High Central Venous Pressure Research Articles

Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis

BackgroundThe association of central venous pressure (CVP) and mortality and acute kidney injury (AKI) in critically ill adult patients remains unclear. We performed a meta-analysis to determine whether elevated CVP is associated with increased mortality and AKI in critically ill adult patients.MethodsWe searched PubMed and Embase through June 2019 to identify studies that investigated the association between CVP and mortality and/or AKI in critically ill adult patients admitted into the intensive care unit. We calculated the summary odds ratio (OR) and 95% CI using a random-effects model.ResultsFifteen cohort studies with a broad spectrum of critically ill patients (mainly sepsis) were included. On a dichotomous scale, elevated CVP was associated with an increased risk of mortality (3 studies; 969 participants; OR, 1.65; 95% CI, 1.19–2.29) and AKI (2 studies; 689 participants; OR, 2.09; 95% CI, 1.39–3.14). On a continuous scale, higher CVP was associated with greater risk of mortality (5 studies; 7837 participants; OR, 1.10; 95% CI, 1.03–1.17) and AKI (6 studies; 5446 participants; OR, 1.14; 95% CI, 1.06–1.23). Furthermore, per 1 mmHg increase in CVP increased the odds of AKI by 6% (4 studies; 5150 participants; OR, 1.06; 95% CI, 1.01–1.12). Further analyses restricted to patients with sepsis showed consistent results.ConclusionsElevated CVP is associated with an increased risk of mortality and AKI in critically ill adult patients admitted into the intensive care unit.Trial registrationPROSPERO, CRD42019126381

Preliminary Experience Using Diastolic Right Ventricular Pressure Gradient Monitoring in Cardiac Surgery

Right ventricular (RV) dysfunction in cardiac surgery is associated with increased mortality and morbidity and difficult separation from cardiopulmonary bypass (DSB). The primary objective of the present study was to describe the prevalence and characteristics of patients with abnormal RV diastolic pressure gradient (PG). The secondary objective was to explore the association among abnormal diastolic PG and DSB, postoperative complications, high central venous pressure (CVP), and high RV end-diastolic pressure (RVEDP). Retrospective and prospective validation study. Tertiary care cardiac institute. Cardiac surgical patients (n=374) from a retrospective analysis (n=259) and a prospective validation group (n=115). RV pressure waveforms were obtained using a pulmonary artery catheter with a pacing port opened at 19 cm distal to the tip of the catheter. Abnormal RV diastolic PG was defined as >4 mmHg. Both elevated RVEDP and high CVP were defined as >16 mmHg. From the retrospective and validation cohorts, 42.5% and 48% of the patients had abnormal RV diastolic PG before cardiac surgery, respectively. Abnormal RV diastolic PG before cardiac surgery was associated with higher EuroSCORE II (odds ratio 2.29 [1.10-4.80] v 1.62 [1.10-3.04]; p = 0.041), abnormal hepatic venous flow (45% v 29%; p = 0.038), higher body mass index (28.9 [25.5-32.5] v 27.0 [24.9-30.5]; p = 0.022), pulmonary hypertension (48% v 37%; p = 0.005), and more frequent DSB (32% v 19%; p = 0.023). However, RV diastolic PG was not an independent predictor of DSB, whereas RVEDP (odds ratio 1.67 [1.09-2.55]; p = 0.018) was independently associated with DSB. In addition, RV pressure monitoring indices were superior to CVP in predicting DSB. Abnormal RV diastolic PG is common before cardiac surgery and is associated with a higher proportion of known preoperative risk factors. However, an abnormal RV diastolic PG gradient is not an independent predictor of DSB in contrast to RVEDP.

Worsening Renal Function in Cardiac Mechanical Support

Venous congestion in heart failure (HF) may lead to worsening renal failure (WRF). We hypothesised that WRF in patients hospitalised for left ventricular assist device (LVAD) implantation is associated with increased 1-year mortality. There is limited data regarding WRF in HF patients with mechanical support. The objective of this paper is to determine whether WRF in HF patients hospitalised for LVAD implantation is associated with increased 1-year mortality and to identify risk factors for WRF. We performed a single centre retrospective chart analysis of 162 patients who received an LVAD between August 2006 and December 2014 with pre-LVAD right heart catheterisation data. We stratified patients to those who demonstrated WRF and the use of haemodialysis (HD) or ultrafiltration (UF). Patients with a higher central venous pressure (CVP) >16 mmHg (17-24 mmHg range) developed WRF (29.7% vs. 14.1%, p=0.019). A CVP ≥16 and glomerular filtration rate (GFR) <30 ml/min/1.74m2 increased the odds of WRF. Worsening renal failure and HD/UF use were associated with increased 1-year mortality. Furthermore GFR <30, atherosclerosis, and right ventricular failure were independent predictors for increased 1-year mortality. A GFR <30 increased the odds of developing WRF five-fold (OR 4.14, CI [1.95-8.78], p<0.0001), and GFR <30 and central venous pressure (CVP) >16 increased the odds of requiring HD/UF. Worsening renal failure is associated with a higher CVP at the time of LVAD implantation and increases the risk of 1-year mortality and the odds of requiring HD/UF. Careful evaluation of renal function and comorbid conditions during LVAD implantation is critical to reduce mortality and for risk stratification.

Diagnosis and management of transfusion‐associated circulatory overload in adults and children

Transfusion‐associated circulatory overload (TACO) is a severe transfusion adverse reaction that is associated with increased mortality and morbidity. The incidence of TACO in adults varies from 1% to 8%; the incidence in the paediatric population is variable according to the different studies. TACO usually occurs in patients who receive a large volume of blood product over a short period of time. It is more common in patients with known risk factors such as cardiovascular disease, renal failure and older or younger age. The typical presentation of TACO is respiratory distress (dyspnoea, tachypnea). Associated signs and symptoms are hypoxia, hypertension, tachycardia, positive fluid balance, high central venous pressure and acute or worsening pulmonary oedema on chest X‐ray. Echocardiography and measurement of brain natriuretic peptide is helpful for diagnosis. Several definition criteria have been proposed for TACO, but none are adapted for children, particularly critically ill children who are more at risk. In a recent study, the incidence of TACO was compared among paediatric intensive care unit patients using different definition criteria. TACO incidence varied from 1·5% to 76%, depending on the definition used. With such wide variability, conclusion was that a more operational definition of TACO is needed in paediatrics, particularly for critically ill children. Treatment for TACO is similar to that of any other cardiogenic pulmonary oedema: oxygen, diuresis and ventilatory support. Prevention is possible by avoiding unnecessary transfusions, transfusing only the necessary amount of blood product, avoiding rapid transfusions and using diuretics.

Thoracic duct-to-vein anastomosis for the management of thoracic duct outflow obstruction in newborns and infants: a CASE series

BackgroundThoracic duct (TD) outflow obstruction causes high morbidity and mortality in newborns. It can be congenital/idiopathic or acquired (secondary to central venous thrombosis or injury during cardiothoracic surgery). Re-routing the TD to the venous system by microsurgical techniques to restore lymphatic flow is a potential surgical solution. We present a series of newborns and infants who underwent thoracic duct-to-vein anastomosis (TDVA) to restore TD outflow. Materials and methodsA retrospective review of all TDVA September 2015–March 2019 was performed. All patients underwent extensive pre-operative imaging evaluation by dynamic MRI and fluoroscopic lymphangiography. The TDVAs were done under high-power microscopy. ResultsEight patients underwent TDVA. Age at surgery was 1 to 9 months. Four patients had a history of cardiac surgery (one with complete thrombosis of the central venous system), one patient had a history of ECMO and thrombosis of the SVC, and three patients had a history of fetal hydrothorax and non-immune hydrops. Six patients had a successful TDVA with restoration of the lymphatic flow through the TD and clinical improvement. Two patients had a technically adequate TDVA but without improvement of the flow due to persistently high central venous pressure. Five patients remain alive, two patients died from complications of the lymphatic disorder, and one patient died from an unrelated cause. ConclusionsPatients with congenital or acquired TD outlet obstruction for whom no improvement is achieved by non-surgical interventions may benefit from TDVA. A thorough understanding of the anatomy and physiology of each patient is critical for the success of the operation. Level of EvidenceLevel IV.

Subversive acts of everyday midwifery

Increasing venous return during cardiopulmonary resuscitation (CPR) has been shown to improve hemodynamics during CPR and outcomes following cardiac arrest (CA). We hypothesized that a high central venous pressure amplitude (CVP-A), the difference between the maximum and minimum central venous pressure during chest compressions, could serve as a robust predictor of return of spontaneous circulation (ROSC) in addition to traditional measurements of coronary perfusion pressure (CPP) and end-tidal CO2 (etCO2) in a porcine model of CA.After 10 min of ventricular fibrillation, 9 anesthetized and intubated female pigs received mechanical chest compressions with active compression/decompression (ACD) and an impedance threshold device (ITD). CPP, CVP-A and etCO2 were measured continuously. All groups received biphasic defibrillation (200 J) at minute 4 of CPR and were classified into two groups (ROSC, NO ROSC). Mean values were analyzed over 3 min before defibrillation by repeated-measures Analysis of Variance and receiver operating characteristic (ROC).Five animals out of 9 experienced ROSC. CVP-A showed a statistically significant difference (p = 0.003) between the two groups during 3 min of CPR before defibrillation compared to CPP (p = 0.056) and etCO2 (p = 0.064). Areas-under-the-curve in ROC analysis for CVP-A, CPP and etCO2 were 0.94 (95% Confidence Interval 0.86, 1.00), 0.74 (0.54, 0.95) and 0.78 (0.50, 1.00), respectively.In our study, CVP-A was a potentially useful predictor of successful defibrillation and return of spontaneous circulation. Overall, CVP-A could serve as a marker for prediction of ROSC with increased venous return and thereby monitoring the beneficial effects of ACD and ITD.

Risk Factors for Prolonged Pleural Effusion After Extracardiac Fontan Operation.

Prolonged pleural effusion after Fontan operation is a significant morbidity that leads to long hospital stays. We investigated the association of multiple risk factors, including clinical characteristics, hemodynamic parameters, and preoperative, operative, and postoperative factors, with prolonged pleural effusion after Fontan operation. Eighty-five patients who underwent a Fontan operation between January 2005 and June 2018 in our center were included in this retrospective study. Patients were divided into two groups: group 1 (n = 36, 42.4%) included those with prolonged pleural effusion, defined as lasting > 14days after the Fontan operation, and group 2 included patients without prolonged pleural effusion. Patients with hypoplastic left heart syndrome (HLHS) were more prevalent in group 1 (n = 15, P = 0.006). No differences in age at Fontan operation, central venous pressure at Fontan operation, or hemodynamic parameters during the pre-Fontan evaluation were found between the two groups. In multivariable analysis, HLHS (P = 0.002), non-fenestration (P = 0.018), and high central venous pressure at bidirectional cavopulmonary shunt (BCPS) operation (P = 0.043) were independent risk factors for prolonged pleural effusion after Fontan operation. Adverse outcomes such as death, need for heart transplantation, and Fontan failure were not associated with prolonged pleural effusion. In conclusion, patients with HLHS and higher central venous pressure at BCPS were more likely to have a prolonged pleural effusion after Fontan operation, but fenestration was more likely to decrease prolonged effusion. We should consider closer management of fluid status before, during, and after surgery in patients with these risk factors after Fontan operation.

Cardiac output-guided hemodynamic therapy for adult living donor kidney transplantation in children under 20kg: A pilot study.

BackgroundA living‐donor (adult) kidney transplantation in young children requires an increased cardiac output to maintain adequate perfusion of the relatively large kidney. To achieve this, protocols commonly advise liberal fluid administration guided by high target central venous pressure. Such therapy may lead to good renal outcomes, but the risk of tissue edema is substantial.AimsWe aimed to evaluate the safety and feasibility of the transpulmonary thermodilution technique to measure cardiac output in pediatric recipients. The second aim was to evaluate whether a cardiac output‐guided hemodynamic therapy algorithm could induce less liberal fluid administration, while preserving good renal results and achieving increased target cardiac output and blood pressure.MethodsIn twelve consecutive recipients, cardiac output was measured with transpulmonary thermodilution (PiCCO device, Pulsion). The algorithm steered administration of fluids, norepinephrine and dobutamine. Hemodynamic values were obtained before, during and after transplantation. Results are given as mean (SD) [minimum‐maximum].ResultsAge and weight of recipients was 3.2 (0.97) [1.6‐4.9] yr and 14.1 (2.4) [10.4‐18] kg, respectively. No complications related to cardiac output monitoring occurred. After transplantation, cardiac index increased with 31% (95% CI = 15%‐48%). Extravascular lung water and central venous pressure did not change. Fluids given decreased from 158 [124‐191] mL kg−1 in the first 2 patients to 80 (18) [44‐106] mL kg−1 in the last 10 patients. The latter amount was 23 mL kg−1 less (95% CI = 6‐40 mL kg−1) than in one recent study, but similar to that in another. After reperfusion, all patients received norepinephrine (maximum dose 0.45 (0.3) [0.1‐0.9] mcg kg−1 min−1). Patient and graft survivals were 100% with excellent kidney function at 6 months post‐transplantation.ConclusionTranspulmonary thermodilution‐cardiac output monitoring appeared to be safe and feasible. Using the cardiac output‐guided algorithm led to excellent renal results with a trend toward less fluids in favor of norepinephrine.

Abnormal glucose metabolism in patients with Fontan circulation: Unique characteristics and associations with Fontan pathophysiology

Fontan patients exhibit a high prevalence of abnormal glucose metabolism (AGM). We aimed to characterize AGM and clarify its association with Fontan pathophysiology. We prospectively evaluated AGM with plasma glucose dynamics [mg/dL; fasting glucose (FPG), and maximum glucose increase (PG-spike)] during oral glucose tolerance test and hemoglobin A1c (HbA1c) in 276 consecutive Fontan patients (aged 19 ± 7 years). Of these, 176 patients had serial AGM assessments with a mean interval of 6.5 years. Initial analysis revealed a high prevalence of impaired glucose tolerance (38.4%) and diabetes mellitus (DM) (4.7%), and positive family history, high HbA1c, and high central venous pressure independently predicted presence of DM. HbA1c was independently determined by hypersplenism and presence of DM (P < .05). Serial assessments revealed an increased PG-spike and a decreased HbA1c (P < .001 for both). Prevalence of DM increased (6.3% to 10.3%), and positive family history, high liver enzymes, and AGM predicted new onset of DM (P < .05 for all). Twenty-one patients died during 7.1-year follow-up. FPG (P < .01) and PG-spike (P < .05) independently predicted all-cause mortality. Particularly, patients with FPG ≤ 74 and/or PG-spike ≥85 had a mortality rate 8.7 times higher than those without (P = .0129). AGM progressed even in young adult Fontan patients, and HbA1c showed limited predictive value for progression. Oral glucose tolerance test plays important roles in uncovering unique Fontan AGM as well as predicting all-cause mortality.

Impact of Severe Tricuspid Valve Insufficiency on the Performance of the Left Ventricular Assist Devices. Acute and Chronic Animal Studies

Purpose Up to 50% of the left ventricular device (LVAD) candidates present with moderate -severe tricuspid valve insufficiency (TVI) at the time of LVAD implantation . The exact strategy weather to perform a TV repair (TVR) or not in these patients is not well investigated. We aimed to evaluate the impact of severe iatrogenic TVI at the time of LVAD implantation on the hemodynamic and LVAD parameters in an acute and chroic ovine model. Methods Chronic stabile heart failure (HF) was induced in 10 ovines (mean weight 61±7 kg) through the application of several coronary ligations. Once stabile HF was obtained (after 15 ± 5 days), animals were brought back to the operating room and supported with HeartWare LVAD (HeartWare Inc., Framingham, MA). Hemodynamic data (mean arterial pressure (MAP),pulmonary artery pressure, central venous pressure (CVP), cardiac output (CO) and heart rate) as well as pump flow, speed and power consumption were obtained in two settings; first with LVAD in place after weaning from cardiopulmonary bypass (CPB) machine (no TVI setting) and second following reinitiating the CPB and induction of severe TRI through resection of the tricuspid valve (TVI setting). Hemodynamic and pump parameters were compared between these two settings without changing the pump speed. Results The total CPB time was 101 ± 22 min and the total LVAD support time was 41 ± 20min. There were no statistical significant differences in the hemodynamic and pump parameters between TVI setting and no TVI conditions except for expected higher CVP in the TVI setting(27±6 mmHg vs. 18±8 mmHg, p=0.013) and higher CO in the TVI setting (2.4 ±1.5 L/ min vs. 3.2± 1.0 L/ min, p = 0.011). At average pump speed of 2300 ± 87 rpm in the TVI and 2322 ± 130rpm in the no TVI setting, the mean pump flow in the TVI and no TVI setting were 3.3 ± 2.1L/min and 3.3 ± 1.0 L/ min respectively (p=0.895). Meanwhile, a MAP of 70 ± 9 mmHg and 69 ±14 mmHg in the TVI and no TVI setting was measured respectively (p= 0.779). Based on these results, two additional chronic animal studies were successively performed. Conclusion This study of severe iatrogenic TVI in chronic HF animals with preserved right ventricular function (RVF) showed no significant differences in the pump performance between TVI setting and no TVI condition. This finding may questions the necessity of TVR by preserved RVF at the time of LVAD implantation.

Mid-term outcomes of individualized surgeries in patients with Ebstein's anomaly.

The variable anatomy of Ebstein's anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein's anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons' preference. Tricuspid repair, either Danielson's or Carpentier's technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6-54) years [16 children (age <14, and 19 adults (age ≥14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson's procedure was used in 17, while Carpentier's technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6days. In the 33 survivors who were followed up at a median of 29.2months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein's anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.

Relation between invasive hemodynamics and measured glomerular filtration rate by 51Cr-EDTA clearance in advanced heart failure

The interaction between hemodynamics and kidney function in heart failure (HF) is incompletely understood. We investigated the association between invasive hemodynamic parameters and measured glomerular filtration rate (mGFR) by plasma clearance of 51-chromium-labeled ethylenediamine tetra-acetic acid (51Cr-EDTA) in patients with advanced HF and tested the hypothesis that patients with reduced mGFR have lower cardiac index (CI) and mean arterial pressure (MAP) as well as higher central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). We retrospectively studied 242 patients (mean age 50 ± 13 years) referred for evaluation for heart transplantation or implantation of a left ventricular assist device with a left ventricular ejection fraction < 45% on optimal medical therapy, who underwent right heart catheterization (RHC) and measurement of 51Cr-EDTA clearance. Mean mGFR was 63 ± 21 mL/min/1.73 m2, CI was 2.3 ± 0.7 L/min/m2, PCWP was 21 ± 9 mmHg, and CVP was 10.3 ± 5.2 mmHg. Univariate analysis demonstrated a significant correlation between mGFR and CI (r2 = 0.030, p = .007) and CVP (r2 = 0.017, p = .049) but not between mGFR and MAP or PCWP. In multivariate analyses, none of the hemodynamic variables remained significantly associated with mGFR. While CVP and CI were correlated with mGFR in univariate analysis the results of analyses adjusted for multiple covariates suggest that hemodynamics are only correlated to renal function in advanced HF to a modest degree challenging the hypothesis that renal dysfunction in HF mainly is a consequence of renal congestion.

Mechanical bridge to heart transplantation

Purpose of the study. The purpose of the work is to assess the effectiveness of using mechanical support for blood circulation in potential cardiac recipients who need urgent transplantation.&#x0D; Material and methods. The study included 47 patients and divided into two groups. The first group included 8 potential cardiac recipients, who had established mechanical support for the BiVAD blood flow. The second group included 39 potential cardiac recipients, who had LVAD's mechanical support for the circulatory system. The main disease that led to the development of terminal congestive heart failure was dilated cardiomyopathy. The INTERMACS scale was used to assess the patient's status. A Scale for the Classification of Patients with Progressive Heart Failure. We used the UNOS scale to assess the status of the patient who needed orthotopic cardiac transplantation. The algorithm of the Thoracic Committee of a single size distribution of organs for determining the urgent implementation of cardiac transplantation.&#x0D; Results and discussion. Biventricular support is necessary for patients with high central venous pressure, increased pulmonary vascular resistance or with malignant arrhythmias, resistant to drug therapy. For the purpose of the final therapy and biventricular support, the system of choice can be a fully artificial heart.&#x0D; Conclusions. Indications for biventricular circulation support are pronounced hemodynamic manifestations of impaired pumping function of the right and left ventricles of the transplanted heart. Systems DK (VAD) is the most effective «bridge to transplantation». It is important to choose the device for the patient, not the patient for the device.

Clinical characteristics of nontraumatic chylothorax in pediatric patients

Purpose: To evaluate clinical characteristics of pediatric nontraumaitc chylothorax and to suggest appropriate therapeutic manage ments. Methods: We retrospectively reviewed medical records of 22 patients with nontraumatic chylothorax from January 2005 to Decem ber 2018 in the Children’s Hospital of Seoul National University. We analyze their etiology, treatment, complications and outcome. Results: Of the 22 patients, 16 were diagnosed before 1 year old and 6 after 1 year old. The causes of chylothorax under 1-year-old children were related to congenital factors (n=9), unknown causes (n=5), and high central venous pressure (n=2). The causes of chylothorax over 1-year-old children were related to congenital factors (n=3), unknown causes (n=1), high venous pressure (n=1), and lymphoma (n=1). All patients had dietary modification. Eight of them were cured by dietary modification, but there was no im provement in over 1-year-old children. Medication was added to patients refractory to dietary modification. Four patients with medication were improved and 5 were improved by surgical management. Nutritional, immunological and other complications oc curred in many patients. Five death cases were reported. Four patients were under 1 year old and 1 was over 1 year old. The causes of nontraumatic chylothorax in dead patients were high central venous pressure (n=3), congenital (n=1), and unknown (n=1). Conclusion: Nontraumatic chylothorax more frequently occurs in under 1-year-old children. The most common cause is congenital factors. Stepwise management is effective in many patients, but specific treatment is needed in some cases. The prognosis is related to the onset of age and underlying diseases. (Allergy Asthma Respir Dis 2019;7:206-211)

Clinical warning signs for intra-abdominal hypertension in septic shock patients.

The latest World Society of the Abdominal Compartment (WSACS) guideline published in 2013 states that risk factors are the most reliable predictors for the diagnosis of intra-abdominal hypertension (IAH) and the bottom line to guide propaedeutic and clinical practice. The objective of this study is to search for clinical, laboratory, and ventilator-associated factors in order to warn medical staff for prompt IAH diagnosis in septic shock patients beyond risk factors simply. This is a prospective, observational study, involving all admitted intensive care unit septic shock patients of a single teaching hospital between April and October 2016. All enrolled patients met Sepsis III and Surviving Sepsis Campaign diagnostic criteria. Patients with primary abdominal conditions were excluded, in order to avoid possible bias. Intra-abdominal pressure (IAP) was measured every 6 hours in accordance with WSACS guidelines. 25 sequential patients were included and followed for 10 days after admission. Median age was 51.13 ± 16.52 years old, 64% male. Pulmonary infection was the most frequent etiology of sepsis, representing 76% of the cases. Elevated IAP correlated with higher central venous pressure (CVP) (P = 0.0421); positive end-expiratory pressure (PEEP) (P = 0.0056); elevated airway pressure (P = 0.0015); accumulated fluid balance (P = 0.0273), and elevated SOFA (P = 0.0393) in all septic patients. Reduction of acidosis (P = 0.0096) and increase of serum bicarbonate (P = 0.0247) correlated with lower IAP values. Elevated CVP, PEEP, SOFA, airway pressure and accumulated fluid balance are correlated with elevated IAP in septic shock patients. Acidosis correction appears to decrease the risk for IAH. Multicentric randomized studies are needed to confirm this hypothesis in a large population.

Risk indicators for acute kidney injury in cardiogenic shock

PurposeIn critical illness, the relation between the macrocirculation, microcirculation and organ dysfunction, such as acute kidney injury (AKI), is complex. This study aimed at identifying predictors for AKI in patients with cardiogenic shock. Materials and methodsThirty-nine adult cardiogenic shock patients, with an admission creatinine <200 μmol l−1, and whose microcirculation was measured within 48 h were enrolled. Patient data were analyzed if AKI stage ≥1 developed according to the Kidney Disease/Improving Outcomes classification within 48 h after admission. Variables with a p < .05 in the univariate analysis were considered for analysis with logistic regression. ResultsTwenty-four patients (61.5%) developed AKI within 48 h. The group that developed AKI had higher central venous pressures (CVP), lower diastolic arterial blood pressures and mean perfusion pressures, higher maximum ventilator pressures as well as positive end expiratory pressures and were treated with higher dosages of dobutamine. There was no difference of the microcirculation. In the multivariate logistic regression analysis, CVP was the only independent predictor for AKI (OR 1.241; 95% CI 1.030–1.495; p = .023). ConclusionsIn this population of patients with cardiogenic shock, CVP was associated with the development of AKI.

Abstract 17013: Preceding Contraction of Less Distensible Ventricular Compartment Plays a Key Role in the Pathogenesis of Mechanical Dyssynchrony in the Univentricular Heart

Background: Septal flash motion is the key to mechanical dyssynchrony in the left bundle branch block in biventricular physiology. In univentricular Fontan circulations, however, morphological variations of systemic ventricles make it difficult to evaluate the negative impact of asynchronous contraction with widened QRS duration on hemodynamics. Methods: A computational simulation of Fontan circulation using a time-varying elastance chamber model combined with a three-element Windkessel vascular model was performed. Systemic ventricles were divided into two ventricular compartments (Vnt 1 , Vnt 2 ) by large ventricular septal defects (VSD), which had various ratios of end-diastolic volumes (EDV 1 /EDV 2 , α) and contractilities (Emax 1 /Emax 2 , β). We introduced delayed contraction onset of Vnt 2 from Vnt 1 (T dys , ms) and simulated hemodynamic changes. We also studied 44 consecutive postoperative Fontan patients with wide QRS (28 male, 1-37 years; median age 16.2 years) and examined their clinical profiles including the analysis of focal ventricular wall motion with 2D speckle tracking echocardiography, hemodynamic parameters in cardiac catheterization, plasma levels of brain natriuretic peptide (BNP, pg/mL) and exercise capacities (peak VO 2 , mL/kg/min). Results: In silico , compared with the ventricles with α &gt; 1 and β &lt; 1, those with α &lt; 1 and β &gt; 1 exhibited significantly decreased cardiac output as T dys increased, and relatively impaired output reserve when tachycardia developed. These deteriorations were characterized by the increased reverse flow from Vnt 2 to Vnt 1 through VSD during mid-systole. Also in vivo , reverse flow during mid-systole via VSD, flash motion during isovolumic contraction time and lower peak systolic strain of smaller ventricular compartment were associated with higher central venous pressures, elevated BNP levels and decreased peak VO 2 (p &lt; 0.05). Conclusion: Delayed contraction in more distensible ventricular compartment can exacerbate the mechanical dyssynchrony characterized by preceding “flash” contraction and subsequent dyskinetic dilation of less distensible compartment, which contributes to the pathogenesis of heart failure in the univentricular heart.

INFERIOR VENA CAVA DILATATION PREDICTS GLOBAL CARDIAC DYSFUNCTION IN ARDS: A STRAIN ECHOCARDIOGRAPHIC STUDY

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigations PRESENTED ON: 10/09/2018 02:30 PM - 03:30 PM PURPOSE: The evaluation of the inferior vena cava (IVC) with ultrasound is frequently utilized to gauge intravascular volume in critically ill patients. The reliability of this technique has been questioned on mechanically ventilated patients, and specific data about its use in acute respiratory distress syndrome (ARDS) is practically nonexistent. We examined the utility of IVC diameter in the evaluation of cardiac and hemodynamic performances in patients with ARDS. METHODS: At a quaternary academic center, we did a retrospective cross-sectional analysis of Doppler Echocardiograms of ventilated patients with moderate-severe ARDS. Right ventricular(RV) fractional area change(RVFAC), tricuspid annular plane systolic excursion(TAPSE) and velocity(S'), and IVC diameter were estimated according to the American Society of Echocardiography guidelines. Using speckle tracking echocardiography, RV free wall(RVFWS), RV septal(RVSS) and RV Global longitudinal(RVGLS) strain were calculated. Left ventricular(LV) ejection fraction(LVEF) and LV diastolic function variables were also measured. Pertinent hemodynamic, ventilatory and laboratory data were collected. RESULTS: Fifty-one patients were included. A bimodal IVC classification method created two groups (IVC<2.1cm and IVC≥2.1cm). An IVC≥2.1cm was associated with lower systolic blood pressure (105±15 vs 124±8 mmHg, p:0.002), higher creatinine (1.4±0.6 vs 0.9±0.4 mg/dL, p:0.004), increased lactate (3.2±1.5 vs 1.8±1.2 mmol/L, p:0.002), higher incidence of shock (62% vs 30%, p:0.02), higher central venous pressure(CVP) (16±4 vs 10±4 mmHg, p:0.0001) and higher systolic pulmonary pressure. RVFAC, TAPSE, S', RVFWS and RVGLS (but not RVSS), were also depressed in this group. An IVC≥2.1cm was also associated with lower LVEF (55±12 vs 67±10%, p:0.01) and abnormal LV diastolic function. Positive correlations of RVFAC, TAPSE, S', RVFWS, RVSS and RVGLS with LVEF were observed. CVP and IVC negatively correlated with LVEF. Regression analysis demonstrated that the best predictor of IVC diameter was CVP (R2:0.35, p:0.001) and that the association RVSS+IVC diameter was a strong independent predictor of LVEF (R2:0.25, p:0.002). No significant differences in ventilatory parameters were observed. CONCLUSIONS: In patients with ARDS, an IVC≥2.1cm was independently associated with worse biventricular cardiac function and more abnormal hemodynamic performance. The biventricular interaction of a functionally impaired RV with the LV only partially explained our observations. The role of systemic negative inotropic factors (i.e., inflammatory response mediators) should be considered. CLINICAL IMPLICATIONS: The hemodynamic management of ARDS patients is extremely challenging. Our study suggests that in moderate-severe ARDS, an IVC≥2.1cm is strongly associated with poor global hemodynamic performance and should signal intensivists the potential necessity for a better hemodynamic optimization. DISCLOSURES: No relevant relationships by Romel Garcia-Montilla, source=Web Response No relevant relationships by Stephen Heitner, source=Web Response No relevant relationships by Faryal Imam, source=Web Response Study PI relationship with United Therapeutics Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support study PI relationship with AstraZeneca Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with National Institute of Health Please note: >$100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Removed 11/29/2017 by Akram Khan, source=Web Response Study PI relationship with Intermune Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Study PI relationship with Lung LLC Please note: $20001 - $100000 Added 11/29/2017 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Actelion pharmaceuticals Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with AstraZeneca Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Bristol-Myers Squibb Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with EMD Serono Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Genentech Please note: $5001 - $20000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Glaxo SmithKline Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with Intermune Please note: $20001 - $100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support Research Grant relationship with United Therapeutics Please note: >$100000 Added 03/02/2018 by Akram Khan, source=Web Response, value=Grant/Research Support No relevant relationships by Mi Miao, source=Web Response No relevant relationships by Srini Mukundan, source=Web Response No relevant relationships by Kathryn Stinson, source=Web Response

High central venous pressure is associated with acute kidney injury and mortality in patients underwent cardiopulmonary bypass surgery

PurposeWe sought to investigate the relationship between high CVP, AKI, and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass. MaterialsAll patients aged 18 years or older who underwent cardiac surgery with CPB were prospectively reviewed. Patients were excluded when renal artery were involved before and during surgery. Patients were dichotomized into high CVP group(>10 mmHg) and low CVP group(<10 mmHg). All patients were followed by telephone. ResultsA total of 1941 patients were included in observed study. In high CVP group, three hundred forty-seven patients (43.32%) developed AKI, while eighty-six (7.543%) in low CVP group(P <0.0001). Furthermore, in every KDIGO stage, patients of AKI in high CVP group were more than those in low CVP group(P <0.0001). The incidence of AKI increased as CVP increased, especially when CVP was higher than 10cmH2O. In a median follow-up time of 9.2 months, Crude mortality is 8.365% in the high CVP group compared to 1.929% in the low CVP group (p<0.0001). In multivariate analysis, CVP remained the independent predictor of survival. ConclusionsHigh CVP is associated with AKI , and it is independently related to all-cause mortality in patients underwent cardiovascular surgery with cardiopulmonary bypass.

Tricuspid annular plane systolic excursion and central venous pressure in mechanically ventilated critically ill patients

BackgroundThe tricuspid annular plane systolic excursion (TAPSE) is commonly recommended for estimating the right ventricular systolic function. The central venous pressure (CVP), which is determined by venous return and right heart function, was found to be associated with right ventricular outflow fractional shortening. This study thus aimed to investigate the relationship between the TAPSE and CVP in mechanically ventilated critically ill patients.MethodsThis is a prospective observational study. From October 1 to December 31, 2017, patients admitted to the intensive care unit with CVP monitoring and controlled mechanical ventilation were screened for enrolment. Echocardiographic parameters, including the TAPSE, mitral annular plane systolic excursion (MAPSE), left ventricular ejection fraction (LVEF), and internal diameter of inferior vena cava (dIVC), and haemodynamic parameters, including the CVP, were collected.ResultsSeventy-four patients were included. Thirty-one were included in the low LVEF (< 55%) group, and 43 were included in the high LVEF (≥55%) group. In the high LVEF group, the TAPSE and CVP were not correlated (r = − 0.234, P = 0.151). In the low LVEF group, partial correlation analysis indicated that the TAPSE and CVP were correlated (r = − 0.516, P = 0.006), and multivariable linear regression analysis indicated that the TAPSE was independently associated with the CVP (standard coefficient: − 0.601, p < 0.001). Additionally, in the low LVEF group, a ROC analysis showed that the area under the curve of the TAPSE for the detection of CVP greater than 8 mmHg was 0.860 (95% confidence interval: 0.730–0.991; P = 0.001). The optimum cut-off value was 1.52 cm, which resulted in a sensitivity of 75.0%, a specificity of 86.7%, a positive predictive value of 84.6% and a negative predictive value of 77.8%.ConclusionsThe TAPSE is inversely correlated with the CVP in mechanically ventilated critically ill patients who have a LVEF less than 55%.