Volume Status Research Articles

Ultrasound Assessment of Prevalence of ‘At Risk Stomach’ in Children Undergoing Elective Surgery- Prospective, Observational Study

Children may be at increased risk of pulmonary aspiration because of retention of gastric contents caused by pain or inadequate fasting. We performed this study to analyze the use of ultrasound for evaluation of gastric ultrasound in children less than 12 years. Two hundred children, 1-12 years of age belonging to ASA physical status I to II, scheduled to undergo elective surgery were included in the study. Patients were scanned in supine position followed by right lateral decubitus position (RLD). In qualitative assessment, the antrum was judged to contain fluid if it appeared to have an endocavitary lumen with hypoechoic content and distended walls. All measurements were taken with antrum at rest (between contraction) to avoid underestimating volume. It was observed that majority of the children were in Perlas grade 0, 116(58%) followed by 75 children in grade 1 and 9 children in grade 2. Using Karl Pearson’s Correlation coefficient, low positive correlation was found between gastric volume and fasting status solid (in hours) and the variation (correlation) was found to be statistically non-significant (r=0.139; p>0.05). There is no proportionate decline in gastric volume with increased duration of preoperative fasting. Ultrasonographic measurement of antral area can be of interest to anesthesiologist for accurate qualitative and quantitative estimation of preoperative gastric contents and volume. However, gastric ultrasonography has to be validated in further trials involving a larger patient population before it can become a routine standard of care in perioperative period.

Role of inferior vena cava assessment in volume management in acute kidney injury patients

BackgroundIntravascular volume assessment is critical to guiding volume management in patients with acute kidney injury (AKI). This study aimed to compare the impact of using inferior vena cava (IVC) diameter and collapsibility index (IVC-CI) measurements versus clinical assessment on the management of volume status and improvement of renal function in patients with AKI.MethodsThis prospective comparative study included 88 patients with AKI or AKI on top of chronic kidney disease (CKD) who were randomly allocated into two groups: In group 1, volume status was managed according to IVC assessment, while in group 2, volume status was managed according to clinical assessment. In addition, group 1 patients were assessed clinically and compared with IVC measurements in the same group.ResultsThere was moderate agreement between the IVC and clinical methods in diagnosing 86.4% of patients (P < 0.001) within group 1. The percentage of patients with edema increased post-treatment in group 2. There was no statistically significant difference between the two groups regarding renal recovery and survival.ConclusionBedside ultrasonographic IVC assessment is a non-invasive method that can facilitate volume management in AKI patients, helping to administer fluids more wisely without unintended excess fluid administration.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

How is bioelectrical impedance used in neonatal intensive care? A scoping review.

There is a paucity of recent robust research papers which investigate the use of bioelectrical impedance in preterm neonates. Available evidence spans a range of 30 years, with technological advancement reducing the application of older studies to the modern neonatal setting. Although this technology may be helpful for decision-making around fluid management and nutrition, in preterm infants, robust evidence is needed to demonstrate the clinical benefit of bioelectrical impedance beyond that of usual care. • Clinical decisions regarding neonatal nutrition and fluid management are currently based upon the interpretation of vital signs, fluid balance, weight trend, biochemical markers, and physical examination. • Bioelectrical Impedance Analysis (BIA) is a non-invasive method of assessing body composition which is now available to be used in infants as small as 23 weeks gestation. • Bioelectrical Impedance has been used in three main ways in the NICU, for fluid status evaluation, for measuring nutrition and growth and to validate BIA as an outcome. • There is a lack of recent robust research data to support the use of the device within clinical decision making in neonatal intensive care.

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. To understand how clinicians personalize decisions about resuscitation in practice. This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Online Qualtrics clinical vignette survey. Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

One Pump for Two Hearts: Using an Impella 5.5 Micro-Axial Pump in Peripartum Cardiogenic Shock.

Cardiogenic shock (CS) occurs infrequently in pregnancy and has a high mortality rate. Medical treatment options are few, with limited evidence of efficacy. Temporary mechanical circulatory supports (tMCS) may play a key role in addressing this therapeutic lacuna. We report successfully managing second-trimester CS using an Impella 5.5 micro-axial pump. Our patient presented in the second-trimester with CS. Hemodynamic parameters indicated biventricular dysfunction (low cardiac index, low pulmonary artery pulsatility index). She received diuresis and inotropic support to optimize her fluid status and cardiac function. However, failure to improve to the point where she would be able to tolerate the hemodynamic stresses of labor despite optimizing medical therapy prompted consideration of tMCS. The Impella 5.5 was chosen for its higher output (to maximize fetal perfusion), relative longevity, and lower hemolysis rates compared to other devices. It was used to support her from gestational weeks 28-30 and through the delivery. Support was continued for 4 weeks postpartum to allow for any potential cardiac recovery. Hope unrealized, a workup for destination therapy was initiated. Patient preference and high panel reactive antibodies informed the decision to pursue destination left ventricular assist device (LVAD) therapy. After a 3 month neonatal intensive care unit (NICU) stay, mother and baby were successfully discharged home.

Group-Based Trajectory Modeling of Fluid Balance in Elderly Patients with Acute Ischemic Stroke: Analysis from Multicenter ICUs.

Acute ischemic stroke (AIS) significantly contributes to severe disability and mortality among the elderly. This study aims to explore the association between longitudinal fluid balance (FB) trajectories and clinical outcomes in elderly patients with AIS. Our hypothesis posits the existence of multiple latent trajectories of FB in patients with AIS during the initial 7days following ICU admission. Patients (age ≥ 65years) with AIS and continuous FB records were identified from two large databases. Group-based trajectory modeling identified latent groups with similar 7-day FB trajectories. Subsequently, multivariable logistic and quasi-Poisson regression were employed to evaluate the relationship between trajectory groups and outcomes. Additionally, nonlinear associations between maximum fluid overload (FO) and outcomes were analyzed using restricted cubic spline models. To further validate our findings, subgroup and sensitivity analysis were conducted. A total of 1146 eligible patients were included in this study, revealing three trajectory patterns were identified: low FB (84.8%), decreasing FB (7.2%), and high FB (7.9%). High FB emerged as an independent risk factor for in-hospital mortality. Compared with those without FO, patients with FO had a 1.57-fold increased risk of hospital mortality (adjusted odd ratio (OR) 1.57, 95% confidence interval (CI) 1.08-2.27), 2.37-fold increased risk of adverse kidney event (adjusted OR 2.37, 95%CI 1.56-3.59), and 1.33-fold increased risk of prolonged ICU stay (adjusted incidence rate ratio (IRR) 1.33, 95%CI 1.19-1.48). The risk of hospital mortality and adverse kidney event increased linearly with rising maximum FO (P for non-linearity = 0.263 and 0.563, respectively). Daily FB trajectories were associated with adverse outcomes in elderly patients with AIS. Regular assessment of daily fluid status and restriction of FO are crucial for the recovery of critically ill patients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fluid therapy in ICU – A review

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

The Utility of Echocardiography in Estimating Fluid Responsiveness.

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

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

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

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

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

Monitoring the venous circulation: novel techniques and applications.

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

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

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