Fluid Administration In Patients Research Articles

The Association and Utility of Left Ventricular End-Diastolic Pressure in Predicting the Development of and in Managing Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography.

Contrast-induced nephropathy (CIN) is a significant complication in patients undergoing coronary angiography, and its development is associated with increased morbidity and mortality. Left ventricular end-diastolic pressure (LVEDP) provides one index of left heart filling status. An elevated LVEDP can reflect volume overload or abnormal diastolic function and indicates a cardiac disorder. Data on the association between an elevated LVEDP and CIN are limited and have had conflicting results. We systematically searched the databases PubMed, Embase, and Scopus for full-text articles from database inception to May 2022. Studies were included if they evaluated the association between a high LVEDP and the incidence of CIN in patients undergoing coronary angiography. The study was registered in the PROSPERO CRD42022334070. A second search in PubMed identified randomized controlled trials using LVEDP to guide fluid administration during coronary procedures. Four studies were identified that used LVEDP to classify patients into groups to determine the association between the level and the development of CIN. In these studies, 240 patients of 2441 patients (9.8%) developed CIN. One study found no association between LVEDP levels and the development of CIN. Two studies found an increased frequency of CIN in patients with elevated levels using 2 cutoff points for LVEDP, ≥20 mm Hg and >30 mm Hg. One study found that lower LVEDP levels (5-14 mm Hg) were associated with the development of CIN. Three randomized control trials used LVDEP levels to manage fluid administration in patients undergoing coronary procedures; only one study found that the use of these levels to guide fluid administration resulted in better outcomes. In patients undergoing coronary angiography, an elevated LVEDP was not consistently associated with increased risk of CIN, and using LVEDP levels to guide fluid administration during these procedures did not always improve outcomes in comparison to other protocols. The use of LVEDP levels can help classify patients with cardiac disorders but does not necessarily provide an adequate description of the hemodynamic patterns in these patients to predict or prevent CIN in patients undergoing angiography.

Nurse-Driven Fluid Responsiveness Evaluation in Patients With Septic Shock: A Quality Improvement Initiative.

Fluid responsiveness should be assessed in patients with septic shock because only 50% of patients are fluid responsive. Dynamic measures of fluid responsiveness, like pulse pressure variation measured after a passive leg raise maneuver, are recommended to guide fluid administration in patients with sepsis after initial fluid resuscitation. The purpose of the project was to evaluate outcomes after implementing a nurse-driven fluid responsiveness evaluation using passive leg raise and pulse pressure variation measurement in patients with septic shock. The project included 30 adult patients with septic shock in a 24-bed medical-surgical intensive care unit at a community hospital. A new nursing process was initiated for bedside fluid responsiveness evaluation (pulse pressure variation measurement after passive leg raise). Staff members received in-person individual training sessions. Preintervention and 20-week postintervention patient outcomes data were collected to estimate the project's impact on incidence of fluid overload and acute kidney injury, duration of mechanical ventilation, and intensive care unit length of stay. Preintervention and postintervention staff satisfaction surveys assessed nurses' perception of the project's value. Before intervention, 24 of 37 patients (65%) met criteria of fluid overload. The project resulted in a 28% decrease in the incidence of fluid overload. Staff satisfaction surveys revealed a significant increase in nurses' feelings of empowerment to positively affect patient outcomes; all nurses agreed that the new process was efficient. The results indicate that the project had a positive impact on patient outcomes and nurse autonomy.

Fluid Responsiveness in Critically Ill Patients Using Carotid Peak Systolic Velocity Variability: A New Frontier.

Background and objectives A fluid responder is a patient who can increase his stroke volume/ cardiac output by more than 10%-15% after a fluid bolus. Left ventricular outflow tract (LVOT) velocity time integral (VTI) variability is widely used as an adynamic parameter of fluid responsiveness, but a transthoracic echo view of LVOT VTI is often time-consuming and, at times, difficult to achieve. So, in the quest for another parameter that might equally be a good surrogate marker of stroke volume variation, carotid peak systolic velocity (CPSV) variation has been studied. The objective was to assess CPSV variation in patients who are already fluid responders. Methods The sample size was calculated considering a minimum correlation coefficient of 0.5. Adult patients in whom the physician wanted to give a fluid bolus and whose average LVOT VTI was more than 15% over 3 respiratory cycles were included in the study. Demographic variables, along with hemodynamic parameters such as heart rate, blood pressure, the need for vasopressors, mode of breathing (spontaneous or mechanical ventilation), andCPSV variation,were noted and averaged over three respiratory cycles. Fluid bolus (Plasmalyte) 6 ml/kg bolus over 10-15 minutes. Post-fluid hemodynamic variables, along with averaged LVOT VTI over three respiratory cycles and averaged CPSV variation over three respiratory cycles, are noted. Results Thirty adult patients were evaluated in the study. In spontaneously breathing patients (n=12), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight was 14.1 ± 3.4 and 5.4 ± 2.6, respectively (p < 0.05). In mechanically ventilated patients (n=18), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight fluid was 15 ± 5.3 and 6.5 ± 3.1, respectively (p <0.005). Overall, there was a statistically significant positive correlation between LVOT VTI variation and CPSV variation before fluid therapy (correlation coefficient 0.56 and p-value 0.001) and a statistically significant moderate positive correlation post-fluid therapy (correlation coefficient 0.37 and p-value 0.043). Conclusion We found a significant decrease in CPSV variation post-fluid administration in patients who are fluid responders, which mimics a decrease in stroke volume variation after fluid administration in patients who are fluid responsive.

Protocol for a systematic review and meta-analysis assessing conservative versus liberal intravenous fluid administration in patients with sepsis or septic shock at risk of fluid overload

IntroductionIntravenous crystalloid fluid resuscitation forms a crucial part of the early intervention bundle for sepsis and septic shock, with the Surviving Sepsis Campaign guidelines recommending a 30 mL/kg fluid bolus...

Evaluation Of Congestion Levels in Septic Patients Admitted to Critical Care Units with a Combined Venous Excess-Lung Ultrasound Score (VExLUS) - a Research Protocol.

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection with a high mortality rate. Septic shock is a subset of sepsis with manifest circulatory dysfunction (use of vasopressors and persistent elevation of lactic acid) . As stated in literature, in addition to the use of empiric antibiotics and control of the infectious focus, intravenous fluid therapy is an essential intervention to promote hemodynamic stabilization. However, the literature also describes harmful outcomes related to fluid overload. Hemodynamic management in critically ill patients has traditionally focused on maintaining adequate cardiac output and arterial blood pressure by relying on fluid administration and/or vasopressor/inotropic support. However, organ perfusion is affected by other important factors, such as venous pressure, which can be overlooked. The evaluation of lung congestion with point of care ultrasound (POCUS), as a signal of extravascular fluid, and, more recently, a venous excess Doppler ultrasound (VExUS) grading system, are parameters for the assessment of the fluid status of the patient and organ congestion. Our main hypothesis is that adding a modified lung ultrasound score to the VExUS protocol could provide higher sensitivity and earlier identification of fluid overload, guiding the clinician in the decision of fluid administration in patients with sepsis.

Haemodynamic monitoring and management in patients having noncardiac surgery

BACKGROUND Haemodynamic monitoring and management is a mainstay of peri-operative anaesthetic care. OBJECTIVE To determine how anaesthesiologists measure and manage blood pressure and cardiac output, and how they guide fluid administration and assess fluid responsiveness in patients having noncardiac surgery. DESIGN Web-based survey. SETTING Survey among members of the European Society of Anaesthesiology and Intensive Care (ESAIC) in October and November 2021. PARTICIPANTS ESAIC members responding to the survey. MAIN OUTCOME MEASURES Respondents’ answers to 30 questions on haemodynamic monitoring and management, and fluid therapy. RESULTS A total of 615 fully completed surveys were analysed. Arterial catheters are usually not placed before induction of general anaesthesia (378/615; 61%) even when invasive blood pressure monitoring is planned. Mean arterial pressure (532/615; 87%) with lower intervention thresholds of 65 mmHg (183/531; 34%) or 20% below pre-operative baseline (166/531; 31%) is primarily used to guide blood pressure management. Cardiac output is most frequently measured using pulse wave analysis (548/597; 92%). However, only one-third of respondents (almost) always use cardiac output to guide haemodynamic management in high-risk patients (225/582; 39%). Dynamic cardiac preload variables are more frequently used to guide haemodynamic management than cardiac output [pulse pressure variation (almost) always: 318/589; 54%]. Standardised treatment protocols are rarely used for haemodynamic management (139/614; 23%). For fluid therapy, crystalloids are primarily used as maintenance fluids, to treat hypovolaemia, and for fluid challenges. The use of 0.9% saline and hydroxyethyl starch has declined over the last decade. The preferred methods to assess fluid responsiveness are dynamic preload variables and fluid challenges, most commonly with 250 ml of fluid (319/613; 52%). CONCLUSION This survey provides important information how anaesthesiologists currently measure and manage blood pressure and cardiac output, and how they guide fluid administration in patients having noncardiac surgery.

Effect of prehospital transportation on 24-h fluid volume, a post hoc analysis of a multicenter, prospective, observational study on fluid volumes in patients with suspected infection.

Infections, including sepsis, are leading causes of death and fluid administration is part of the treatment. The optimal fluid therapy remains controversial. If the patient is transported by Emergency Medical Services (EMS), fluids can be initiated during transportation, which may result in increased overall fluid administration and fluid overload, which may be harmful. The aim of the study was to investigate the effect of EMS transportation on 24-h fluid administration in patients with suspected infection. This is a post hoc study of a prospective, multicenter, observational study, conducted in three Danish Emergency Departments (EDs), 20 January-2 March 2020, aiming at describing fluid administration in patients with suspected infection. Patients were stratified into the groups: simple infection or sepsis, in accordance with SEPSIS-3-guidelines. The primary outcome of the current study was 24-h total fluid volume (oral and intravenous) stratified by transportation mode to the EDs. Total 24-h fluids were registered for 734 patients. Patients with simple infection or sepsis arriving by EMS (n = 388, 54%) received mean 3,774 ml (standard deviation [SD]: 1900) and non-EMS received 3,627 ml (SD: 1568); mean difference (MD) was 303 ml [95% CI: 32; 573] adjusted for age, site, and total SOFA-score. Patients brought in by EMS received more intravenous fluids (MD: 621 ml [95% CI: 378; 864]) and less oral fluids (MD: -474 ml [95% CI: -616; -333]) than non-EMS patients. Patients transported by EMS received more intravenous fluids and less oral fluids but overall, more fluid in total in the first 24-h than non-EMS after adjusting for age, site and SOFA-score.

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Intravenous fluid administration is recommended to improve outcomes for patients with septic shock. However, there are few data on fluid administration for patients with preexisting heart failure with reduced ejection fraction (HFrEF). To evaluate the association between preexisting HFrEF, guideline-recommended intravenous fluid resuscitation, and mortality among patients with community-acquired sepsis and septic shock. A cohort study was conducted of adult patients hospitalized in an integrated health care system from January 1, 2013, to December 31, 2015, with community-acquired sepsis and preexisting assessment of cardiac function. Follow-up occurred through July 1, 2016. Data analyses were performed from November 1, 2020, to August 8, 2022. Preexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis. Multivariable models were adjusted for patient factors and sepsis severity and clustered at the hospital level to generate adjusted odds ratios (aORs) and 95% CIs. The primary outcome was the administration of 30 mL/kg of intravenous fluid within 6 hours of sepsis onset. Secondary outcomes included in-hospital mortality, intensive care unit admission, rate of invasive mechanical ventilation, and administration of vasoactive medications. Of 5278 patients with sepsis (2673 men [51%]; median age, 70 years [IQR, 60-81 years]; 4349 White patients [82%]; median Sequential Organ Failure Assessment score, 4 [IQR, 3-5]), 884 (17%) had preexisting HFrEF, and 2291 (43%) met criteria for septic shock. Patients with septic shock and HFrEF were less likely to receive guideline-recommended intravenous fluid than those with septic shock without HFrEF (96 of 380 [25%] vs 699 of 1911 [37%]; P < .001), but in-hospital mortality was similar (47 of 380 [12%] vs 244 of 1911 [13%]; P = .83). In multivariable models, HFrEF was associated with a decreased risk-adjusted odds of receiving 30 mL/kg of intravenous fluid within the first 6 hours of sepsis onset (aOR, 0.63; 95% CI, 0.47-0.85; P = .002). The risk-adjusted mortality was not significantly different among patients with HFrEF (aOR, 0.92; 95% CI, 0.69-1.24; P = .59) compared with those without, and there was no interaction with intravenous fluid volume (aOR, 1.00; 95% CI, 0.98-1.03; P = .72). The results of this cohort study of patients with community-acquired septic shock suggest that preexisting HFrEF was common and was associated with reduced odds of receiving guideline-recommended intravenous fluids.

406EMF Early Fluid Delivery by Emergency Medical Services for Sepsis Using a Novel Rapid Infusion Device

406EMF Early Fluid Delivery by Emergency Medical Services for Sepsis Using a Novel Rapid Infusion Device

Importance of Intravenous Fluid administration in Patients’ Reference to the Emergency Department from Patients and Their Companions’ Point of View

Importance of Intravenous Fluid administration in Patients’ Reference to the Emergency Department from Patients and Their Companions’ Point of View

EVALUATION OF MORTALITY IN LARGE- VS SMALL-VOLUME FLUID ADMINISTRATION IN PATIENTS WITH SEPSIS AND SEPTIC SHOCK

EVALUATION OF MORTALITY IN LARGE- VS SMALL-VOLUME FLUID ADMINISTRATION IN PATIENTS WITH SEPSIS AND SEPTIC SHOCK

Outcomes Similar with Restricted vs. Standard IV Fluid Administration in Patients with Septic Shock.

According to this study: Among adults in the ICU with septic shock, restriction of IV fluids didn't result in fewer deaths at 90 days than standard IV fluid therapy.The number of days alive without life support and days alive out of the hospital were also similar in the two groups.

Does Fluid Administration Based on Fluid Responsiveness Tests such as Passive Leg Raising Improve Outcomes in Sepsis?

The management of sepsis requires the rapid administration of fluid to support blood pressure and tissue perfusion. Guidelines suggest that patients should receive 30 ml per kg of fluid over the first one to three hours of management. The next concern is to determine which patients need additional fluid. This introduces the concept of fluid responsiveness, defined by an increase in cardiac output following the administration of a fluid bolus. Dynamic tests, measuring cardiac output, identify fluid responders better than static tests. Passive leg raising tests provide an alternative approach to determine fluid responsiveness without administering fluid. However, one small randomized trial demonstrated that patients managed with frequent passive leg raising tests had a smaller net fluid balance at 72 hours and reduced requirements for renal replacement therapy and mechanical ventilation, but no change in mortality. A meta-analysis including 4 randomized control trials reported that resuscitation guided by fluid responsiveness does not improve mortality outcomes in patients with sepsis. Recent studies have demonstrated that the early administration of norepinephrine may improve outcomes in patients with sepsis. The concept of fluid responsiveness helps clinicians analyze the clinical status of patients, but this information must be integrated into the overall management of the patient. This review considers the use and benefit of fluid responsiveness tests to direct fluid administration in patients with sepsis.

Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department: a retrospective cohort study

BackgroundAppropriate and timely administration of intravenous fluids to patients with sepsis-induced hypotension is one of the mainstays of sepsis management in the emergency department (ED), however, fluid resuscitation remains an ongoing challenge in ED. Our study has been undertaken with two specific aims: firstly, for patients with sepsis, to identify factors associated with receiving intravenous fluids while in the ED; and, secondly to identify determinants associated with the actual time to fluid administration.MethodsWe conducted a retrospective multicentre cohort study of adult ED presentations between October 2018 and May 2019 in four metropolitan hospitals in Western Sydney, Australia. Patients meeting pre-specified criteria for sepsis and septic shock and treated with antibiotics within the first 24 h of presentation were included. Multivariable models were used to identify factors associated with fluid administration in sepsis.ResultsFour thousand one hundred forty-six patients met the inclusion criteria, among these 2,300 (55.5%) patients with sepsis received intravenous fluids in ED. The median time to fluid administration from the time of diagnosis of sepsis was 1.6 h (Interquartile Range (IQR) 0.5 to 3.8), and the median volume of fluids administered was 1,100 mL (IQR 750 to 2058). Factors associated with patients receiving fluids were younger age (Odds Ratio (OR) 1.05, 95% Confidence Interval (CI (1.03 to 1.07), p < 0.001); lower systolic blood pressure (OR 1.11, 95% CI (1.08 to 1.13), p < 0.001); presenting to smaller hospital (OR 1.48, 95% CI (1.25 to 1.75, p < 0.001) and a Clinical Rapid Response alert activated (OR 1.64, 95% CI (1.28 to 2.11), p < 0.001). Patients with Triage Category 1 received fluids 101.22 min earlier (95% CI (59.3 to131.2), p < 0.001) and those with Category 2 received fluids 43.58 min earlier (95% CI (9.6 to 63.1), p < 0.001) compared to patients with Triage Category 3–5. Other factors associated with receiving fluids earlier included septic shock (-49.37 min (95% CI (-86.4 to -12.4), p < 0.001)); each mmol/L increase in serum lactate levels (-9.0 min, 95% CI (-15.7 to -2.3), p < 0.001) and presenting to smaller hospitals (-74.61 min, 95% CI (-94.0 to -55.3), p < 0.001).ConclusionsYounger age, greater severity of sepsis, and presenting to a smaller hospital increased the probability of receiving fluids and receiving it earlier. Recognition of these factors may assist in effective implementation of sepsis management guidelines which should translate into better patient outcomes. Future studies are needed to identify other associated factors that we have not explored.

Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)\u2014protocol for a multicenter, randomized, clinical, proof-of-concept trial

BackgroundIntravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care.MethodsThis is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care.The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions.Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022.DiscussionSepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis.Trial registrationEudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).

Fluid Resuscitation and Progression to Renal Replacement Therapy in Patients With COVID-19.

BackgroundCoronavirus disease 2019 (COVID-19) is associated with respiratory symptoms and renal effects. Data regarding fluid resuscitation and kidney injury in COVID-19 are lacking, and understanding this relationship is critical.ObjectivesTo determine if there is an association between fluid volume administered in 24 h and development of renal failure in COVID-19 patients.MethodsRetrospective chart review; 14 hospitals in Indiana. Included patients were adults admitted between March 11, 2020 and April 13, 2020 with a positive test for severe acute respiratory syndrome coronavirus 2 within 3 days of admission. Patients requiring renal replacement therapy prior to admission were excluded. Volumes and types of resuscitative intravenous fluids in the first 24 h were obtained with demographics, medical history, and other objective data. The primary outcome was initiation of renal replacement therapy. Logistic regression modeling was utilized in creating multivariate models for determining factors associated with the primary outcome.ResultsThe fluid volume received in the first 24 h after hospital admission was associated with initiation of renal replacement therapy in two different multivariate logistic regression models. An odds ratio of 1.42 (95% confidence interval 1.01–1.99) was observed when adjusting for age, heart failure, obesity, creatinine, bicarbonate, and total fluid volume. An odds ratio of 1.45 (95% confidence interval 1.02–2.05) was observed when variables significant in univariate analysis were adjusted for.ConclusionsEach liter of intravenous fluid administered to patients with COVID-19 in the first 24 h of presentation was independently associated with an increased risk for initiation of renal replacement therapy, supporting judicious fluid administration in patients with this disease.

Changes in peripheral perfusion index during intraoperative end-expiratory occlusion tests do not predict the response to fluid administration in patients undergoing lung protective ventilation.

The end-expiratory occlusion test (EEOT) may predict the response to fluid administration in patients undergoing lung-protective ventilation, but arterial catheter insertion is necessary to evaluate changes in stroke volume (SV). The peripheral perfusion index is a potential noninvasive alternative to evaluate SV. The aim of this study is to investigate whether changes in perfusion index during an intraoperative EEOT can predict the response to fluid administration in patients undergoing lung-protective ventilation (tidal volume 7ml/kg predicted body weight). Forty-one elective surgical patients were enrolled. The SV and perfusion index were recorded before (baseline), during a 40-s EEOT and after volume expansion (250ml of lactated Ringer's solution over 10min). Patients with an increase in SV greater than 10% after volume expansion were defined as responders. ΔPI (change in perfusion index between baseline and 20 (ΔPI20) or 40s (ΔPI40) after the beginning of EEOT were calculated using: ΔPI20 (%) = [(PI at 20s after EEOT beginning-PIbaseline)/PIbaseline] × 100, ΔPI40 (%) = [(PI at 40s after EEO beginning-PIbaseline)/PIbaseline] × 100). Sixteen patients were responders, and 25 were non-responders. The area under the receiver operating characteristics curves generated for ΔPI20 and ΔPI40 to predict response to a fluid challenge were 0.561 (95% CI 0.374-0.749) and 0.688 (95% CI 0.523-0.852), respectively. Changes in perfusion index during intraoperative EEOT in patients undergoing lung-protective ventilation (7ml/kg) were unable to predict the response to fluid administration.

Evaluation of fluid responsiveness during COVID-19 pandemic: what are the remaining choices?

Non-protocolized fluid administration in critically ill patients, especially those with acute respiratory distress syndrome (ARDS), is associated with poor outcomes. Therefore, fluid administration in patients with Coronavirus disease (COVID-19) should be properly guided. Choice of an index to guide fluid management during a pandemic with mass patient admissions carries an additional challenge due to the relatively limited resources. An ideal test for assessment of fluid responsiveness during this pandemic should be accurate in ARDS patients, economic, easy to interpret by junior staff, valid in patients in the prone position and performed with minimal contact with the patient to avoid spread of infection. Patients with COVID-19 ARDS are divided into two phenotypes (L phenotype and H phenotype) according to their lung compliance. Selection of the proper index for fluid responsiveness varies according to the patient phenotype. Heart–lung interaction methods can be used only in patients with L phenotype ARDS. Real-time measures, such a pulse pressure variation, are more appropriate for use during this pandemic compared to ultrasound-derived measures, because contamination of the ultrasound machine can spread infection. Preload challenge tests are suitable for use in all COVID-19 patients. Passive leg raising test is relatively better than mini-fluid challenge test, because it can be repeated without overloading the patient with fluids. Trendelenburg maneuver is a suitable alternative to the passive leg raising test in patients with prone position. If a cardiac output monitor was not available, the response to the passive leg raising test could be traced by measurement of the pulse pressure or the perfusion index. Preload modifying maneuvers, such as tidal volume challenge, can also be used in COVID-19 patients, especially if the patient was in the gray zone of other dynamic tests. However, the preload modifying maneuvers were not extensively evaluated outside the operating room. Selection of the proper test would vary according to the level of healthcare in the country and the load of admissions which might be overwhelming. Evaluation of the volume status should be comprehensive; therefore, the presence of signs of volume overload such as lower limb edema, lung edema, and severe hypoxemia should be considered beside the usual indices for fluid responsiveness.

Collapsibility of the Right Internal Jugular Vein Predicts Responsiveness to Fluid Administration in Patients Receiving Pressure Support Ventilation: A Prospective Cohort Study.

BackgroundThe aim of this study was to evaluate the utility of collapsibility of the internal jugular veins (IJVs) and subclavian veins (SCVs) in comparison with collapsibility of the inferior vena cava (IVC) in patients receiving pressure support ventilation.MethodsPatients receiving pressure support ventilation were prospectively enrolled when fluid bolus administration was clinically indicated. The antero-posterior diameters of IJVs, SCVs and IVC were measured. Fluid responsiveness was defined as an 8% increase in stroke volume calculated with arterial pulse contour analysis after a passive leg raising maneuver.ResultsTwenty-seven patients (34 measurements) were included. Eighteen measurements were deemed fluid responsive. The area under the receiver operating characteristic curve of collapsibility of the right IJV antero-posterior diameter was 0.88 (95% confidence interval (CI): 0.75 - 0.99), while the area under the ROC curves for the antero-posterior diameter of the left IJV, right SCV, left SCV and the IVC were 0.57 (95% CI: 0.37 - 0.77), 0.61 (95% CI: 0.41 - 0.80), 0.55 (95% CI: 0.35 - 0.76) and 0.57 (95% CI: 0.37 - 0.77), respectively.ConclusionsThese results suggest that collapsibility of the right IJV is a useful predictor of fluid responsiveness in patients receiving pressure support ventilation. Collapsibility of the IVC did not predict fluid responsiveness in these patients.

Acute adverse events in cardiac MR imaging with gadolinium-based contrast agents: results from the European Society of Cardiovascular Radiology (ESCR) MRCT Registry in 72,839 patients

ObjectivesTo assess the incidence of acute adverse events (AAEs) in gadolinium-enhanced cardiac magnetic resonance (CMR) imaging.MethodsGadolinium-based contrast agent (GBCA)–enhanced CMR data from the multinational, multicenter European Society of Cardiovascular Radiology MRCT Registry was included. AAE severity was classified according to the American College of Radiology Manual on Contrast Media (mild, moderate, severe). Multivariable generalized linear mixed effect models were used to assess the likelihood of AAEs in various GBCA, adjusting for pharmacological stressor, main indications (i.e., suspected or known coronary artery disease or myocarditis), age, sex, and submitting center as a random effect.ResultsIn the study population of 72,839 GBCA-enhanced CMRs, a total of 260 AAEs were reported (0.36%), with a minority of severe AAEs (n = 24, 0.033%). Allergic-like AAEs were less likely than physiologic AAEs (29% versus 71%). Patients without pharmacological stress imaging had a lower AAE rate (0.22%) compared to stress imaging (0.75%), with the highest AAE rates for regadenoson (2.95%). AAE rates also varied by GBCA subtype (overall p < 0.001). There was significant interaction between GBCA and pharmacological stressor (interaction p = 0.025), with AAE rates ranging between 0 and 10% for certain GBCA/stressor combinations. There was further marginal evidence that higher GBCA volume was associated with higher AAE incidence (OR = 1.02, p = 0.05).ConclusionGBCA-enhanced CMR imaging demonstrates low AAE rates comparable to those of other body regions. AAE likelihood correlates with GBCA subtype, pharmacological stressor, and imaging indication. Intravenous fluid administration in patients with cardiac impairment might contribute to these findings.Key Points• Acute adverse event rates in cardiac magnetic resonance (CMR) imaging with gadolinium-based contrast agents (GBCAs) are low (0.36%), especially for severe adverse events (0.033%).• Mild and moderate adverse events are more frequent during stress CMR imaging.• Physiologic AAEs are more common than allergic AAEs in CMR imaging.