Central Venous Pressure Measurement Research Articles

Ultrasound Measurement of Inferior Vena Cava Diameter versus Central Venous Pressure as a Tool of Assessment of Intravascular Volume in Adult ICU Patients

Abstract Background Measurements of central venous pressure (CVP), pulmonary arterial catheterization, esophageal Doppler, ultrasound, and trans-esophageal echocardiography may be used to determine the volume status of critically ill patients. Appropriate interpretation of the information offered by hemodynamic monitoring requires the integration of several variables. Echocardiography is increasingly used as a first tool to identify a problem and help select initial treatment. To improve patient management and outcome, the clinician must understand the advantages and the limitations of the various tools and parameters used during ICU stay. Aim of the Work to assess the intravascular volume by comparing between IVC diameter, IVC collapsibility index by ultrasound with central venous pressure (CVP) in critically ill patients. Patients and Methods A clinical interventional study was carried out at department of intensive care at Ain Shams University hospitals – Cairo – Egypt., during a three months (from October 2017 till December 2017).This study was approved by Ethical Committee of Faculty of Medicine, Ain Shams University, including the informed consents which were obtained from either the patient or the closest family member. Results In our study the IVC Collapsibility Index correlated well with the Central Venous Pressure. The sensitivity and specificity of IVC Collapsibility to Central Venous Pressure were also found to be highly statistically significant. The change in IVC diameters were also found to be statistically significant when compared to Central Venous Pressure. Conclusion The IVC CI% can provide a useful guide for noninvasive intravascular volume status and an alternative to CVP measurement assessment in critically ill patients.

How Modest Sonographic Training Changed Outcomes of Critical Cases

Most physicians consider sonography as a radiologist’s concern and still prefer to use clinical parameters or traditional tools to reach a prognosis or to make a delayed diagnosis if other and more sophisticated tools are not readily available. Point of care sonography is nowadays spreading as a multi-utility tool in most specialties because of the failure of traditional tools and impracticality of using sophisticated tools. Ultrasound machines are nowadays cheaper and more portable besides being fast, being reusable, safe and promise a steep curve of learning. I want here to share some of its applications made by junior anesthesia trainees. After only a modest learning period, they made a huge difference in the fate of critical cases or, at least, eased the managements or early prediction of potential problems. In a case of gradual hypoxemia, which was intraoperatively non-responsive to usual measures, sonographic examination of the case showed pneumothorax in which clear clinical parameters usually appear too late and portable x-ray machines are unavailable in the operating theater. In a case of postoperative hypoxemia, tachypnea and tachycardia with high D-dimer, the approach was towards treating it as pulmonary embolism. Sonography excluded pulmonary consolidation and pleural effusion but the diaphragm was seen to be significantly high, which lead to a diagnosis of collapse that caused the management line to be diverted. For acute attack of chest pain and shock, resident ultrasonically excluded pericardial effusion and massive pulmonary embolism but there was also significant myocardial hypokinesia (early sign of cardiac ischemia) while troponin and ECG changes appeared only later. During CPR, we couldn’t be sure whether tracheal tube was placed correctly as capnography failed here. Our examination showed signs of a double trachea (esophageal intubation). In addition to routine use of ultrasound machines by some junior anesthetists for the following purposes: 1. To preoperatively exclude deep vein thrombosis in immobile or other risky patients; 2. To ensure empty stomach preoperatively; 3. To diagnose an approaching shock by evaluating inferior vena cava collapsibility during breathing to guide fluid responsiveness in addition to following B-lines to avoid pulmonary fluid overload. In this way central venous pressure measurements with the concomitant risks were avoided; 4. Peripherally inserted catheter (or cannula) with the aid of ultrasound has gradually replaced the central venous catheter placement and its risks. This has been applied even by some nurses who lacked experience with central catheterization to save many patients who had coagulopathy, long hospitalization, undergoing chemotherapy, suffering from shock, obesity or burn injuries; 5. All this in addition to applying FAST (Focused Assessment with Sonography in Trauma) exam to seek for pathology. Unfortunately, this tool is not yet in wide enough use among different clinical specialties. We do not have to be experts in the use of the ultrasound machine to be able to make a difference in patients’ lives. Let us encourage the use of these machines.

The effects of static and dynamic measurements using transpulmonary thermodilution devices on fluid therapy in septic shock: A systematic review.

Transpulmonary thermodilution devices have been widely shown to be accurate in septic shock patients in assessing fluid responsiveness. We conducted a systematic review to assess the relationship between fluid therapy protocols guided by transpulmonary thermodilution devices on fluid balance and the amount of intravenous fluid used in septic shock. We searched MEDLINE, Embase and The Cochrane Library. Studies were eligible for inclusion if they were prospective, parallel trials that were conducted in an intensive care setting in patients with septic shock. The comparator group was either central venous pressure, early goal-directed therapy or pulmonary artery occlusion pressure. Studies assessing only the accuracy of fluid responsiveness prediction by transpulmonary thermodilution devices were excluded. Two reviewers independently performed the search, extracted data and assessed the bias of each study. In total 27 full-text articles were identified for eligibility; of these, nine studies were identified for inclusion in the systematic review. Three of these trials used dynamic parameters derived from transpulmonary thermodilution devices and six used primarily static parameters to guide fluid therapy. There was evidence for a significant reduction in positive fluid balance in four out of the nine studies. From the available studies, the results suggest the benefit of transpulmonary thermodilution monitoring in the septic shock population with regard to reducing positive fluid balance is seen when the devices are utilised for at least 72 hours. Both dynamic and static parameters derived from transpulmonary thermodilution devices appear to lead to a reduction in positive fluid balance in septic shock patients compared to measurements of central venous pressure and early goal-directed therapy.

Effect of clustered nursing interventions on physiological responses in critically ill patients

Background Caring of the critically ill patients is a fundamental component of a nurse’s clinical practice in ICUs. Clustered nursing interventions are defined as a group of interventions of more than six for each patient in one nursing interaction. Physiological responses may be an immediate response or long-term effects of one or more of the body systems related to physiological condition and therapeutic interventions. Critical care nurses monitor physiologic patient parameters on a regular basis to ensure patient’s stability. Objective The aim was to determine physiological responses related to clustered nursing interventions among critically ill patients. Participants and methods The study was conducted on 80 mechanically ventilated adult patients admitted to ICUs of Alexandria Main University Hospital and Damanhour Medical National Institute. The most common procedures provided by nurses in direct care for those patients based on a pilot study of 10 patients were vital signs measurements, central venous pressure measurement, suctioning, feeding, laboratory sampling, general care, repositioning, and administration of medications. Physiological parameters measured were end-tidal carbon dioxide using capnography, vital signs using bed side monitor, and oxygen saturation using pulse oximeter. They were measured before, at 5 min and 10 min during clustered nursing interventions, immediately after, and 15 min after clustered nursing intervention performance. Results Respiratory rate, systolic blood pressure, and oxygen saturation were significantly changed in relation to clustered nursing interventions. Conclusion Clustered nursing interventions may worsen some physiological parameters in critically ill patients, and therefore, nonclustered interventions should be applied instead. Moreover, continuous monitoring of physiological responses during nursing care is crucial.

Ultrasonographic measurement of inferior vena cava collapsibility index and its correlation to central venous pressure in adult critically ill patients

Background Central venous pressure (CVP) is currently one of the most widely used parameters for the determination of volume status in critically ill patients. To measure CVP, a central venous catheter must be inserted. This process is invasive, requires complex training, and has many complications such as bleeding, traumatic pneumothorax, and infection. Also it may be contraindicated in the presence of coagulation abnormalities which are not a rare finding in critically ill patients. Transabdominal ultrasonographic determination of inferior vena cava (IVC) collapsibility index (CI) can provide a rapid, noninvasive, easy, and reproducible method of determination of volume status in critically ill patients, which avoids the risk and complications of invasive central venous catheterization. Patients and methods The prospective study was carried out in Zagazig University Hospital. A total of 86 patients who were admitted to trauma and surgical emergency ICU at Zagazig University Hospitals were eligible for enrollment in this study over the period of 2 years (October 2015–October 2017). Each patient had simultaneous measurement of CVP and IVC-CI on four different sessions; the first was on admission, the second was 6 h after admission, the third was 12 h after admission, and the fourth was 24 h after admission. The patient sample was divided into two subgroups based on the mode of ventilation and CVP value to compare the strength of correlation between caval index and CVP value in the two groups. Results Our study showed that IVC-CI has significant negative correlation with CVP value (r=−85, P˂0.001 at 95% confidence interval) and it is better correlated with mean arterial blood pressure and lactate clearance as compared with CVP. However, it correlated better in spontaneously breathing patients (r=−0.86, P˂0.001) than in mechanically ventilated patients (r=−0.84, P˂0.001). IVC-CI has shown to correlate better with CVP value in lower values (˂10 cmH2O) (r=−0.8, P˂0.001) than in higher values (≥10 cmH2O) (r=−0.6, P˂0.001). We also concluded an IVC-CI cutoff value of 29% to discriminate between CVP values less than 10 cmH2O and values more than or equal to 10 cmH2O with high sensitivity (88.6%) and specificity (80.4%). Conclusion IVC-CI has a strong inverse relationship with CVP which is more pronounced at low CVP values. Point-of-care ultrasonographically measured IVC-CI is very likely to be a good alternative to CVP measurement with a high degree of precision and reproducibility

P2473Non-invasive assessment of central venous pressure in heart failure: comparing three-dimensional echocardiography and Swan-Ganz catheter

Abstract Background Assessing hemodynamics, in particular central venous pressure (CVP) is essential in heart failure diagnostics, leading individual therapy. Hereby, invasive measurement through Swan-Ganz right heart catheterization (RHC) is considered gold standard for patient evaluation, but catheterization implies risks of invasiveness including bleeding, infection, vessel and nerve injury, as well as patient discomfort. Non-invasive methods are warranted, but no alternative technique is validated yet. Two-dimensional echocardiography (2DE) is believed to be uncertain in this approach as vena cava often shows ellipse-shapes. Therefore, this study sought to investigate standardized and breathing corrected three-dimensional inferior vena cava echocardiography (3DE) to directly compare CVP with right heart catheterization. Methods and results We prospectively included 100 consecutive heart failure patients in this study (mean age 53±12 years, body mass index 27±5, New York Heart Association functional class 2.3±0.6, left ventricular ejection fraction 34.1±12.8%, brain natriuretic peptide 658.13±974.03, 76% male), all underwent Swan-Ganz right-heart catheterization and immediately both 2DE and 3DE (Philips EPIQ 7G) of inferior vena cava. From two-dimensional data the diameter of IVC was measured perpendicularly in long and short-axis. From 3DE data a cross-sectional image of IVC was reconstructed for both vertical and horizontal diameters of IVC as well as the area of IVC. Established 2DE images revealed mean vena cava sizes of 15.9±5.9 mm, while standardized cross-sectional breathing corrected 3DE images showed diameters of 19.8±7.8 mm in longitudinal axis and 15.74±7.8 in short axis. RHC mean CVP was 9.00±5.4 mmHg and correlation of CVP and 2DE measurements failed adequate correlation (2DE 95% CI 0.19–1.61; r=0.25; p=0.312). However, 3DE axis ratio assessment correlated well with invasive CVP and showed reproducible results (3DE 95% CI 0.26–0.69; r=0.89; p<0.01). This resulted for a CVP cut point of 10 mmHg in a 89% true negative and 50% true positive correct detection. Conclusions Standardized 3DE correlates well with invasive CVP while established 2DE usual care assessment does not show reliable CVP correlation. 3DE CVP assessment may represent a more feasible and easily applicable method for CVP measurement, including absence for risks of right heart catheterization. Further studies are ongoing to validate these findings in the future.

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

THE ROLE OF INFERIOR VENA CAVA DIAMETER VARIATION RATIO MEASURED BY ULTRASONOGRAPHY VERSUS CENTRAL VENOUS PRESSURE IN ASSESSMENT OF VOLUME RESPONSIVENESS OF SHOCKED HEPATIC PATIENTS

Background: Liver cirrhosis is a major cause of morbidity and mortality in chronic liver disease patients which is multifactorial in nature, leading to several complications including ascites, variceal bleeding, hepatic encephalopathy and hepatorenal syndrome. Aim of the study: to evaluate the relationship between inferior vena cava (IVC) diameter variation ratio measured by ultrasonography (USG) versus central venous pressure as measured via central venous catheter, and whether it is reliable for use in evaluating intravascular volume status during the management of shock in hepatic patients. Patients and Methods: This study included one hundred cirrhotic liver patients with Child-Pugh classification B and C with acute circulatory failure of either sex, aging ≥18 years old, admitted in the ICU at Ain Shams University hospitals. A standard resuscitation strategy was applied. The patients were monitored using mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP) and ultrasound guided IVC collapsibility index (IVCCI) simultaneously at baseline and along the subsequent stages of standard shock management protocol at intervals 1, 4 and 8 hours. Results: The current study showed that 77 patients (77%) responded to volume resuscitation with improvement as regard elevated MAP with maximal mean value of 67.34 (±4.01) mmHg., decreased HR with minimal mean value of 103 (±4.89) b/min., elevated central venous pressure with maximal mean value of 9.05(±2.07) cmH2O and decreased IVC- CI with minimal mean value of 0.64 (±0.05) after 8 hours of volume management, these patientswere considered volume responders., while 23 patients (23%) didn’t respond to volume resuscitation with no response or even deterioration as regard low MAP with maximal mean value of 49.61 (±3.56) mmHg., high HR with minimal mean value of 133 (±4.86) b/min., low central venous pressure with maximal mean value of 2.17 (±0.78) cmH2O and low fixed IVC- CI with minimal mean value of 0.39 (±0.06) after 8 hours of volume management, despite maximal possible volume of fluid resuscitation necessitating use of vasopressor agents, these patients were considered volume non responders.Conclusion: Measurements of CVP and IVC-CI throughout the study in volume responder patients were found to have a solid negative correlation denoting that Inferior Vena Cava collapsibility index assessment is a safe option being non invasive technique and sensitive at least when compared to measuring CVP and to avoid complications of central venous line (CVL) insertion with its complications especially in hepatic patients with coagulopathy.

Hemodynamic effects of subclinical, clinical and supraclinical plasma alfaxalone concentrations in cats

ObjectiveTo characterize the hemodynamic effects of subclinical, clinical and supraclinical plasma alfaxalone concentrations in cats. Study designExperimental study. AnimalsA group of six adult healthy male neutered cats. MethodsCats were anesthetized with desflurane in oxygen for instrumentation. Catheters were placed in a medial saphenous vein for drug administration and in a carotid artery for arterial blood pressure measurement and blood collection. A thermodilution catheter was placed in the pulmonary artery via an introducer placed in a jugular vein for measurement of central venous pressure, pulmonary artery pressure, pulmonary artery occlusion pressure, cardiac output and core body temperature, and for sampling mixed venous blood. A lead II electrocardiogram was connected. Desflurane administration was discontinued and a target-controlled infusion system was used to administer alfaxalone to reach six plasma alfaxalone concentrations ranging from 1.0 to 30.4 mg L−1, with 7.6 mg L−1 considered a clinical concentration for anesthesia. Cardiovascular measurements were recorded, and arterial and mixed-venous blood samples were collected for blood-gas analysis and plasma alfaxalone concentration measurement at each target concentration. Data were analyzed using a repeated-measures analysis of variance and Dunnett’s test for comparisons to the lowest target concentration. Significance was set at p < 0.05. ResultsMean ± standard deviation plasma alfaxalone concentrations were 0.73 ± 0.32, 1.42 ± 0.41, 3.44 ± 0.40, 6.56 ± 0.43, 18.88 ± 6.81 and 49.47 ± 5.50 mg L−1 for the 1, 1.9, 3.8, 7.6, 15.2, and 30.4 mg L−1 target concentrations, respectively. PaCO2 increased with increasing target plasma alfaxalone concentrations and was 69.4 ± 14.2 mmHg (9.3 ± 1.9 kPa) at the 30.4 mg L−1 target. Some cardiovascular variables were statistically significantly affected by increasing target plasma alfaxalone concentrations. Conclusion and clinical relevanceWithin the plasma concentration range studied, alfaxalone caused hypoventilation, but the cardiovascular effects were of small clinical significance.

Bedside hand vein inspection for noninvasive central venous pressure assessment

Rapid estimates of the central venous pressure (CVP) can be helpful to administer early fluid therapy or to manage cardiac preload in intensive care units, operating rooms or emergency rooms in order to start and monitor an adequate medical therapy. Invasive CVP measurements have inherent and non-negligible complication rates as well as great expenditures. Several noninvasive methods of CVP measurements, like ultrasound-guided techniques, are available, but require trained skills and special equipment which might not be at hand in all situations.Our purpose was to evaluate the feasibility and accuracy of CVP estimates assessed upon the height of hand veins collapse (HVC) using invasively measured CVP as the gold standard.The HVC was determined by slowly lifting the patient's hand while watching the dorsal hand veins to collapse. The vertical distance from the dorsal hand to a transducer air zero port was noted and converted to mmHg. The observer was blinded to the simultaneously measured CVP values, which were categorized as low (<7 mmHg), normal (7–12 mmHg) and high (>12 mmHg).Measurements were performed in 82 patients who had a median [IQR] age of 67 [60;74]. Median CVP was 12 [8;15] mmHg and the median absolute difference between the measured HVC and CVP was 4 [2;7] mmHg. The Spearman correlation coefficient between CVP and HVC was 0.55, 95%-CI [0.35;0.69]. Overall CVP categorization was correct in 45% of the cases. HVC had a sensitivity of 92% for a low CVP with a negative predictive value of 98%. A high HVC had a sensitivity of 29% but a high specificity of 94% for a high CVP.The overall performance of observing the hand vein collapse to estimate CVP was only moderate in the intensive care setting. However, the median difference to the CVP was low and HVC identifies a low CVP with a high sensitivity and excellent negative predictive value.

Effect of Positive End Expiratory Pressure on Central Venous Pressure in Mechanically Ventilated Patients

Background: Central venous pressure (CVP) monitoring remains in common use as an index of circulatory filling and cardiac preload. Positive end-expiratory pressure (PEEP) in mechanically ventilated patients can affect CVP via increasing intra-thoracic pressure. Critical care nurses should be able to measure the CVP competently and identify the factors affecting its readings. Aim: The current study was conducted to determine the effect of PEEP on the CVP readings in mechanically ventilated patients. Methods: a descriptive design used in this study. A convenient sample of 200 adult critically ill patients of both sex, hemodynamically and respiratory stable, having a central venous catheter (CVC) in place, and attached to a mechanical ventilator and pulse oximeter were included in the study. The patient's baseline CVP was recorded while the patient connected to the mechanical ventilator, then the patients were temporary disconnected from the mechanical ventilator and the CVP measured again without the effect of PEEP. Results: About 40% of the study sample aged 45 to 64 years, 52.5% were males, 50 % suffered from respiratory disorders, and 49% were overhydrated. Eighty eight percent of the study sample was on PEEP levels between 5 to 2O. The CVP readings while the patients connected to MV were higher than CVP reading while the patients without PEEP, but these differences were not significant. Conclusion: CVP readings are not significant affected by the PEEP up to 15 cmH2O. The CVP can be reliably measured while patients are connected to MV. Recommendations: Measurement of CVP can be obtained while the patient is connected to MV.

Comparison of Central Venous Pressure (Cvp) Score among Patients on Mechanical Ventilator with Head of Bed (Hob) Elevation 30O; Neutral, Right, and Left Side Positions

Early mobilization is important for critical patients to improve cough reflexes, eliminate bronchial secretions, facilitate work of mucociliary drainage muscles, and to prevent associated pneumonia ventilators and pressure sores. However, at the same time the patient often experiences vital signs change due to fluctuating conditions. Central Venous Pressure (CVP) measurement is oftenly needed to monitor central circulatory system. Unfortunately, in the clinical setting, the patient’s position must be changed first in a 30o neutral head of bed (HoB) position rather than left or right side HoB position. This study aims to examine the differences in of CVP score among patients on mechanical ventilation at HoB position elevation 30o in a neutral, right side, and left side position. This quantitative comparative study involved 24 subjects who were recruited consecutively. Data were analyzed using ANOVA. The results showed that the mean CVP value at neutral HoB position elevation was 13.5 ± 3.96, right sight HoB elevation was 12.8 ± 4.16, and left side HoB elevation was 14.4 ± 4.17. There was a significant difference (p &lt;0.05) among those three positions. Post hoc analysis test found the HoB position 30o neutral vs left side possition was higher and signifficantly difference with HoB elevation 30o neutral vs right side positions (p&lt;0.05). This study suggested nurses need to consider the change of CVP values while changing patiens’ position of HoB elevation 30o neutral, right side, and left side positions. Athough there was statistically difference among three positions, in fact, the value difference was less than 1 cmH2O which clinically did not see any differences.

Inflammatory response and optimalisation of perioperative fluid administration during hyperthermic intraoperative intraperitoneal chemotherapy surgery.

Surgical cytoreduction and simultaneous hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis has a high incidence of postoperative complications. Inadequate intraoperative volume therapy is a known risk factor for the development of postoperative complications. Another possible risk factor is the inflammatory response due to surgery and HIPEC. The aim of this observational pilot study was to monitor fluid intake in the first 24 hours peri- and postoperative by using a non-invasive cardiac output indicator. Furthermore, we measured circulating cytokines and evaluated the possible relation of these changes of inflammatory response with the non-invasive monitored fluid management. Twenty-four patients undergoing cytoreductive surgery and HIPEC for peritoneal carcinomatosis were included. Patients were randomised into either a liberal fluid management group using intra-arterial blood pressure and central venous pressure measurement or a restrictive group by using intra-arterial blood pressure and central venous pressure measurement with FloTrac/Vigileo monitoring. Cytokines were measured with multiplex immunoassays. We found no difference in the amount of fluid administration in patients undergoing HIPEC surgery with FloTrac/Vigileo monitoring compared to standard care. Furthermore, there was no difference in mortality, ICU and hospital length of stay between both groups. A severe inflammatory response was seen in all patients after the HIPEC procedure with a rapid increase of interleukins and C-reactive protein (CRP). There was however no difference between our intervention and control group in the severity of this reaction. Finally, we found no relation between the severity of the inflammatory response and mortality, or a composite end-point of mortality and severe complications within 30 days postoperative. FloTrac/Vigileo monitoring does not lead to a more restrictive fluid administration and does not influence short-term clinical course in patients undergoing HIPEC surgery. The procedure itself leads to a severe inflammatory response, which is not affected by the use of FloTrac/Vigileo. Our data do not support the use of FloTrac/Vigileo monitoring in patients undergoing HIPEC surgery concerning fluid restrictive management.

Three-Dimensional inferior vena cava for assessing central venous pressure in patients with cardiogenic shock

Evaluation of central venous pressure (CVP) by inferior vena cava (IVC) measurements is crucial in the management of patients with cardiogenic shock to optimize drugs therapy. IVC has a complex 3-dimensional (3D) shape but measurements used to estimate CVP remain based on 2-dimensional (2D) echocardiographic imaging. The aim of this study was to investigate the accuracy of CVP estimation by IVC size and collapsibility index obtained using 3D-echocardiography compared with 2D in patients with cardiogenic shock. Eighty consecutive echocardiographic examinations performed in 33 patients (72 ± 15 years, left ventricular ejection fraction = 19 ± 10%) admitted for cardiogenic shock were prospectively included. Two and three-dimensional images of the IVC, performed at baseline and when CVP was ≤ 10 mmHg, were acquired simultaneous with invasive measurement of CVP, both at rest and during sniff test. 2D and 3D IVC diameters, 3D IVC area and collapsibility index (IVCCI) were assessed. The eccentricity index (EI) was computed from 3D data as the ratio of maximum over minimum IVC diameter. The cut-off value of 10 mmHg of CVP defined patient with euvolemia hemodynamic status. At rest, the IVC diameter averaged 23 ± 7 mm by 2D and 25 ± 8 × 19 ± 7 mm by 3D. IVC had an eccentric shape (EI = 1.3) that increased when CVP was ≤10 mmHg and during sniff test ( P < 0.001). IVC measurements by 2D and 3D were correlated with CVP. The best correlation was obtained with IVCCI derived from 2D diameters (R = -0.69) and 3D areas (R = −0.82). Using the cutoff value of 50% for IVCCI, a discrepancy between invasive CVP measurements and IVCCI has been observed for 11 examinations (13%) by 2D but only one was misclassified by 3D. Inter and intra-observer reproducibility for IVC area was 7 ± 6% and 5 ± 3%, respectively ( Fig. 1 ). In patients with cardiogenic shock, IVCCI from area by 3D echocardiography is reproducible and accurate to evaluate CVP.

Furosemide stress test, a novel assessment tool for tubular function in critically ill patients with acute kidney injury: potential therapeutic and prognostic values

Introduction Acute kidney injury (AKI) is well recognized for its effect on the outcome of patients admitted to ICU. The pursuit of improved biomarkers for the early diagnosis of AKI and its outcomes is an area of intense contemporary research; studies demonstrated the utility of furosemide stress test (FST) for predicting the severity of AKI, and a possibility of administration as a treatment for acute kidney injury network (AKIN) I and II.Patients and methods A total of 80 patients in ICU of Nasser Institute Hospital (July 2014–2015) were recruited, including 40 patients who received FST and 40 patients who received standard management. Patients included were those who developed AKI grades Ι–Π according to AKIN criteria. They were assessed clinically and followed through the duration of the study by hourly central venous pressure measurement (CVP) and urine output for 6 h, besides daily kidney function tests and estimated glomerular filtration rate for 3 days.Results In the first 6 h, there was a significant increase in urine output in group I after first and second hours (P=0.026, 0.008, respectively), as well as cumulative UOP over 6 h (P=0.003), as compared with group II. The cutoff point regarding UOP for detection of progress to AKIN III and dialysis was found to be 325 ml in both groups, with sensitivity of 86.7% and specificity of 68% in group I and sensitivity of 95% and specificity of 95% in group II. There was a highly significant difference between the two groups concerning hypotension, which occurred in 11 patients in group I versus none in group II, with P value of 0.001, whereas there was no significant difference between both the groups concerning progression to AKIN III and dialysis, with P value of 0.260; ICU stay, with P value of 0.621; and mortality, with P value of 0.201. Our results in group I patients who did not show worsening of AKIN class had significantly higher urine output as compared with those whose AKIN class worsened, with P value of 0.001.Conclusion FST is a good predictor of severity of tubular damage in early stages of AKI, with no additional privilege over standard management in the treatment of AKI. Moreover, it carries more risk of hemodynamic compromise.

The Effect of Changes in Postural Position Angle Degree on Central Venous Pressure Measurement

Background: Central venous pressure is often used in intensive care, especially in patients who ex­pe­rience impaired fluid balance, heart failure, evaluation of therapeutic response and media for the­­rapy or hypertonic fluid. The patient's hemodynamic condition during treatment in the intensive care unit (ICU) is con­­stantly changing (unstable), therefore, serial monitoring of central venous pressure is needed and the patient's position must be constant. Changing the position of the patient in a place is some­ti­­mes something that cannot be avoided when the patient is in intensive room. This study aimed to examine the effect of changing the position of patients in bed at 0 0 , 15 0 , 30 0 , and 45 0 on central venous pressure (CVP) va­lues. Subjects and Method: This was quasi-experimental study, using a post test with­out control group with repeated measures. This study was conducted in the ICU/ICCU Room at Tarakan Ho­s­pital, No­rth Kalimantan, from May to June 2019. A total of 30 patients was selected by acci­den­­­tal sampling. The dependent variable was central venous pressure. The independent variable was the position of the patient when a central venous pressure examination was carried out, with the degree of positions which were 0 0 , 15 0 , 30 0 , and 45 0 . The data was obtained from observation she­et. CVP was measured by water manometer. The data were analyzed by Anova. Results: The lowest mean CVP was achieved at 0o (Mean=15.13; SD= 5.79). The highest mean CVP was achieved at 45o (Mean=18.18; SD=5.35). The different mean between 0o and 45o was sta­tis­tically significant (p=0.001). The mean CVD at 15o was mean=16.35; SD=5.73. The mean CVD at 30o was mean=17.07; SD=5.42). The different mean between 15o and 30o was statistically sig­ni­fi­cant (p=0.047). Conclusion: The best position for perform central venous pressure is 45 o . Keywords: central vein pressure, intensive care, patient position Correspondence: Hendy Lesmana. Nursing Department, Faculty of Health, Universitas Borneo Tarakan. Email: damayanti.titha@gmail.com. Indonesian Journal of Medicine (2019), 4(3): 192-200 https://doi.org/10.26911/theijmed.2019.04.03.01

Use of Handheld Ultrasound to Estimate Fluid Status of Hemodialysis Patients

Introduction: Accurate assessment of fluid status in hemodialysis patients presents a significant challenge. Nephrologists have long relied on dry weight estimation based solely on clinical parameters to decide the ultrafiltration volume for patients with end-stage kidney disease on dialysis. However, this method is far from accurate and many patients recurrently suffer from signs and symptoms of fluid overload or circulatory collapse from overaggressive ultrafiltration. Invasive methods such as measurement of central venous pressure cannot be used routinely. We evaluated the usefulness of inferior vena cava (IVC) diameter measured by handheld ultrasound in the estimation of fluid status in patients before and after hemodialysis. Materials and Methods: Clinical assessment included patients’ symptoms, weight, blood pressure, heart rate, and presence of edema before and after dialysis session. Dry weight was assessed based on the above parameters. Each patient underwent measurement of inferior vena cava before and after hemodialysis. The anteroposterior IVC diameter (IVCD) was measured 1.5 cm below the diaphragm in the hepatic segment in supine position during normal inspiration and expiration.Results: Thirty hemodialysis patients (mean age 51.6±18.03 years) were evaluated in outpatient dialysis unit. Following hemodialysis mean IVCe (IVC diameter in expiration) decreased from 1.40±0.38 to 0.91±0.30 cm (p&lt;0.001). Similarly, mean IVCi (IVC diameter in inspiration) decreased from 0.67±0.34 to 0.35±0.19 cm (p&lt;0.001). Changes in IVCD were significantly correlated with alterations in body weight following dialysis (p&lt;0.0001). The IVC collapsibility index (IVC-CI, per cent of change in IVC diameter in expiration vs. inspiration) increased significantly from 0.53±0.18 to 0.68±0.18 after dialysis (p=0.002). IVC diameter and IVC-CI clearly reflected alterations in fluid status. Regarding the clinical parameters of fluid status, following hemodialysis, mean heart rate increased from 81.17±5.21 beats per minute to 86.50±7.99, (p=0.003), systolic blood pressure increased from 148.67±26.36 mmHg to 155.00±28.50, (p=0.05), and diastolic blood pressure increased from 78.62±12.74 mmHg to 84.83±14.55, (p&lt;0.001).Conclusions: Our findings support the applicability of IVCD measurement and IVC-CI in the estimation of fluid status in end stage kidney disease patients on hemodialysis. The clinical parameters of fluid status including heart rate, systolic blood pressure, and diastolic blood pressure suggest that significant numbers of patients underwent excess ultrafiltration based on their traditional dry weight calculation. Thus, using IVC parameters before and during hemodialysis might give a better estimation of fluid status of the patient and guide the amount of ultrafiltration to be done.

Characteristics, management, and in-hospital mortality among patients with severe sepsis in intensive care units in Japan: the FORECAST study

BackgroundSepsis is a leading cause of death and long-term disability in developed countries. A comprehensive report on the incidence, clinical characteristics, and evolving management of sepsis is important. Thus, this study aimed to evaluate the characteristics, management, and outcomes of patients with severe sepsis in Japan.MethodsThis is a cohort study of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) study, which was a multicenter, prospective cohort study conducted at 59 intensive care units (ICUs) from January 2016 to March 2017. We included adult patients with severe sepsis based on the sepsis-2 criteria.ResultsIn total, 1184 patients (median age 73 years, interquartile range (IQR) 64–81) with severe sepsis were admitted to the ICU during the study period. The most common comorbidity was diabetes mellitus (23%). Moreover, approximately 63% of patients had septic shock. The median Sepsis-related Organ Failure Assessment (SOFA) score was 9 (IQR 6–11). The most common site of infection was the lung (31%). Approximately 54% of the participants had positive blood cultures. The compliance rates for the entire 3-h bundle, measurement of central venous pressure, and assessment of central venous oxygen saturation were 64%, 26%, and 7%, respectively. A multilevel logistic regression model showed that closed ICUs and non-university hospitals were more compliant with the entire 3-h bundle. The in-hospital mortality rate of patients with severe sepsis was 23% (21–26%). Older age, multiple comorbidities, suspected site of infection, and increasing SOFA scores correlated with in-hospital mortality, based on the generalized estimating equation model. The length of hospital stay was 24 (12–46) days. Approximately 37% of the patients were discharged home after recovery.ConclusionOur prospective study showed that sepsis management in Japan was characterized by a high compliance rate for the 3-h bundle and low compliance rate for central venous catheter measurements. The in-hospital mortality rate in Japan was comparable to that of other developed countries. Only one third of the patients were discharged home, considering the aging population with multiple comorbidities in the ICUs in Japan.Trial registrationUMIN-CTR, UMIN000019742. Registered on 16 November 2015.

Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study.

BackgroundAcute kidney injury (AKI) after cardiac surgery is associated with adverse outcomes. Venous congestion can impair kidney function, but few tools are available to assess its impact at the bedside. The objective of this study was to determine whether portal flow pulsatility and alterations in intrarenal venous flow assessed by Point‐Of‐Care ultrasound are associated with AKI after cardiac surgery.Methods and ResultsThis single‐center prospective cohort study recruited patients undergoing cardiac surgery with cardiopulmonary bypass. Hepatic and renal Doppler ultrasound assessments were performed before surgery, at the intensive care unit admission, and daily for 3 days after surgery. The primary statistical analysis was performed using proportional hazards model for time‐dependent variables. Among the 145 patients included, 49 patients (33.8%) developed AKI after cardiac surgery. The detection of portal flow pulsatility was associated with an increased risk of AKI (hazard ratio: 2.09, confidence interval, 1.11–3.94, P=0.02), as were severe alterations of intrarenal venous flow (hazard ratio: 2.81, confidence interval, 1.42–5.56, P=0.003). These associations remained significant in multivariable models. The addition of these markers to preoperative risk factors and central venous pressure measurement at intensive care unit admission improved the prediction of AKI. (Continuous net reclassification improvement: 0.364, confidence interval, 0.081–0.652 for portal Doppler and net reclassification improvement: 0.343, confidence interval, 0.081–0.628 for intrarenal Doppler)ConclusionsPortal flow pulsatility and intrarenal flow alterations are markers of venous congestion and are independently associated with AKI after cardiac surgery. These tools might offer valuable information to develop strategies aimed at treating or preventing congestive cardiorenal syndrome after cardiac surgery.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02831907.

Alterations in cerebral ventricle size in children with congenital heart disease.

Children with tetralogy of Fallot (TOF) and superior cavopulmonary anastomoses (SCPA) can have chronically elevated central venous pressure (CVP), which has been postulated to put patients at risk for cerebral ventriculomegaly. We aimed to examine cerebral ventricle size in children with these congenital heart lesions before and after surgery to determine how changes in CVP affect ventricle size. We reviewed the records of patients who underwent SCPA or TOF repair between 2006 and 2015. Patients with pre- or post-operative cranial imaging were included. Frontal-occipital (FO) horn ratios were calculated as measures of cerebral ventricle volume. Reported normal mean FO ratio is 0.37 ± 0.03. Patient characteristics including occipito-fronto circumference (OFC) and available CVP measurements were recorded. CVP, FO ratios, and OFC percentiles were compared using paired and unpaired t tests and Wilcoxon matched pairs signed-rank test as appropriate. We reviewed 44 patients who underwent SCPA and 31 patients who underwent TOF repair who had cranial imaging studies available. In the 22 patients who underwent SCPA and had pre- and post-operative imaging, mean FO ratios significantly increased from 0.37 ± 0.03 to 0.40 ± 0.04 (P< 0.001). In contrast, in the seven patients with TOF with pre- and post-operative imaging, FO ratio was elevated at baseline and remains so after surgical repair, 0.43 ± 0.08 to 0.42 ± 0.08 (P= 0.65). Similar patterns were noted with OFC percentiles, which were significantly increased as compared to baseline after SCPA (P< 0.001) but were not significantly changed after TOF repair (P= 0.58). Finally, when available, preoperative and postoperative CVP measurements of all patients were examined, CVP increased in patients who underwent SCPA, from 6.5 ± 2mmHg preoperatively to 9.1 ± 2.3mmHg postoperatively (P< 0.001), while CVP remained statistically unchanged in patients who underwent TOF repair, 12.9 ± 3.3mmHg preoperatively to 14.4 ± 3.1mmHg postoperatively (P= 0.2). Cerebral ventriculomegaly was observed in patients with SCPA and TOF, and the observed changes in FO ratio and OFC may be related, at least in part, to CVP.