphyxiated neonates at high or low-risk of mortality. The accuracy of the model was evaluated using area under curve, and calibration plot. To measures all accuracy internal validation using bootstrapping technique were assessed. We evaluated the clinical impact of the model using a decision curve analysis across various threshold probabilities.ResultIncidence of neonatal mortality with asphyxia was 27.2% (95% CI: 24.1, 30.6). Rural residence, bad obstetric history, amniotic fluid status, multiple pregnancy, birth weight (< 2500 g), hypoxic-ischemic encephalopathy (stage II and III), and failure to suck were identified in the final risk prediction score. The area under the curve for mortality using 7 predictors was 0.78 (95% CI 0.74 to 0.82). With ≥ 7 cutoffs the sensitivity and specificity of risk prediction score were 0.64 and 0.82 respectively.Conclusion and recommendationIncidence of neonatal mortality with asphyxia was high. The risk prediction score had good discrimination power built by rural residence, bad obstetric history, stained amniotic fluid, multiple pregnancy, birth weight (< 2500 g), hypoxic-ischemic encephalopathy (stage II and III), and failure to suck. Thus, using this score chart and improve neonatal and maternal service reduce mortality among asphyxiated neonates.

Utility of the Venous Excess Ultrasound (VEXUS) score to track dynamic change in volume status in patients undergoing fluid removal during haemodialysis – the ACUVEX study

BackgroundThe use of ultrasound assessment, including the Venous Excess Ultrasound (VEXUS) score, is increasingly being utilised as part of fluid status assessment in clinical practice. We aimed to evaluate the ability of the VEXUS score to track fluid removal during the course of the dialysis session and explore the relationship between traditional measures of fluid status and venous congestion.MethodsSingle-centre, observational study in patients undergoing intermittent haemodialysis, who presented above their target dry weight. Patients had serial assessment using VEXUS, lung ultrasound and selected echocardiographic measures, before, during and after fluid removal.ResultsAmongst 33 patients analysed, 5 (15%) had an elevated VEXUS score (> 0). There was no difference in starting weight, dry weight or amount of fluid removed in patients with a normal VEXUS score and those with an elevated VEXUS score. In all patients with elevated VEXUS scores, the degree of venous congestion improved during the course of fluid removal. All patients with an elevated VEXUS score had evidence of both right and left ventricular systolic impairment.ConclusionIn patients with ESRF undergoing haemodialysis, the incidence of venous congestion as measured by the VEXUS is low. In patients with elevated VEXUS scores, removal of fluid through haemodialysis improves the venous congestion score. The pattern of LV and RV systolic dysfunction suggests that VEXUS may be a reflection of cardiac failure rather than venous volume status.Trial registrationEthical approval was provided by South Central-Berkshire Research and Ethics Committee and registered on clinicaltrials.org (IRAS305720). Trial registration: ISRCTN14351189 – Retrospectively registered on 30/11/2023.

Evaluating fluid overload in critically ill children.

To review the evaluation and management of fluid overload in critically ill children. Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence. Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.

Predictive value of estimated plasma volume for postoperative hypotension in percutaneous intramyocardial septal radiofrequency ablation treating for hypertrophic obstructive cardiomyopathy

BackgroundEstimated plasma volume status (ePVS) estimated by the Duarte formula is associated with clinical outcomes in patients with heart failure. It remains unclear the predictive value of the ePVS to the postoperative hypotension (POH) in percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) treating hypertrophic obstructive cardiomyopathy (HOCM).MethodsData of HOCM patients who underwent PIMSRA were retrospectively collected. Preoperative ePVS was calculated using the Duarte formulas which derived from hemoglobin and hematocrit ratios. Clinical variables including physical assessment, biological and echocardiographic parameters were recorded. Patients were labeled with or without POH according to the medical record in the hospital. Univariable and multivariable logistic regression were performed to evaluate the association between ePVS and POH. Using different thresholds derived from quartiles and the best cutoff value of the receiver operating characteristic curve, the diagnostic performance of ePVS was quantified.ResultsAmong the 405 patients included in this study, 53 (13.1%) patients were observed with symptomatic POH. Median (IQR) of ePVS in overall patients was 3.77 (3.27~4.40) mL/g and in patients with POH were higher than those without POH. The ePVS was associated with POH, with the odds ratio of 1.669 (95% CI 1.299 ~ 2.144) per mL/g. After adjusted by potential confounders, ePVS remained independently associated with POH, with the approximate odds ratio in different models.ConclusionThe preoperative ePVS derived from the Duarte formulas was independently associated with postoperative hypotension in HOCM patients who underwent PIMSRA and showed prognostic value to the risk stratification of postoperative management.Trial registrationNCT06003478 (22/08/2023).

Positive correlation between echocardiographic tricuspid E peak velocity and central venous pressure in dogs: A preliminary study.

In the absence of vascular obstruction, central venous pressure (CVP) is a hydrostatic pressure in the cranial and caudal vena cava, providing valuable information about cardiac function and intravascular volume status. It is also a component in evaluating volume resuscitation in patients with septic shock and monitoring patients with right heart disease, pericardial disease, or volume depletion. Central venous pressure is calculated in dogs by invasive central venous catheterization, which is considered high-risk and impractical in critically ill patients. This study aimed to investigate the feasibility of using echocardiographic tricuspid E/E' as a noninvasive method to estimate CVP in anesthetized healthy dogs under controlled hypovolemic conditions. Ten male mixed-breed dogs were included in the study after a thorough health assessment. For hypovolemia induction, blood withdrawal was performed, and echocardiographic factors of the tricuspid valve, including peak E and E' velocities, were measured during CVP reduction. Repeated measures analysis of variance and Bonferroni post hoc tests were employed to compare the average difference between measured echocardiographic indices and CVP values derived from catheterization and intermittent measurement methods. Spearman's ρ correlation coefficient was used to evaluate the correlation between echocardiographic indices and CVP. E peak velocity had a significant negative correlation with venous blood pressure phases (r=-0.44, P=.001), indicating a decrease in peak E velocity with progressive CVP reduction. However, tricuspid valve E' peak velocity and E/E' did not correlate with CVP, suggesting that these parameters are not reliable for CVP estimation in dogs.

Beyond the brain: General intensive care considerations in pediatric neurocritical care

Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients.The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.

The Application of Regional Citrate Anticoagulation in Protein A Immunoadsorption: A Single-Center Retrospective Cohort Study

Introduction: Protein A immunoadsorption (IA) is proving to be an effective treatment method for autoimmune diseases and other disorders. Regional citrate anticoagulation (RCA) prevents clotting in extracorporeal circuits without increasing hemorrhage risk in high bleeding risk patients, but there are no specific guidelines for its application in IA. We aimed to evaluate the safety and adverse effects of RCA used in IA therapy. Methods: We conducted a retrospective cohort study of forty-five RCA-IA sessions in 14 HLA-incompatible kidney transplant recipients with focus on the safety and adverse effects of RCA in IA. The extracorporeal circuit was equipped with 4% trisodium citrate solution as an anticoagulant and 10% calcium gluconate solution to compensate for calcium loss. The adverse events, including coagulation and blood biochemical indexes, especially calcium level, were recorded. Results: Our study found that 93.33% of the sessions were without circuit clotting or other significant complications. A slight decrease in fibrinogen level was observed, but without significant variations in other coagulation indexes or platelet count. There was a slight elevation in the potential of hydrogen, bicarbonate, and base excess after 2 h and 6 h posttreatment relative to prior treatment, but these returned to normal levels within 24 h posttreatment. Conclusion: RCA is a feasible, effective, and safe anticoagulation option for IA treatment in HLA-incompatible kidney transplant recipients. Electrolyte disturbances, especially alkalosis, hypocalcemia, hypomagnesemia, and fluid status, should be closely monitored and managed.