Ultrasonic Cardiac Output Monitor Research Articles

Factors influencing ultrasound cardiac output monitor waveform quality in patients admitted to the emergency intensive care unit

ObjectiveThe ultrasonic cardiac output monitor (USCOM), an instrument that monitors the evolution of a patient's hemodynamic status and determines the type of shock, has become an important tool for assessing cardiac pathology and predicting changes in disease, but there are some variations in the instrumental findings for different physical conditions of patients. This article examines whether there are differences in the quality of USCOM waveforms measured in different types of critically ill patients based on clinical characteristics and test parameters. MethodsBaseline data, diagnoses, echocardiograms, ventilation patterns, and USCOM results were retrospectively collected from patients in the emergency intensive care unit. Waveform quality was quantified using the Fremantle score to determine the extent to which age, body mass index (BMI), chronic obstructive pulmonary disease (COPD), respiratory failure, cardiac enlargement, valvular heart disease, and ventilation pattern influenced USCOM waveform quality. ResultsAge, body mass index, chronic obstructive pulmonary disease, respiratory failure, right and left heart enlargement, aortic valve disease (excluding aortic stenosis), and ventilation mode did not have a significant effect on USCOM waveform quality in critically ill patients (P > 0.05). ConclusionsVarious physical conditions of critically ill patients may have limited effect on the quality of the USCOM waveform, potentially rendering USCOM suitable for early assessment of hemodynamic status during ICU admission.

Aortic arch blood flow measurements as a predictor of successful ECMO weaning in cardiogenic shock

ObjectiveAcute cardiogenic shock is a life-threatening condition with mortality rates of up to 50%. If conventional therapy fails, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy has emerged to a promising alternative for temporary cardiac and respiratory support in specialized centers. However, it is only a bridge to recovery, final decision, heart transplantation or the permanent implantation of a left ventricular assist device. Therefore, the identification of the optimum weaning time point is challenging, and standardized weaning protocols are rare. MethodsIn this explorative pilot study, we evaluated the potential benefit of blood flow measurements in the aortic arch using an ultrasonic cardiac output monitor (USCOM) for the primary endpoint of successful VA-ECMO weaning. 12 patients under VA-ECMO therapy for acute cardiogenic shock and a hemodynamic condition which qualified for a stepwise weaning process were included in this study. Main exclusion criterion was the presence of additional venting therapy for left ventricular unloading, e.g. Impella. Statistical comparisons were performed using the Mann-Whitney test and corrected for multiple testing by the Holm-Sidak method. ResultsPeak velocity of flow in the aortic arch showed a positive correlation with weaning success independent of ECMO flow (weaning success vs. failure: 0.75 vs. 0.35 m/s (low ECMO support), p = 0.049), whereas we identified only a trend for mean pressure gradient, minute distance and stroke volume index. ConclusionWe hypothesize, that USCOM might provide an additive benefit to conventional strategies in its ability to predict successful VA-ECMO weaning and prevent pulmonary congestion. Larger upcoming trials are required to address this relevant topic and provide standardized treatment protocols for optimized weaning in the future.

Hemodynamic evaluation in preterm infants using ultrasonic cardiac output monitor (USCOM).

We aimed to establish reference ranges for USCOM parameters in preterm infants, determine factors that affect cardiac output, and evaluate the measurement repeatability. This retro-prospective study was performed at Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy. We included infants below 32weeks of gestational age (GA) and/or 1500g of birth weight (BW). We excluded infants with congenital heart diseases or hemodynamic instability. Measurements were performed at 3 ± 1, 7 ± 2, and 14 ± 2 postnatal days. We analyzed 204 measurements from 92 patients (median GA = 30.57weeks, BW = 1360g). The mean (SD) cardiac output (CO) was 278 (55) ml/min/kg, cardiac index (CI) was 3.1 (0.5) L/min/m2, and systemic vascular resistance (SVRI) was 1292 (294) d*s*cm-5/m2. CO presented a negative correlation with postmenstrual age (PMA), while SVRI presented a positive correlation with PMA. The repeatability coefficient was 31ml/kg/min (12%). Conclusion: This is the first study describing reference values for USCOM parameters in hemodynamically stable preterm infants and factors affecting their variability. Further studies to investigate the usefulness of USCOM for the longitudinal assessment of patients at risk for cardiovascular instability or monitoring the response to therapies arewarranted. What is Known: • The ultrasonic cardiac output monitoring (USCOM) has been widely used on adult and pediatric patients and reference ranges for cardiac output (CO) by USCOM have been established in term infants. What is New: • We established reference values for USCOM parameters in very preterm and very-low-birth-weight infants; the reference ranges for CO by USCOM in the study population were 198-405 ml/kg/min. • CO normalized by body weight presented a significant negative correlation with postmenstrual age (PMA); systemic vascular resistance index presented a significant positive correlation with PMA.

Assessing Fluid Responsiveness Using Noninvasive Hemodynamic Monitoring in Pediatric Shock: A Review

AbstractNoninvasive hemodynamic monitoring devices have been introduced to better quantify fluid responsiveness in pediatric shock; however, current evidence for their use is inconsistent. This review aims to examine available noninvasive hemodynamic monitoring techniques for assessing fluid responsiveness in children with shock. A comprehensive literature search was conducted using PubMed and Google Scholar, examining published studies until December 31, 2022. Articles were identified using initial keywords: [noninvasive] AND [fluid responsiveness]. Inclusion criteria included age 0 to 18, use of noninvasive techniques, and the emergency department (ED) or pediatric intensive care unit (PICU) settings. Abstracts, review papers, articles investigating intraoperative monitoring, and non-English studies were excluded. The methodological index for nonrandomized studies (MINORS) score was used to assess impact of study bias and all study components were aligned with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Our review yielded 1,353 articles, 17 of which met our inclusion criteria, consisting of 618 patients. All were prospective observational studies performed in the ED (n = 3) and PICU (n = 14). Etiologies of shock were disclosed in 13/17 papers and consisted of patients in septic shock (38%), cardiogenic shock (29%), and hypovolemic shock (23%). Noninvasive hemodynamic monitors included transthoracic echocardiography (TTE) (n = 10), ultrasonic cardiac output monitor (USCOM) (n = 1), inferior vena cava ultrasonography (n = 2), noninvasive cardiac output monitoring (NICOM)/electrical cardiometry (n = 5), and >2 modalities (n = 1). To evaluate fluid responsiveness, most commonly examined parameters included stroke volume variation (n = 6), cardiac index (CI) (n = 6), aortic blood flow peak velocity (∆V peak) (n = 3), and change in stroke volume index (n = 3). CI increase >10% predicted fluid responsiveness by TTE in all ages; however, when using NICOM, this increase was only predictive in children >5 years old. Additionally, ∆SV of 10 to 13% using TTE and USCOM was deemed predictive, while no studies concluded distensibility index by transabdominal ultrasound to be significantly predictive. Few articles explore implications of noninvasive hemodynamic monitors in evaluating fluid responsiveness in pediatric shock, especially in the ED setting. Consensus about their utility remains unclear, reiterating the need for further investigations of efficacy, accuracy, and applicability of these techniques.

Stroke Volume Measurements by Echocardiography and Ultrasonic Cardiac Output Monitor in Children: A Prospective Observational Cohort Study.

Stroke volume (SV) and cardiac output monitoring is a cornerstone of hemodynamic assessment. Noninvasive technologies are increasingly used in children. This study compared SV measurements obtained by transcutaneous Doppler ultrasound techniques (ultrasonic cardiac output monitor [USCOM]), transthoracic echocardiography jugular (TTE-J), and parasternal (TTE-P) views performed by pediatric intensivists (OP-As) with limited training in cardiac sonography (20 previous examinations) and pediatric cardiologists (OP-Bs) with limited training in USCOM (30 previous examinations) in spontaneously ventilating children. A single-center study was conducted in 37 children. Each operator obtained 3 sets of USCOM SV measurements within a period of 3 to 5 minutes, followed with TTE measurements from both apical and jugular views. The investigators were blinded to each other's results to prevent visual and auditory bias. Both USCOM and TTE methods were applicable in 89% of patients. The intraobserver variability of USCOM, TTE-J, and TTE-P were less than 10% in both investigators. The SV measurements by OP-As using USCOM, TTE-J, and TTE-P were 46.15 (25.48) mL, 39.45 (20.65) mL, and 33.42 (16.69) mL, respectively. The SV measurements by OP-Bs using USCOM, TTE-J, and TTE-P were 43.99 (25.24) mL, 38.91 (19.98) mL, and 37.58 (19.81) mL, respectively.The percentage error in SV with USCOM relative to TTE-J was 36% in OP-As and 37% in OP-Bs. The percentage error in SV with TTE-P was 33% relative to TTE-J in OP-As and 21% in OP-Bs. Our findings show that the methods are not interchangeable because SV values by USCOM are higher in comparison with the SV values obtained by TTE. Both methods have low level of intraobserver variability. The SV measurements obtained by TTE-P were significantly lower compared with the TTE-J for the operator with limited training in echocardiography. The TTE-P requires longer practice compared with the TTE-J; therefore, we recommend to prefer TTE-J to TTE-P for inexperienced operators.

The role of cardiac power and lactate clearance as an indicator of resuscitation success among pediatric patients with shock in the intensive care unit of Cipto Mangunkusumo Hospital

BackgroundShock in children remains the primary cause of mortality and morbidity worldwide. Furthermore, its management outcome is improved using many hemodynamic parameters, such as cardiac power (CP) and lactate clearance (LC). Cardiac power is a contractility index based on the measurement of flow and pressure, and it is a relatively new hemodynamic parameter with limited studies. In contrast, LC has been proven useful as a target outcome in shock resuscitation. This study aims to explore the values of CP and LC in pediatric shock and their association with clinical outcomes.MethodsThis prospective observational study was conducted on children (1 month-18 years old) with shock at Cipto Mangunkusumo Hospital, Indonesia, from April to October 2021. We measured CP using ultrasonic cardiac output monitoring (USCOM®) and serum lactate levels at 0, 1, 6, and 24 h post-initial resuscitation. Subsequently, the variables were described and analyzed with the resuscitation success, length of stay, and mortality.ResultsA total of 44 children were analyzed. There were 27 (61.4%), 7 (15.9%), 4 (9.1%), 4 (9.1%), and 2 (4.5%) cases of septic, hypovolemic, cardiogenic, distributive, and obstructive shock, respectively. Within the first 24 h post-initial resuscitation, CP and LC had an increasing trend. Compared to children who had successful resuscitation, those who did not have successful resuscitation had similar CP at all time points (p > 0.05) and lower LC at 1 and 24 h post-initial resuscitation (p < 0.05). Lactate clearance was an acceptable predictor of resuscitation success (area under the curve: 0.795 [95% CI: 0.660–0.931]). An LC of 7.5% had a sensitivity, specificity, positive predictive value, and negative predictive value of 75.00%, 87.5%, 96.43%, and 43.75%, respectively. Lactate clearance in the first hour post-initial resuscitation had a weak correlation (r=-0.362, p < 0.05) with hospital length of stay. We found no difference in CP and LC among survivors compared to nonsurvivors.ConclusionsWe found no evidence that CP was associated with resuscitation success, length of stay, or mortality. Meanwhile, higher LC was associated with successful resuscitation and shorter length of stay at the hospital, but not mortality.

The prediction of hypertensive disorders by maternal hemodynamic assessment in the first trimester of pregnancy

Background Hypertensive disorders of pregnancy and fetal growth restriction share common etiopathological origins and could be caused by maternal hemodynamic maladaptation to pregnancy. Objective The aim of our study is to evaluate if there is a correlation between maternal hemodynamic detected by UltraSonic Cardiac Output Monitor (USCOM®) during the first trimester and the pregnancy outcome. Study design We recruited a nonconsecutive series of women in the first trimester of pregnancy with no previous history of hypertensive disorders. We measured the pulsatility index uterine arteries and performed a hemodynamic evaluation by USCOM® device. After delivery, we reported the development of hypertensive disorders or intrauterine fetal growth restriction later during gestation. Results A total of 187 women were enrolled during the first trimester; 17 (9%) developed gestational hypertension or preeclampsia while 11 (6%) delivered a restricted growth fetus. Mean uterine artery pulsatility index above the 95th percentile was significantly more frequent in both women who developed hypertension and those with fetal growth restriction compared to controls. Hemodynamic parameters (reduced cardiac output and increased total vascular resistance) were significantly different in the group that developed hypertensive disorders, compared to uncomplicated pregnancy. ROC curves demonstrated the usefulness of uterine artery pulsatility index in the prediction of fetal growth restriction, while hemodynamic parameters were significantly associated to the development of hypertensive disorders. Conclusions Hemodynamic maladaptation to pregnancy may predispose to the development of hypertension, while we demonstrated a significative relationship between growth restriction and mean uterine pulsatility index. Further studies are needed to assess the value of hemodynamics evaluation in screening protocols of preeclampsia.

Use of hemodynamic and laboratory monitoring tools to reduce the risk of mortality from pediatric septic shock

Background Early recognition of septic shock in terms of clinical, macrocirculatory hemodynamic, and microcirculatory laboratory parameters is a fundamental challenge in the emergency room and intensive care unit for early identification, adequate management, prevention of disease progression, and reduction of mortality risk.&#x0D; Objective To evaluate for possible correlations between survival outcomes of post-resuscitation pediatric septic shock patients and parameters of clinical signs, macrocirculatory hemodynamics, as well as microcirculatory laboratory findings.&#x0D; Methods This prospective, study was conducted in the PICU at Saiful Anwar Hospital, Malang, East Java. Inclusion criteria were children diagnosed with septic shock according to the 2005 Surviving Sepsis Campaign (SSC) criteria, aged &gt;30 days-18 years, who were followed up for 72h after resuscitation. The measured variables such as cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume index (SVI) were obtained from ultrasonic cardiac output monitor (USCOM). Blood gas and lactate were obtained from laboratory findings. Heart rate, pulse strength, extremity temperature, mean arterial pressure (MAP), systolic blood pressure (SBP), capillary refill time (CRT), Glasgow coma scale (GCS), and diuretic used were obtained from hemodynamic monitoring tools. Survival outcomes of post-resuscitation pediatric septic shock patients were noted.&#x0D; Results There was a significant correlation between the outcomes of the pediatric septic shock patients 72h after fluid resuscitation and clinical, macrocirculatory hemodynamic, and microcirculatory laboratory parameters. After the 6th hour of observation, strong pulse was predictive of survival, with 88.2% area under the curve (AUC). At the 12th hour of observation, MAP &gt;50th percentile for age was predictive of survival, with 94% AUC.&#x0D; Conclusion For pediatric patients with septic shock, the treatment target in the first 6 hours is to improve strength of pulse, and that in the first 12 hours is to improve MAP &gt;50th percentile for age to limit mortality.

Comparison of hemodynamic indices of dialysis patients in continuous renal replacement therapy and intermittent renal replacement therapy methods with ultrasonic cardiac output monitor in intensive care unit

Introduction: Acute kidney injury (AKI) is a common complication in the intensive care unit (ICU) and is independently associated with end-stage renal disease and higher mortality in the ICU. There are different methods to supporting kidney function in critically ill patients. The renal replacement therapy (RRT) can be conducted continuously, intermittently, or in combination. Objectives: The purpose of our study is to investigate the hemodynamic indices of dialysis patients in the ICU by two methods high flow continuous renal replacement therapy (CRRT) and intermittently renal replacement therapy (IRRT) of ultrasonic cardiac output monitor (USCOM). Patients and Methods: In this study conducted at Sina hospital, patients requiring dialysis hospitalized to the ICU were studied. Around 48 patients benefited from rapid CRRT or IRRT in the opinion of a specialist. Basic patient information was recorded. To check hemodynamic parameters during dialysis, USCOM was carried out to check corrected flow time value (FTc) parameters, systemic vascular resistance (SVR) and cardiac output. Results were compared between the IRRT and CRRT groups. Results: This study was conducted on 48 patients who were candidates for dialysis. Patients were divided into high flow CRRT and IRRT groups based on clinical indications. In CRRT group, 19 patients (79.2%) and in the IRRT group, 20 patients (83.3%) were male (P=0.712). Their mean age was 68.70 ± 8.25 years in the CRRT group and 68.58 ± 7.19 years in the IRRT group. All patients had cardiac output monitored using USCOM or ultrasound. The mean Sequential Organ Failure Assessment (SOFA) score in the CRRT group was 7 and in the IRRT group was 6, with no significant difference among them. FTc value variable or modified flow time in the carotid artery, cardiac output, cardiac index, SVR variable and mean arterial pressure in in the two groups at four evaluated times (before dialysis, 15 minutes later, one hour later and end of dialysis) from the study the difference were not statistically significant. Conclusion: Although previos studies have recommended CRRT, our study showed significant difference may not be existed between IRRT and CRRT.

Systemic vascular resistance may influence the outcome of in vitro fertilization

Introduction: The number of pregnancies obtained through in vitro fertilization (IVF) techniques are increasing, and only few studies have investigated hemodynamic variations in women undergoing IVF techniques. The aim of this study was to evaluate the hemodynamic parameters in women undergoing IVF, to assess a possible correlation between hemodynamics and embryo implantation. Methods: 45 normotensive non-obese women, age ≤ 43 years, with idiopathic or tubal infertility, referred to the Reproductive Physiopathology and Andrology Unit, Sandro Pertini Hospital, Rome, during the period 2020/2021, underwent IVF techniques. All women were evaluated with Ultra Sonic Cardiac Output Monitor (USCOM) to detect hemodynamic parameters at two different stages: at the mid-luteal phase, before the beginning of IVF, and at the day of embryo transfer (dET). All demographics and hormonal parameters in both groups were comparable. The hemodynamic parameters were compared between women with a positive β-HCG test vs. those testing negative. Results: 11 out of 45 (24,5%) women obtained positive β-HCG test. All demographics and hormonal parameters were comparable in both groups. Women with a positive β-HCG test showed statistically lower systemic vascular resistance (SVR) at mid-luteal phase (868.61 ± 100.1 vs. 1009 ± 168.4) and dET (818,9 ± 104.5 vs 1038.52 ± 150.82 dynes × s/cm5). Conclusions: Hemodynamic assessment can identify a more favorable pre-pregnancy cardiovascular adaptation. Embryo implantation might be positively influenced by the hemodynamic parameters, e.g. lower SVR, before the beginning of IVF techniques, and during the window of implantation.

Different Hemodynamic Types of Preeclampsia Observed Under Ultrasonic Cardiac Output Monitor (USCOM): A Report of Two Cases

Preeclampsia is a serious and uncommon complication of pregnancy, which affects 5% to 7% of pregnancies and is associated with maternal and fetal adverse outcomes. Moreover, preeclampsia is a polymorphic disease with different hemodynamic types, thus requiring different therapeutic strategies. As a hemodynamic tool, the ultrasonic cardiac output monitor (USCOM) is useful in the detection of preeclampsia as early as the 5th to 16th week of gestation, with abnormal hemodynamic indicating preeclampsia. Although blood pressure (BP) rises in preeclamptic patients, it is not a sensitive indicator for the diagnosis of preeclampsia. However, hemodynamic may change in the 5th to 11th week of gestation. In this paper, the hemodynamic types of two cases were reported using USCOM. The SV, CO, and SVRI values were significantly different in both the cases, indicating the patients had different types of preeclampsia. The hemodynamic parameters were more useful than blood pressure for managing the two cases. Moreover, the mother and fetal were safe after treatment. If preeclampsia had been assessed only from the perspective of BP, the two cases would have been diagnosed as having mild hypertension, and we would not be able to determine the severity. USCOM allowed the identification of preeclampsia-associated hemodynamics and defined individualized therapeutic targets, which cannot be identified by BP alone.

Hemodynamic assessment in patients with preterm premature rupture of the membranes (pPROM)

ObjectiveThe aim of this study was to assess the hemodynamic differences in women with pPROM versus physiological pregnancies. Study designThis was a prospective case control study of 15 patients with pPROM and 45 controls. Patients and controls were submitted at enrollment to a non-invasive hemodynamic evaluation with UltraSonic Cardiac Output Monitor (USCOM), and to blood tests to check white blood cells count and C-reactive protein (CRP) levels. We followed pPROM patients until delivery noting fetal/neonatal and maternal unfavorable outcomes (maternal fever, APGAR 1′ and 5′< 7, stillbirth). ResultsPatients with pPROM showed higher values of cardiac output (9.1 ± 2.3 vs 7.1 ± 0.85, p < 0.01), lower systemic vascular resistances (792.1 ± 162 vs 1006.2 ± 110.7, p < 0.01), higher minute distance (32.3 ± 7.8 vs 25 ± 2.8, p < 0.01), lower Potential to Kinetic Energy Ratio (16.5 ± 5.3 vs 22.4 ± 6.8, p < 0.01), higher heart rate (97.5 ± 15.4 vs 82.4 ± 12, p < 0.01) and higher oxygen delivery (1313.2 ± 325.8 vs 1080.7 ± 151.8, p < 0.01) vs. controls. Six out of 15 pPROM patients had an unfavorable outcome. There were no significant differences in CRP levels and WBC count at admission in the two pPROM subgroups, whereas maternal hemodynamics was characterized by lower SVR (718 ± 72 vs 863 ± 123, p = 0.02) in subsequently complicated patients. ConclusionsMaternal hemodynamics is altered in pPROM patients, with a lower Systemic Vascular Resistance and higher Cardiac Output vs. controls. This hyperdynamic circulation appears to anticipates the changes of serum markers of inflammation (CRP, WBC count) and seems to be more pronounced at admission in pPROM patients developing unfavorable outcomes.

Ultrasonic cardiac output monitoring in intubated patients with and without COVID-19 in the ICU: a prospective cohort study

Objective: The present study was conducted to compare mechanically ventilated patients with and without COVID-19 in terms of hemodynamic instability using cardiovascular indicators.&#x0D; Methods: This prospective cohort study assigned intubated and mechanically ventilated patients to two groups, i.e. with COVID-19 and without COVID-19. The hemodynamic parameters measured and compared between the two groups on the first day of ICU admission and the following four consecutive days using an ultrasonic cardiac output monitor (USCOM) included cardiac output (CO), systemic vascular resistance (SVR), stroke volume (SV), flow time corrected (FTc), minute distance (MD) and potential kinetic energy (PKE).&#x0D; Results: Forty-three patients (males: 62.7%) were assigned to the COVID-19 group and 40 (males: 64.1%) to the one without COVID-19. Insignificant differences were observed between the two groups at baseline in terms of the mean homodynamic variables measured using the USCOM (P&gt;0.05). The mean CO increased (P=0.020), the mean SVR insignificantly changed (P=0.267), the mean MD increased (P=0.005) and PKE decreased (P=0.066) in the COVID-19 group during the five days of evaluation. In the same period, the mean CO insignificantly changed (P=0.937), the mean SVR increased (P=0.028) and changes in MD (P=0.808) and PKE (P=0.539) were insignificant in the group without COVID-19. The two groups were not significantly different in terms of the other homodynamic parameters during the follow-up (P&gt;0.05).&#x0D; Conclusion: The five-day changes in the USCOM-measured homodynamic parameters were lower in the group without COVID-19 compared to in that with COVID-19. In the group without COVID-19, no statistically-significant differences were observed between the mean follow-up values of the variables, excluding SVR, and their baseline values.

Measurement of Cardiac Output Using an Ultrasonic Cardiac Output Monitor (USCOM) in Patients with Single-Ventricle Physiology.

We evaluate the validity of cardiac index (CI) measurements utilizing the Ultrasonic Cardiac Output Monitor (USCOM), a non-invasive Doppler ultrasound device, by comparing measurements to cardiac catheterization-derived CI measurements in patients with single-ventricle physiology. USCOM measurements were repeated three times for each patient at the beginning of a cardiac catheterization procedure for twenty-six patients undergoing elective pre-Glenn or pre-Fontan catheterization. CI was measured by USCOM and was calculated from cardiac catheterization data using Fick's method. Bland-Altman analysis for CI showed bias of 0.95 L/min/m2 with the 95% limits of agreement of - 1.85 and 3.75. Pearson's correlation coefficient was 0.89 (p < 0.001) indicating a strong positive relationship between USCOM and cardiac catheterization CI measurements. When excluding two patients with significant dilation of the neo-aortic valve (z-score > + 5), the bias improved to 0.66 L/min/m2 with the 95% limits of agreement of - 1.38 and 2.70. Percent error of limits of agreement was 34%. There was excellent intra-operator reproducibility of USCOM CI measurements with an intra-class coefficient of 0.96. We demonstrate the use of USCOM to measure CI in patients with single-ventricle physiology for the first time, showing acceptable agreement of the CI measurements between USCOM and cardiac catheterization with a high intra-operator reproducibility.

Prognotic value of ultrasonic cardiac output monitoring for mechanically ventilated patients with AECOPD

Prognotic value of ultrasonic cardiac output monitoring for mechanically ventilated patients with AECOPD

The clinical value of ultrasonic cardiac output monitor in very-low birth-weight and extremely-low-birth-weight infants undergoing PDA ligation

BackgroundCardiorespiratory instability occurs very often in very-low-birth-weight (VLBW) and extremely-low-birth-weight (ELBW) infants undergoing patent ductus arteriosus (PDA) ligation during the early postoperative period. This study aimed to investigate ultrasonic cardiac output monitor (USCOM) as a bedside tool by evaluating the hemodynamic changes in preterm infants following PDA ligation and assessing factors that may influence these changes. MethodsThis was a single-center prospective observational study at a third-level neonatal intensive care unit. A total of 33 infants, including 21 VLBW and 12 ELBW infants, were involved. Hemodynamic measurements were performed in these infants using a USCOM preoperatively as well as 0–1 h, 8–10 h, and 24 h postoperatively. ResultsThe PDA ligation was associated with reductions of the left ventricular cardiac output (LVCO) (P < 0.001), cardiac index (P < 0.001), flow time corrected (FTC) (P < 0.001), Smith–Madigan inotropy index (SMII) (P < 0.001), oxygen delivery (DO2) (P < 0.001), and oxygen delivery index (DO2I) (P < 0.001) and an increase of the systemic vascular resistance index (SVRI) (P < 0.001) at 0–1 h, 8–10 h, and 24 h post-ligation compared with the respective preoperative values. Compared with the respective values at 0–1 h post-ligation, there was no significant difference in the CI, SMII, or FTC at 8–10 h and 24 h post-ligation. However, the SVRI decreased at 8–10 h and 24 h post-ligation. Moreover, the DO2I increased at 8–10 h and 24 h post-ligation, and the LVCO and DO2 increased at 24 h post-ligation. ConclusionOur study confirmed that the hemodynamic changes measured by the USCOM were similar to those measured by echocardiography in previous reports. Thus, USCOM is a useful and convenient bedside tool for assessing hemodynamic changes to guide the use of fluids, inotropic agents, and vasopressors and help modify the post-ligation course, and they may be a surrogate for repeated echocardiography during the early post-ligation period in preterm infants or a preliminary screening method.

Maternal haemodynamic profile in pregnancy after assisted reproductive technology: A pilot study.

Singleton pregnancies obtained by assisted reproductive technology (ART) are at increased risk of adverse pregnancy outcome. Aim of this pilot study was to compare maternal hemodynamic profile in ART and spontaneous singleton pregnancies. Patients were enrollered during a third trimester routine obstetric examination. Maternal haemodynamic assessment was carried out by a single trained operator using an UltraSonic Cardiac Output Monitor in standardized conditions. Our pilot data suggests that women conceived after ART may have significantly lower Cardiac Output and significantly higher Systemic Vascular Resistance when compared to those conceiving spontaneously. These differences, if confirmed in larger studies, might explain the increased prevalence of adverse outcome, especially hypertensive disorders of pregnancy, in singleton ART pregnancies.

Serum NT-Pro-BNP versus Noninvasive Bedside Inotropic Index in Paediatric Shock: A Contest of Myocardial Performance in Response to Fluid Loading

Background Mild elevation of serum amino-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is associated with myocardial dysfunction. A significantly lower Smith–Madigan inotropic index (SMII) has been shown to accurately represent cardiac contractility among heart failure subjects. We aim to monitor the effect of fluid resuscitation on cardiac function among paediatric patients by measuring serum NT-pro-BNP and SMII. Methods This is an observational study on 70 paediatric shock patients. NT-pro-BNP and noninvasive bedside haemodynamic monitoring were done by using an ultrasonic cardiac output monitor (USCOM, USCOM, Sydney, Australia). The presence of cardiac diseases was excluded. SMII was obtained from the USCOM. An increase in the stroke volume index (SVI) of ≥15% indicates fluid responders. Measurements were taken before and after fluid loading. Results Preloading NT-pro-BNP and SMII category were significantly different between the fluid responsiveness group, p=0.001 and p=0.004, respectively. Higher median NT-pro-BNP (preloading NT-pro-BNP of 1175.00 (254.50–9965.00) ng/mL vs. 196.00 (65.00–509.00) ng/mL, p=0.002) was associated with fluid nonresponders (subjects >12 months old). Preloading NT-pro-BNP <242.5 ng/mL was associated with fluid responders (AUC: 0.768 (0.615–0.921), p=0.003), 82.1% sensitivity, and 68.7% specificity for subjects >12 years old. Delta NT-pro-BNP in fluid responders (15.00 (−16.00–950.00) ng/mL) did not differ from fluid nonresponders (505.00 (−797.00–1600.00) ng/mL), p=0.456. Postloading SMII >1.25 W·m−2 was associated with fluid responders (AUC: 0.683 (0.553–0.813), p = 0.011), 61.9% sensitivity, and 66.7% specificity, but not preloading SMII. Fluid responders had a higher mean postloading SMII compared to nonresponders (1.36 ± 0.38 vs. 1.10 ± 0.34, p=0.006). Conclusion Higher NT-pro-BNP and lower SMII in the absence of cardiac diseases were associated with poor response to fluid loading. The SMII is affected by low preload conditions.

Maternal hemodynamic changes in gestational diabetes: a prospective case-control study.

The aim of the study is to compare maternal hemodynamic adaptations in gestational diabetes (GDM) versus healthy pregnancies. A prospective case-control study was conducted, comparing 69 singleton pregnancies with GDM and 128 controls, recruited between September 2018 and April 2019 in Maternal-Fetal Medicine Unit, Careggi University Hospital, Florence, Italy. Hemodynamic assessment by UltraSonic Cardiac Output Monitor (USCOM) was performed in both groups in four gestational age intervals: 17-20weeks (only in early GDM cases), 26-30weeks, 32-35weeks and 36-39weeks. We evaluated six hemodynamic parameters comparing GDM cases versus controls: cardiac output (CO), cardiac index (CI), stroke volume (SV), total vascular resistance (TVR), inotropy index (INO) and potential to kinetic energy ratio (PKR). GDM group had significantly lower values of CO and SV than controls from the early third trimester (26-30weeks) until term (p < 0.001). CI is significantly lower in GDM women already at the first evaluation (p = 0.002), whereas TVR and PKR were significantly higher in GDM (p < 0.001). GDM women showed also lower INO values than controls in all assessments. A hemodynamic maternal maladaptation to pregnancy can be detected in GDM women. The effect of hyperglycemia on vascular system or a poor pre-pregnancy cardiovascular (CV) reserve could explain this hemodynamic maladaptation. The abnormal CV response to pregnancy in GDM women may reveal a predisposition to develop CV disease later in life and might help in identifying patients who need a CV follow-up.

Maternal cardiovascular function in the prediction of fetal distress in labor: a prospective cohort study

Objective To explore the strength of association and the diagnostic accuracy of maternal hemodynamic parameters detected noninvasively in predicting an adverse perinatal outcome in labor. Methods Prospective cohort study of singleton women undergoing antepartum care at 37–39 weeks of gestation. A noninvasive ultrasonic cardiac output monitor (USCOM®) was used for cardiovascular assessment. The study outcome was a composite score of adverse perinatal outcome, which included at least one of the following variables: Cesarean or instrumental delivery for abnormal fetal heart monitoring, umbilical artery pH <7.10 or admission to neonatal special care unit. Attending clinicians were blinded to maternal cardiovascular indices. Multivariate logistic regression and area under the curve (AUC) analyses were used to test the diagnostic accuracy of different maternal and ultrasound characteristics in predicting adverse perinatal outcome. Results A total of 133 women were recruited. The rate of adverse perinatal outcome was 25.6% (34/133). Women who delivered without abnormal perinatal outcome (controls) were more likely to be parous, compared to those who had an adverse perinatal outcome (44.4 vs. 73.5%; p = .005). Control women had significantly lower systemic vascular resistance (SVR) (median, 1166 vs. 1352 dynes × s/cm5, p = .023) and SVR index (SVRI) (median, 2168 vs. 2627 dynes × s/cm5/m2, p = .039) compared to women who had an adverse perinatal outcome. In this latter group the prevalence of SV <50 ml was significantly higher than in the control group (38.2% (13/34) vs. 11.1%, (11/99) p = .0012). At multivariable logistic regression analysis, SVR (aOR 1.307; 95% CI 1.112–2.23), SV <50 ml (aOR 4.70; 95% CI 1.336–12.006) and parity (3.90: 95% CI 1.545–10.334) were the only variables independently associated with adverse perinatal outcome. A model considering only SVR showed an AUC of 0.631. Integration of SVR with SV <50 ml and parity significantly improves the diagnostic performance of SVR alone to predict adverse outcome (AUC 0.732; p = .016). Conclusion Pre-labor modifications of maternal cardiovascular variables are associated with adverse perinatal outcome. However, their predictive accuracy for perinatal compromise is low, and thus their use as standalone screening test for adverse perinatal outcome in singleton pregnancies at term is not supported.