Central Venous Pressure In Patients Research Articles

Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial

BackgroundConventional anesthesia used to reduce central venous pressure (CVP) during hepatectomy includes fluid restriction and vasodilator drugs, which can lead to a reduction in blood perfusion in vital organs and may counteract the benefits of low blood loss. In this study, we hypothesized that milrinone is feasible and effective in controlling low CVP (LCVP) during laparoscopic hepatectomy (LH). Compared with conventional anesthesia such as nitroglycerin, milrinone is beneficial in terms of intraoperative blood loss, surgical environment, hemodynamic stability, and patients’ recovery.MethodsIn total, 68 patients undergoing LH under LCVP were randomly divided into the milrinone group (n = 34) and the nitroglycerin group (n = 34). Milrinone was infused with a loading dose of 10 µg/kg followed by a maintenance dose of 0.2–0.5 µg/kg/min and nitroglycerin was administered at a rate of 0.2–0.5 µg/kg/min until the liver lesions were removed. The characteristics of patients, surgery, intraoperative vital signs, blood loss, the condition of the surgical field, the dosage of norepinephrine, perioperative laboratory data, and postoperative complications were compared between groups. Blood loss during LH was considered the primary outcome.ResultsBlood loss during hepatectomy and total blood loss were significantly lower in the milrinone group compared with those in the nitroglycerin group (P < 0.05). Both the nitroglycerin group and milrinone group exerted similar CVP (P > 0.05). Nevertheless, the milrinone group had better surgical field grading during liver resection (P < 0.05) and also exhibited higher cardiac index and cardiac output during the surgery (P < 0.05). Significant differences were also found in terms of fluids administered during hepatectomy, urine volume during hepatectomy, total urine volume, and norepinephrine dosage used in the surgery between the two groups. The two groups showed a similar incidence of postoperative complications (P > 0.05).ConclusionOur findings indicate that the intraoperative infusion of milrinone can help in maintaining an LCVP and hemodynamic stability during LH while reducing intraoperative blood loss and providing a better surgical field compared with nitroglycerin.Trial registrationChiCTR2200056891,first registered on 22/02/2022.

Low versus standard central venous pressure during laparoscopic liver resection: A systematic review, meta-analysis and trial sequential analysis.

To compare the outcomes of low central venous pressure (CVP) to standard CVP during laparoscopic liver resection. The study design was a systematic review following the PRISMA statement standards. The available literature was searched to identify all studies comparing low CVP with standard CVP in patients undergoing laparoscopic liver resection. The outcomes included intraoperative blood loss (primary outcome), need for blood transfusion, mean arterial pressure, operative time, Pringle time, and total complications. Random- effects modelling was applied for analyses. Type I and type II errors were assessed by trial sequential analysis (TSA). A total of 8 studies including 682 patients were included (low CVP group, 342; standard CVP group, 340). Low CVP reduced intraoperative blood loss during laparoscopic liver resection (mean difference [MD], -193.49 mL; 95% confidence interval [CI], -339.86 to -47.12; p = 0.01). However, low CVP did not have any effect on blood transfusion requirement (odds ratio [OR], 0.54; 95% CI, 0.28-1.03; p = 0.06), mean arterial pressure (MD, -1.55 mm Hg; 95% CI, -3.85-0.75; p = 0.19), Pringle time (MD, -0.99 minutes; 95% CI, -5.82-3.84; p = 0.69), operative time (MD, -16.38 minutes; 95% CI, -36.68-3.39; p = 0.11), or total complications (OR, 1.92; 95% CI, 0.97-3.80; p = 0.06). TSA suggested that the meta-analysis for the primary outcome was not subject to type I or II errors. Low CVP may reduce intraoperative blood loss during laparoscopic liver resection (moderate certainty); however, this may not translate into shorter operative time, shorter Pringle time, or less need for blood transfusion. Randomized controlled trials with larger sample sizes will provide more robust evidence.

Reliability of transient elastography as a noninvasive method for estimating central venous pressure in adult patients after a Fontan procedure

BackgroundIn adult patients, after a Fontan procedure, high central venous pressure (CVP) is a hemodynamic risk factor associated with poor prognosis. High liver stiffness (LS) on transient elastography (TE) is associated with high CVP in patients with heart failure without liver disease. Here, we investigated whether LS assessment using TE is a reliable method to noninvasively evaluate CVP in adult patients after a Fontan procedure, who can present varying degrees of liver fibrosis as a complication. MethodsWe measured LS using TE and CVP by cardiac catheterization in 24 adult patients who had undergone a Fontan procedure. The estimated CVP was calculated using the previously reported formula: −5.8 + 6.7 × ln[LS]. We examined the correlation between LS and CVP, and degree of agreement between the estimated and measured CVPs. Patients were divided into two groups, with or without suspected liver cirrhosis, based on abdominal imaging studies. ResultsThe median patient age was 35 years (interquartile range 25, 39). Overall, there was a strong correlation between LS and CVP (ρ = 0.83, p < 0.001). The estimated CVP based on LS and the CVP measured using cardiac catheterization were positively correlated; however, the estimated CVP tended to be higher than the measured CVP (mean difference 0.9 mmHg [95% limits of agreement: −2.8 to 4.6 mmHg]). These results were consistent across all groups. ConclusionsIn adult patients after a Fontan procedure, LS measured by TE showed a positive correlation with CVP by cardiac catheterization. TE can be useful as a noninvasive estimation of CVP.

Correlation of Internal Jugular Vein Collapsibility With Central Venous Pressure in Patients With Liver Cirrhosis.

We aimed to compare internal jugular vein and inferior vena cava ultrasonography as predictors of central venous pressure in cirrhotic patients. We performed ultrasound assessments of the internal jugular vein (IJV) and the inferior vena cava and then invasively measured central venous pressure (CVP). We then compared their correlation with CVP and performed area under the receiver operating characteristic curves to determine which had best sensitivity and specificity. IJV cross-sectional area collapsibility index at 30° correlated better with CVP ( r = -0.56, P < 0.001), and an IJV AP-CI at 30° ≤ 24.8% was better at predicting a CVP ≥8 mm Hg, with 100% sensitivity and 97.1% specificity. Thus, IJV point-of-care ultrasound might be superior than inferior vena cava point-of-care ultrasound as a predictor of CVP in cirrhotic patients.

Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous Congestion.

Assessment of volume status through the estimation of central venous pressure (CVP) is integral in the care of heart failure (HF). Bedside assessment is limited by obesity, variation in physical examination skills, and expertise in ultrasonography. To validate the accuracy of quantitative and qualitative point-of-care ultrasonography assessment of jugular venous pressure (JVP) in predicting elevated CVP. Prospective observational study using convenience sampling. 2 U.S. academic hospitals. Adult patients undergoing right heart catheterization between 5 February 2019 and 1 March 2021. Estimation of the JVP height by handheld ultrasound device (uJVP), JVP by traditional physical examination, and qualitative presence of a distended uJVP in the upright position (upright-uJVP) was done before invasive measurements. Receiver-operating characteristic analysis of the uJVP was compared with invasive hemodynamics. In 100 participants undergoing right heart catheterization for HF indications (mean age, 59.6 years; 44% with preserved ejection fraction), the uJVP in a reclined position accurately predicted elevated right atrial pressure (RAP) (>10 mm Hg), with an area under the curve of 0.84. A positive uJVP in the upright position was 94.6% specific for predicting elevated RAP. Limited examiners, only 2 centers, and convenience sampling. Point-of-care ultrasonography assessment of the uJVP is feasible, reproducible, and accurately predictive of elevated CVPs in patients undergoing right heart catheterization. Further investigation of clinical application of ultrasound-measured JVP seems warranted. None.

The effects of positive end-expiratory pressure on central venous pressure in patients with different chest wall elastic resistance

Objective: To investigate the role of chest wall elastic resistance in determining the effects of positive end-expiratory pressure (PEEP) on central venous pressure (CVP) in patients with mechanical ventilation (MV). Methods: In this prospective study, according to the median of ratio of chest wall elastic resistance to respiratory system elastic resistance (Ers), patients were divided into high chest wall elastic resistance group (Ecw/Ers≥0.24) and low chest wall elastic resistance group [elastance of chest wall (Ecw)/Ers<0.24]. PEEP was set at 5, 10, 15 cmH2O (1 cmH2O=0.098 kPa) respectively. Clinical data including CVP, heart rate (HR), blood pressure (BP) and respiratory mechanics were recorded. Results: Seventy patients receiving MV were included from November 2017 to December 2018. Clinical characteristics including age, BP, HR, baseline PEEP, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F) and comorbidities were comparable in two groups. However, patients with high Ecw/Ers ratio presented higher body mass index (BMI) than those with low Ecw/Ers ratio[ (25.4±3.2) kg/m2 vs. (23.4±3.2) kg/m2, P=0.011]. As PEEP increased from 5 cmH2O to 10 cmH2O, CVP in high Ecw/Ers group increased significantly compared with that in low Ecw/Ers group [1.75(1.00, 2.13) mmHg (1 mmHg=0.133kPa) vs. 1.50(0.50, 2.00)mmHg,P=0.038], which was the same as PEEP increased from 10 cmH2O to 15 cmH2O [2.00(1.50, 3.00)mmHg vs. 1.50(1.00, 2.00)mmHg,P=0.041] or PEEP increased from 5 cmH2O to 15 cmH2O [ 3.75(3.00,4.63)mmHg vs. 3.00(1.63, 4.00)mmHg, P=0.012]. When PEEP increased from 5 cmH2O to 10 cmH2O, 10 cmH2O to 15 cmH2O and 10 cmH2O to 15 cmH2O, there were significant correlations between Ecw/Ers and CVP elevation (r=0.29, P=0.016; r=0.31, P=0.011; r=0.31, P=0.01 respectively). Conclusions: In patients receiving mechanical ventilation, elevation of PEEP leads to a synchronous change of CVP, which is corelated with patients' chest wall elastic resistances.

CVP and echo Measurements are Associated with Improved Outcomes in Patients with Gastrointestinal (GI) Hemorrhage: A Retrospective Analysis of the MIMIC- IV Database.

Purpose: Mortality associated with acute Gastrointestinal (GI) hemorrhage in intensive care units (ICU) has remained high in patients suffering from hemodynamic instability. Prompt recognition and rapid assessment of bleeding severity are crucial to improve survival. Central venous pressure (CVP) monitoring is commonly used for early recognition of intravascular imbalances, but its effectiveness in predicting fluid responsiveness is often questioned. Echocardiography (echo) is a rapid, noninvasive method to repeatedly assess cardiac function and fluid responsiveness. This study investigated the impact of CVP and echo measurements on the outcomes of critically ill patients with GI hemorrhage. Methods: The study was based on the Medical Information Mart for Intensive Care IV (MIMIC- IV) database. Patients were divided into four groups according to the usage of CVP and/or echo. The primary outcomes were 7-day, 14-day, 28-day, and overall mortalities after ICU admission. Cox Proportional-Hazards Models were used to elucidate the relationship between CVP/ Echo monitoring and mortality. The severity of illness of patients were adjusted by qSOFA score, SOFA score and base deficit level at admission. Results: Among 1705 eligible patients, 82 patients had both CVP and echo, 85 had CVP only, and 116 had Echo only. The results of survival analysis indicated that, comparing with those without either CVP or echo, the echo utilization was associated with improved mortalities at all time points during ICU stay for patients with moderate GI hemorrhage, and the combined use of CVP and echo was associated with lower 7-day,14-day and overall mortalities for patients with severe GI hemorrhage. Conclusion: Early usage of CVP and echo monitoring or echo alone are associated with lower mortality in the short and long-term when compared to patients without either measurement. Clinicians should consider goal-directed resuscitation guided by echo with/without CVP in patients with GI hemorrhage early after admission to ICU.

A randomized comparison between pulse pressure variation and central venous pressure in patients undergoing renal transplantation.

Background and Aims:Intraoperative fluid management is important in renal transplant recipients with end-stage renal disease. Conventionally, central venous pressure (CVP) has been used to guide perioperative fluid administration but with high incidence of poor graft outcome. There is a requirement of reliable parameter to guide the fluid therapy in these patients so as to minimize the perioperative complications and improve the outcome. Hence, this study was conducted.Material and Methods:This prospective study included 75 patients of chronic kidney disease undergoing renal transplantation. Patients were divided into two groups. Group A (control group): Intraoperative fluids were guided by CVP; Group B: Intraoperative fluids were guided by pulse pressure variation (PPV). Primary outcome measure of this study was incidence of delayed graft functioning, i.e., need of hemodialysis within 7 days of renal transplant. Secondary outcome measures were incidence of perioperative hypotension, post-transplant pulmonary edema, tissue edema, and lactic acidosis.Results:Total amount of fluid before reperfusion was significantly greater in the control group (P = 0.005). However, the total amount of fluid required at the end of surgery was comparable. Delayed graft functioning was seen only in CVP group, although it was not statistically significant. The postoperative tissue edema was more in CVP group (P = 0.03). The postoperative nausea and vomiting, pulmonary edema, and mechanical ventilation were more in CVP group but not statistically significant. Increase in lactate value was more in CVP group.Conclusion:Perioperative fluid guidance by PPV is better than central venous pressure in renal transplant patients.

Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis

Study objectivePrevious studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy. DesignA systematic review and meta-analysis of randomized controlled trials (RCTs). Review methodsRCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation. Main resultsEighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = −311.92 mL, 95% CI [−429.03, −194.81]; P < 0.001, I2 = 96%). Furthermore, blood transfusion volume (MD = −158.85 mL, 95% CI [−218.30, −99.40]; P < 0.001, I2 = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27–0.65, P < 0.001, I2 = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups. ConclusionThe findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy.PROSPERO registration number: CRD42021232829.

Posisi Pasien terhadap Tekanan Vena Sentral

This study aims to identify an increase in central venous pressure in patients given lateral or prone position interventions and to identify the rise in central venous pressure in patients given semi-fowler position intervention in the intensive care unit. This study uses a Quasi-Experimental method with a Case-Control design. The results obtained are the p-value of 0.000, meaning that the research significantly affects the positioning of the central venous pressure (CVP). In conclusion, there was an increase in the average CVP value before and after the passive position intervention was -1,967 cmH2O; on the other hand, there was a decrease in the average CVP value before and after the semi fowler position intervention was 1,867 cmH2O.&#x0D; &#x0D; Keywords: Supine and Semi Fowler Position, Central Venous Pressure

A comparative study of pulse pressure variation, stroke volume variation and central venous pressure in patients undergoing kidney transplantation.

Optimal intraoperative fluid management guided by central venous pressure (CVP), a traditional intravascular volume status indicator, has improved transplanted graft function during kidney transplantation (KT). Pulse pressure variation (PPV) and stroke volume variation (SVV) - dynamic preload indexes - are robust predictors of fluid responsiveness. This study aimed to compare the accuracy of PPV and CVP against SVV in predicting fluid responsiveness in terms of cost-effectiveness after a standardised empiric volume challenge in KT patients. 36 patients undergoing living-donor KT were analysed. PPV, SVV, CVP and cardiac index (CI) were measured before and after fluid loading with a hydroxyethyl starch solution (7 mL/kg of ideal body weight). Patients were classified as responders (n = 12) or non-responders (n = 24) to fluid loading when CI increases were ≥10% or <10%, respectively. The ability of PPV, SVV and CVP to predict fluid responsiveness was assessed using receiver operating characteristic (ROC) curves. SVV and CVP measured before fluid loading were correlated with changes in CI caused by fluid expansion (ρ = 0.33, P = 0.049 and ρ = -0.37, P = 0.026) in contrast to PPV (ρ = 0.14, P = 0.429). The ROC analysis showed that SVV and CVP predicted response to volume loading (area under the ROC curve = 0.781 and 0.727, respectively; P < 0.05). Under the conditions of our study, SVV and CVP exhibited similar performance in predicting fluid responsiveness and could inform fluid management during KT as compared with PPV.

The Most Useful Method To Evaluate The Volume Status Of Critical Patients In The Emergency And Intensive Care Units: Point Of Care Ultrasound

Background: Accurate and rapid assessment of intravascular volume status of the patients in emergency services and intensive care units at diagnosis, treatment and follow-up stages is crucial yet rather difficult. The purpose of hemodynamic monitoring is to determine cardiovascular insufficiency and to provide the most suitable treatment for unstable patients in critical condition.&#x0D; Aim: The study aims to compare vena cava inferior diameter, vena cava inferior- collapsibility index (for spontaneously breathing patients) and vena cava inferior- distensibility index (for patients breathing on mechanical ventilation support) measurement by ultrasonography to central venous pressure measurement by placing invasive catheter for assessment of the intravascular volume status and making an accurate volume replacement in emergency service and intensive care units and to determine the correlation between them.&#x0D; Material and Methods: The study was carried out prospectively on the patients above the age of 18 who applied to the emergency service clinic between the dates of 01.06.2014 and 01.04.2015 or who stayed in the emergency intensive care unit between these dates. Measurements were taken from vena cava inferior in both the inspirium and expirium phases by using M mode and they were recorded in millimeter. Simultaneous central venous pressure measurements were performed on the patients by using manometric devices and the results were recorded in cm H2O.&#x0D; Results: 43.3% of the patients were female (n: 26) and 56.7% were male (n: 34), and the mean age is 70.58 ± 14.86. The study found high degree of positive correlation between central venous pressure and vena cava inferior diameters and high degree of negative correlation between vena cava inferior- collapsibility index . The study also found that there is a high degree of negative correlation between vena cava inferior- distensibility index and central venous pressure in patients receiving mechanical ventilatory support.&#x0D; Conclusion: Measurement of respiratory variation in vena cava inferior diameter by using ultrasonography is a quick, reliable, easily applicable, cost-efficient and non-invasive method in critical patients receiving mechanical ventilatory support or have spontaneous respiration in emergency services and intensive care units and it can be useful in assessing the volume status and estimating central venous pressure.

Pengaruh PEEP Terhadap CVP pada Pasien yang terpasang Ventillator Mekanik : Literatur Review

The purpose of this literature review is to discuss PEEP (Positive End Ekspiratory Pressure) and CVP (Central Venous Pressure) in patients who have ventilators. Adequate interpretation is needed by nurses who make direct observations about the patient's actual volume status without the influence of expiratory end pressure due to the administration of PEEP to patients who are attached to a ventilator. Study of this literature through a search of scientific publications using the database Pubmed, Google Scholar, Science Direct. Pubmed. Criteria for inclusion of this research article on PEEP and CVP in patients who are ventilators with publications between 2010-2017. This study shows that the effect of changing CVP values greatly influences hemodynamics and fluid status in the patient's body and determines the next interventions that will be given to patients so that changes in CVP values with PEEP in patients who are fitted with mechanical ventilators are needed in order to determine a meaningful CVP value. Based on this description, it is recommended that research studies related to changes in the conversion of CVP values with PEEP.

Влияние положения Тренделенбурга и пневмоперитонеума на сердечно-сосудистую систему при робот-ассистированной радикальной простатэктомии.

Introduction. Prostate cancer remains one of the most common malignant neoplasms of the genitourinary system. Robot-assisted radical prostatectomy (RARP) is currently considered the most effective option for the treatment of this pathology. Special conditions of this operation, such as long-term stay of the patient in the Trendelenburg position and pneumoperitoneum, affect blood pressure, vascular resistance and inotropic function of the heart. The clinical significance of this effect remains poorly understood. The aim of the study was to systematize new information about hemodynamic disorders in patients with pneumoperitoneum in the Trendelenburg position in RARP. Materials and methods. The search for relevant studies published before may 2019 was conducted in the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar using the keywords: «prostatectomy», «robotic surgery», «robotic assisted», «robotic laparoscopic radical prostatectomy», «pneumoperitoneum», «Trendelenburg position», «hemodynamics», «hemodynamic changes», «cardiac function», «cardiovascular function» without restrictions on the publication language. Forty one studies were identified, of which 15 were selected according to pre-defined inclusion criteria. Results. Most studies revealed an increase in arterial and central venous pressure in patients with pneumoperitoneum in the Trendelenburg position. Changes in stroke volume and cardiac output were multidirectional. There was also an increase in pulmonary artery pressure and filling pressure, a decrease in the aortic diameter and an increase in vascular resistance, a deterioration in central hemodynamic parameters, and increased microcirculation. Eleven studies did not show a negative effect of the Trendelenburg position and pneumoperitoneum on the cardiovascular system. The developed changes were easily controlled during anesthesia, and in the postoperative period, the indicators of the cardiovascular system returned to normal. In 4 studies, the negative impact of these factors was noted: the development of mitral valve dysfunction, a significant prolongation of the QT interval and an increase in blood pressure, and hemodynamic instability. Conclusions. The position of the Trendelenburg and pneumoperitoneum and in RARP are accompanied by hemodynamic disorders, most of which are controlled and reversible. Further studies with a longer follow-up period are needed to determine their clinical safety.

Relation of Peripheral Venous Pressure to Central Venous Pressure in Patients With Heart Failure, Heart Transplant, and Left Ventricular Assist Device

Peripheral venous pressure (PVP) monitoring is a noninvasive method to assess volume status. We investigated the correlation between PVP and central venous pressure (CVP) in heart failure (HF), heart transplant (HTx), and left ventricular assist device (LVAD) patients undergoing right heart catheterization (RHC). A prospective, cross-sectional study examining PVP in 100 patients from October 2018 to January 2020 was conducted. The analysis included patients undergoing RHC admitted for HF, post-HTx monitoring, or LVAD hemodynamic testing. Sixty percent of patients had HF, 30% were HTx patients, and 10% were LVAD patients. The mean PVP was 9.4 ± 5.3 mm Hg, and the mean CVP was 9.2 ± 5.8 mm Hg. The PVP and CVP were found to be highly correlated (r = 0.93, p < 0.00001). High correlation was also noted when broken down by HF (r = 0.93, p < 0.00001), HTx (r = 0.93, p < 0.00001), and LVAD groups (r = 0.94, p < 0.00005). In conclusion, there is a high degree of correlation between PVP and CVP in HF, HTx, and LVAD patients. PVP measurements can be used as a rapid, reliable, noninvasive estimate of volume status in these patient populations.

A preoperative estimate of central venous pressure is associated with early Fontan failure

ObjectiveEarly Fontan failure is a serious complication after total cavopulmonary connection, characterized by high central venous pressure, low cardiac output, and resistance to medical therapy. This study aimed to estimate postoperative central venous pressure in patients with total cavopulmonary connection using data routinely collected during preoperative assessment. We sought to determine if this metric correlated with measured postoperative central venous pressure and if it was associated with early Fontan failure. MethodsIn this retrospective study, central venous pressure in total cavopulmonary connection was estimated in 131 patients undergoing pre–total cavopulmonary connection assessment by cardiac magnetic resonance imaging and central venous pressure measurement under general anesthesia. Postoperative central venous pressure during the first 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the first 30 days. ResultsEstimated central venous pressure in total cavopulmonary connection correlated significantly with central venous pressure during the first 24 hours in the intensive care unit (r = 0.26, P = .03), particularly in patients without a fenestration (r = 0.45, P = .01). Central venous pressure in total cavopulmonary connection was significantly associated with early Fontan failure (odds ratio, 1.1; 95% confidence interval, 1.01-1.21; P = .03). A threshold of central venous pressure in total cavopulmonary connection 33 mm Hg or greater was found to have the highest specificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confidence interval, 2.5-62.3; P = .002). This association was stronger in patients with single superior vena cava. ConclusionsEstimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flow data. Higher central venous pressure in total cavopulmonary connection is associated with an increased risk of early Fontan failure and is correlated with directly measured post–total cavopulmonary connection pressure. Identification of patients at risk of early Fontan failure has the potential to guide risk-mitigation strategies.

Response of Jugular Venous Pressure to Exercise in Patients With Heart Failure and Its Prognostic Usefulness

Jugular venous pressure (JVP) has been established for the assessment of central venous pressure in patients with heart failure (HF), but data are limited regarding the response of JVP to exercise because of its complicated methods. Simplifying the estimation of JVP may be applied in such situations. JVP was assessed before and after the 6-minute walk test (6MWT) in 81 patients with HF using a simple method by which the JVP was considered high when the internal jugular venous pulsation on the right side was visually identified above the right clavicle in the sitting position. The primary outcome was a composite of cardiovascular death and hospitalization for worsening HF. None of the patients exhibited high JVP before the 6MWT and 11 patients (14%) had a high JVP after. The 6MWT distances were lower in patients with a high JVP after the 6MWT (338 ± 114 m) than those in patients without a high JVP (417 ± 78 m, p = 0.04). During a follow-up period of 13.4 ± 6.9 months, 11 patients died and 8 patients were hospitalized for worsening HF. The incidence of adverse cardiac events was higher in patients with a high JVP after the 6MWT (64%) than in patients without a high JVP after (64% vs 17%; hazard ratio, 7.52; 95% confidence interval, 2.69 to 20.83; p <0.001). In conclusion, high JVP after exercise was associated with exercise intolerance and poor prognosis. The response of JVP to exercise using this simple technique of physical examination may be a new approach for patients with HF for risk assessment.

Central venous pressure and the risk of diuretic-associated acute kidney injury in patients after cardiac surgery

When prescribing diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery. We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1-mm Hg increase in CVP among patients receiving intravenous loop diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting. Among 4,164 patients receiving intravenous loop diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of diuretic use (n = 5,396), the adjusted risk ratio for AKI with diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP. Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for diuretic therapy.

Influence of different lying positions on monitoring of central venous pressure in patients with mechanical ventilation: a systematic review

Objective To review systematically the influence of different lying positions on monitoring of central venous pressure (CVP) in patients with mechanical ventilation. Methods Relevant articles published publicly from database establishment date to June, 30th, 2018 in PubMed, Cochrane Library, Embase, Web of Science, CBM, Chinese Academic Journal Full-text Database (CJFD) , Wanfang and VIP Database were searched on computer. Two researchers independently screened and extracted the literature. RevMan 5.3 software was used for meta-analysis of the included studies. Results Nine literatures were included, including 380 subjects. Meta-analysis showed that there were significant statistical differences in CVP values between 30 degree semi-recumbent position and supine position (WMD=-0.70, 95%CI: -1.15--0.24, P=0.003) , and between 45 degree semi-recumbent position and supine position (WMD=-1.34, 95%CI: -1.82--0.86, P<0.001) , and between 60 degree semi-recumbent position and supine position (WMD=-2.96, 95%CI: -3.91--2.00, P<0.001) . Conclusions There are differences between the CVP measurements in the 30°, 45°, 60° hemi-recumbent position and the supine position. To ensure the accuracy of the CVP measurement values in mechanical ventilation patients, we should take the supine position for measurement. Key words: Central venous pressure; Lying position; Monitoring; Mechanical ventilation; Systematic review

Influence of directed restrictive fluid management strategy on patients with serious burns complicated by severe inhalation injury

Objective: To explore the influence of directed restrictive fluid management strategy (RFMS) on patients with serious burns complicated by severe inhalation injury. Methods: Sixteen patients with serious burns complicated by severe inhalation injury hospitalized in our department from December 2014 to December 2017, meeting the inclusion criteria and treated with RFMS, were enrolled in directed treatment group. Thirty-four patients with serious burns complicated by severe inhalation injury hospitalized in our department from December 2012 to December 2017, meeting the inclusion criteria and without RFMS, were enrolled in routine treatment group. Medical records of patients in 2 groups were retrospectively analyzed. Within post injury day 2, mean arterial pressure (MAP), central venous pressure (CVP), extravascular lung water index (ELWI), global end-diastolic volume index, and pulmonary vascular permeability index of patients in directed treatment group were monitored by pulse contour cardiac output monitoring technology, while MAP and CVP of patients in routine treatment group were monitored by routine method. On post injury day 3 to 7, patients in 2 groups were treated with routine fluid supplement therapy of our Department to maintain hemodynamic stability, and patients in directed treatment group were treated according to RFMS directed with goal of ELWI≤7 mL·kg(-1)·m(-2). On post injury day 3 to 7, total fluid intake, total fluid output, and total fluid difference between fluid intake and output within 24 h, value of blood lactic acid, and oxygenation index of patients in 2 groups were recorded. Occurrence of acute respiratory distress syndrome (ARDS) on post injury day 3 to 7 and 8 to 28, mechanical ventilation time within post injury day 28, and occurrence of death of patients in 2 groups were counted. Data were processed with chi-square test, t test, and analysis of variance for repeated measurement. Results: The total fluid intakes within 24 h of patients in directed treatment group were close to those in routine treatment group on post injury day 3, 4, 5, 6, 7 (t=-0.835, -1.618, -2.463, -1.244, -2.552, P>0.05). The total fluid outputs and total fluid differences between fluid intake and output within 24 h of patients in 2 groups on post injury day 3 were close (t=0.931, -2.274, P>0.05). The total fluid outputs within 24 h of patients in directed treatment group were significantly higher than those in routine treatment group on post injury day 4, 5, 6, 7 (t=2.645, 2.352, 1.847, 1.152, P<0.05). The total fluid differences between fluid intake and output within 24 h of patients in directed treatment group were (2 928±768), (2 028±1 001), (2 186±815), and (2 071±963) mL, significantly lower than (4 455±960), (3 434±819), (3 233±1 022), and (3 453±829) mL in routine treatment group (t=-4.331, -3.882, -3.211, -4.024, P<0.05). The values of blood lactic acid of patients in directed treatment group and routine treatment group on post injury day 3, 4, 5, 6, 7 were close (t=0.847, 1.221, 0.994, 1.873, 1.948, P>0.05). The oxygenation indexes of patients in directed treatment group on post injury day 3 and 4 were (298±78) and (324±85) mmHg (1 mmHg=0.133 kPa ), which were close to (270±110) and (291±90) mmHg in routine treatment group (t=-1.574, 2.011, P>0.05). The oxygenation indexes of patients in directed treatment group on post injury day 5, 6, 7 were (372±88), (369±65), and (377±39) mmHg, significantly higher than (302±103), (313±89), and (336±78) mmHg in routine treatment group (t=3.657, 3.223, 2.441, P<0.05). On post injury day 3, 4, 5, 6, 7, patients with ARDS in directed treatment group were less than those in routine treatment group, but with no significantly statistical difference between the 2 groups (χ(2)=0.105, P>0.05). On post injury day 8 to 28, patients with ARDS in directed treatment group were significantly less than those in routine treatment group (χ(2)=0.827, P<0.05). The mechanical ventilation time within post injury day 28 of patients in directed treatment group was apparently shorter than that in routine treatment group (t=-2.895, P<0.05). Death of patients in directed treatment group within post injury day 28 was less than that in routine treatment group, but with no significantly statistical difference between the 2 groups (χ(2)=0.002, P>0.05). Conclusions: Under the circumstance of hemodynamics stability, RFMS directed with goal of ELWI≤7 mL·kg(-1)·m(-2) on post injury day 3 to 7 is an useful strategy, which can reduce occurrence rate of ADRS and shorten mechanical ventilation time of patients with serious burns complicated by severe inhalation injury at late stage of burns.