Background: Dynamic assessment of cardiac output (CO) with passive leg raise (PLR), stroke volume variation (SVV), and pulse pressure variation (PPV) offer effective and safe methods to predict fluid responsiveness in patients with shock. The primary aim of this study was to evaluate the reliability of CO and SVV readings with the ultrasonic cardiac output monitor (USCOM) 1A device compared to PPV measurements in determining fluid responsiveness of patients in shock. Materials and Method: Intubated and mechanically ventilated patients aged 18-95 with shock admitted to the medical intensive care unit from June 2019 to December 2020 were included in the study. Fluid responsiveness was assessed using PPV from arterial monitoring and CO/SVV using the USCOM 1A device. CO, PPV, and SVV data were recorded before and after PLR. Results: Out of 145 shock patients, 92 were included. Before the PLR maneuver, 67 patients had PPV values above 12% and were stated as fluid responsive. The SVV index measured by the USCOM device demonstrated good sensitivity (85%) and specificity (96%) in identifying fluid responsiveness. The agreement with PPV was substantial (Cronbach's alpha reliability: 0.718 [ P < 0.001]), and the index was internally consistent (kappa agreement: 0.707 [ P < 0.001]). The SVV index moderately correlated with PPV (R: 0.588 [ P = 0.001]). Regarding fluid responsiveness determined by PPV, the AUC value of SVV was 0.797 (0.701-0.894) (p: 0.001). Conclusion: SVV measured by the USCOM device is a reliable and practical tool for hemodynamic assessment in clinical practice, particularly when invasive methods are unsuitable.

Intraoperative hypotension (IOH) is inevitable during moderate-to-high-risk surgeries. In kidney transplantation, intraoperative hypotensive events can badly affect postoperative graft and patient outcomes. Traditionally, central venous pressure monitoring has been regarded as a fundamental aspect of intraoperative haemodynamic management during kidney transplantation. Recently, the focus has changed by including newer haemodynamic tools (FloTrac, Hemosphere, etc.) to reduce intraoperative hypotensive events and postoperative complications. The primary objective was to record IOH (incidence, duration, and severity).

This study was done retrospectively to observe the effect of haemodynamic monitoring on IOH. Recipients with dilated cardiomyopathy (DCMP) aged 18-60 years who underwent kidney transplantation from June 2022 to May 2024 were included and had cardiac output measured by FloTrac or Hemosphere. The primary outcome was to record the time-weighted average (TWA) of IOH. Secondary outcomes were to record the average number of hypotensive events per patient and the average duration of each hypotensive event.

Twenty-eight patients with DCMP were included. The primary outcome of TWA of the area under threshold (MAP < 65 mmHg) per patient was more in patients in the FloTrac group in comparison to the Acumen group (P = 0.613). Secondary outcomes, namely the incidence of hypotensive events per patient and total time of hypotension, were significantly higher in the FloTrac group as compared to the Acumen group (P < 0.0001).

Hypotension prediction index (HPI) provides superior intraoperative haemodynamic management in kidney transplant recipients with DCMP in terms of reduced duration, incidence, and severity of IOH.

To investigate whether point-of-care ultrasound of the external jugular vein (EJV) can predict fluid responsiveness (FR) in healthy, anesthetized, mechanically ventilated dogs.

Prospective, nonrandomized experimental study.

University-based small animal research facility.

Six healthy Beagle dogs.

Dogs were investigated at six time points (TPs): baseline (TP1); 20 mL/kg of circulating blood was collected over 10 min (TP2); half of the collected blood was autotransfused for 10 min (TP3); remaining collected blood was autotransfused for 10 min (TP4); 0.9% normal saline (10 mL/kg for 10 min) was administered (TP5); and an additional dose of 0.9% normal saline (10 mL/kg for 10 min) was administered (TP6). Hemodynamic variables, Doppler images of the left ventricular outflow tract (LVOT), and M-mode images of the EJV were obtained at each TP. FR was evaluated during TP3-6. FR was defined as an increase of >15% in the LVOT velocity time integral following fluid challenge, while other results were defined as fluid nonresponsiveness (FNR). The external jugular vein distensibility index (EJVDI) was calculated as follows: [(maximal EJV diameter - minimal EJV diameter)/minimal EJV diameter] × 100%. The maximal EJV diameter was measured during inspiration, and the minimal EJV diameter was measured during expiration. In addition, gray zones indicating the range of diagnostic uncertainty were proposed in various indices for predicting FR.

Among the 24 fluid challenges performed between TP3 and TP6, 11 FR and 13 FNR were identified. The area under the receiver operating characteristic curve for the EJVDI in predicting FR was 0.92, with a cut-ff value of 22.7%, and the gray zone was identified as 22.6%-27.3%.

The EJVDI could be used to predict FR in healthy, anesthetized, mechanically ventilated dogs. Further studies are required before point-of-care ultrasound of the EJV can be applied in various clinical settings.

Background: Sepsis-associated acute kidney injury (AKI) is linked to increased mortality and prolonged hospital stays. The exact relationship between central venous pressure (CVP) and AKI remains unclear. We explored the correlation between CVP and AKI in septic shock patients. Methods: This retrospective study included adult patients with septic shock admitted to Mayo Clinic Rochester between 2006 and 2018. CVP levels were measured at 6, 12, 24, and 48 h after the diagnosis of sepsis, and patients were stratified into two groups based on CVP levels (CVP < 8 or ≥8 mmHg). Results: Of 5600 patients with septic shock, 3128 patients without AKI on admission are included. One-thousand-and-ninety-eight patients (35.1%) developed AKI within a median of 4.4 days. The median CVP levels and frequency of elevated CVP at 6, 12, 24, and 48 h are significantly higher in the AKI group. Elevated CVP (≥8 mmHg) at 6, 12, 24, and 48 h is associated with AKI incidence, even after adjusting for mean arterial pressure (MAP) levels. This association, after multivariable adjustments, only remains significant at 12 h with an odds ratio (OR) of 1.60 (95% CI, 1.26-2.05), p < 0.001 and 48 h with an OR of 1.60 (95% CI, 1.29-1.99), p < 0.001. Conclusions: Our findings indicate that CVP ≥ 8 mmHg is strongly associated with an increased risk of AKI, even after adjusting for MAP at the 12 and 48 h time points. These findings underscore a critical 12 or 48h window for interventions to lower CVP.

Effective invasive and non-invasive monitoring, when coupled with good clinical decision making, can improve outcomes for critically ill patients. When deciding on the best monitoring technique, it is important to consider the specific information that is needed to guide critical care management, while balancing the reliability of the data obtained and the risks of invasive monitor placement. Here, we review invasive and non-invasive options for hemodynamic and neurologic monitoring in the Surgical Intensive Care Unit. Understanding how each monitoring device functions, its indications, risks, and limitations is key when deciding how to monitor bedside physiologic data that guide clinical decision making. Level of evidence: Level IV.

To evaluate whether early-combination diuretic therapy guided by serial post-diuretic urine sodium concentration (UNa+) assessments in acute heart failure (AHF) facilitates safe and effective decongestion.

The Diuretic Treatment in Acute Heart Failure with Volume Overload Guided by Serial Spot Urine Sodium Assessment (DECONGEST) study is a pragmatic, 2-center, randomized, parallel-arm, open-label study aiming to enroll 104 patients with AHF and clinically evident fluid overload requiring treatment with intravenous loop diuretics. Patients are randomized to receive standard of care or a bundled approach comprising: (1) systematic post-diuretic UNa+ assessments until successful decongestion, defined as no remaining clinical signs of fluid overload with a post-diuretic UNa+ ≤ 80 mmol/L; (2) thrice-daily intravenous loop diuretic bolus therapy, with dosing according to estimated glomerular filtration rate; (3) upfront use of intravenous acetazolamide (500 mg once daily [OD]); and (4) full nephron blockade with high-dose oral chlorthalidone (100 mg OD) and intravenous canreonate (200 mg OD) for diuretic resistance, defined as persisting signs of fluid overload with a post-diuretic UNa+ ≤ 80 mmol/L. The primary endpoint of the DECONGEST study is a hierarchical composite of (1) survival at 30 days; (2) days alive and out of hospital or care facility up to 30 days; and (3) greater relative decrease in natriuretic peptide levels from baseline to day 30.

The DECONGEST study aims to determine whether an intensive diuretic regimen focused on early combination therapy, guided by serial post-diuretic UNa+ assessments, safely enhances decongestion, warranting further evaluation in a larger trial powered for clinical events.

Advanced haemodynamic monitoring has been recommended for use in high-risk surgeries and high-risk patients undergoing surgery. This study aims to assess the current practices of haemodynamic monitoring in high-risk surgical patients among Malaysian anaesthesiologists.

This is a cross-sectional survey among Malaysian anaesthesiologists, following approval from the institution's Medical Research Ethics Committee and the National Medical Research Register. The survey utilised a questionnaire developed by Cannesson et al. to gather demographic data, practice information, and haemodynamic monitoring practices. Statistical analysis was performed using SPSS, and results were presented as the mean, median, or frequency as appropriate.

A total of 366 participants responded to the questionnaire, and 2 dropped out due to an incomplete form. This study found differences in the frequency of haemodynamic optimisation and monitoring techniques used in different healthcare settings. Written protocols or statements concerning haemodynamic management in high-risk surgical cases were only available to 15.7% of participants in the institution. The overall utilisation rate of cardiac output monitoring was found to be 31.1%, with a significant majority of the usage observed in university hospitals (p < 0.001). Central venous pressure was more commonly used in university hospitals and private hospitals compared to public hospitals (p < 0.001). The usage of advanced parameters such as stroke volume variation, cardiac index, and systemic vascular resistance was significantly higher in university hospitals, with a p value < 0.001. Transthoracic echocardiography was the most common tool used for high-risk surgical patients. The primary reasons for participants not utilising cardiac output monitoring include the lack of availability of such monitoring in their respective settings, which constitutes 66.9% of the respondents. The overwhelming majority of participants, namely 98%, expressed the belief that there is room for improvement in their present haemodynamic care.

This study offers significant insights into the prevailing haemodynamic monitoring practices employed by Malaysian anaesthesiologists in the context of high-risk surgical patients. The findings have the potential to contribute to future educational initiatives and establish practice standards for haemodynamic monitoring in high-risk surgical procedures.

Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.

Critically ill patients with cirrhosis and liver failure do not uncommonly have hypotension due to multifactorial reasons, which include a hyperdynamic state with increased cardiac index (CI), low systemic vascular resistance (SVR) due to portal hypertension, following the use of beta-blocker or diuretic therapy, and severe sepsis. These changes are mediated by microvascular alterations in the liver, systemic inflammation, activation of renin-angiotensin-aldosterone system, and vasodilatation due to endothelial dysfunction. Haemodynamic assessment includes measuring inferior vena cava indices, cardiac output (CO), and SVR using point-of-care ultrasound (POCUS), arterial waveform analysis, pulmonary artery pressures, and lactate clearance to guide fluid resuscitation. Fluid responsiveness reflects the ability of fluid bolus to increase the CO and is assessed effectively by POCUS, passive leg raises manoeuvre, and dynamic tests such as pulse pressure and stroke volume variation in spontaneously breathing and mechanically ventilated patients. Albumin has pleiotropic benefits through anti-inflammatory properties besides its standard action on oncotic pressure and volume expansion in patients with cirrhosis but has the potential for precipitating pulmonary oedema. In conclusion, fluid therapy in critically ill patients with liver disease is a complex and dynamic process that requires individualized management protocols to optimize patient outcomes.

Fluid volume abnormalities are a major cause of exacerbations in heart failure patients. However, there is few efficient, rapid, or cost-effective clinical approach for determining volume status, resulting in inadequate or unsatisfactory treatment. The aim was to develop an early fluid volume detection model for heart failure patients utilizing a machine learning stratification.

The training set data collected by Tianjin Chest Hospital on heart failure patients from December 2016 to December 2021, included 2056 samples and 97 medical characteristics. The minimum Redundancy Maximum Relevance(mRMR) feature selection method was utilized to filter features that were strongly related to the patient's fluid volume status. Four machine learning classification models were used to predict patients' fluid volume status, and their effectiveness was measured using the receiver operating characteristic (ROC) area under the curve (AUC), calibration curve, accuracy, precision, recall, F1 score, specificity, and sensitivity. Data from 186 heart failure patients collected between January 2022 and July 2022 were employed as an external validation set to investigate the effects of model training. SHapley Additive exPlanations (SHAP) were used to interpret the ML models.

Thirty features were selected for model development, and the area under the ROC curve AUC (95 % CI) for the four machine learning models in the testing set was 0.75 (0.73-0.77), 0.77 (0.74-0.79), 0.70 (0.67-0.73), and 0.76 (0.73-0.78), and the AUC (95 % CI) in the external validation set was 0.74 (0.71-0.76), 0.70 (0.67-0.73), 0.64 (0.59-0.68), and 0.67 (0.63-0.71). Logistic regression models were globally interpreted using SHAP-based summary plots.

Machine learning methods are effective in detecting fluid volume status in heart failure patients and can assist physicians with assisted diagnosis, thus helping clinicians to tailor precise management.

Accurate assessment of a patient's volume status is crucial in many conditions, informing decisions on fluid prescribing, vasoactive agents, and decongestive therapies. Determining a patient's volume status is challenging because of limitations in examination and investigations and the complexities of fluid homeostasis in disease states. Point-of-care ultrasound (POCUS) is useful in assessing hemodynamic parameters related to volume status, fluid responsiveness, and fluid tolerance. It requires understanding several physiologic concepts to interpret and integrate POCUS findings accurately into volume-related clinical decision-making.

The following concepts serve as a scaffold for a comprehensive volume status assessment: central venous pressure, right-sided heart function, left-sided heart assessment, extravascular volume, and venous congestion. POCUS allows us access to these hemodynamic and structural data points as an extension and refinement of the physical examination. Often, multiple POCUS applications are used, and findings must be integrated with the rest of the clinical evaluation. We illustrate this using 3 common scenarios: hypotension, hypoxia, and acute kidney injury. Clinicians must be aware of the strengths and weaknesses of findings in different physiologic states and the potential pitfalls of image acquisition and interpretation. Further studies are necessary to determine the benefits and clinical outcomes of a POCUS-directed volume status assessment.

Volume status assessment is ubiquitous, yet is challenging to perform. This review summarizes foundational physiologic concepts relevant to volume status evaluation and highlights how multiorgan POCUS elucidates hemodynamic parameters that can be combined with the conventional clinical assessment to make fluid-related decisions.

Paediatric kidney transplantation has an increased risk of surgical and vascular complications, with intensive care monitoring required postoperatively. This study aimed to determine if perioperative management affects early graft function in living donor paediatric kidney transplantation.

Clinical data was extracted from the electronic medical record for living donor kidney transplants at two paediatric centres covering the state of New South Wales (NSW), Australia from 2009 to 2021. Estimated glomerular filtration rate (eGFR) of 7 days and 1-month post-transplant were calculated as measures of early graft function.

Thirty-nine eligible patients (female n (%) 13 (33%)) with a median (IQR) age of 6 (3-9) years and pre-transplant eGFR of 7 (6-10) mL/min/1.73 m2 were analysed. Mean (SD) central venous pressure (CVP) after revascularisation was 11 (4) mmHg. Intraoperatively, mean volume of fluid administered was 84 (39) mL/kg, and 34 (87%) patients received vasoactive agents. Average systolic blood pressure (BP) in the first 24-h post-transplant was 117 (12) mmHg. Postoperatively, median volume of fluid administered in the first 24 h was 224 (159-313) mL/kg, and 17 (44%) patients received vasoactive agents. Median eGFR 7 days and 1-month post-transplant were 115 (79-148) and 103 (83-115) mL/min/1.73 m2, respectively. Linear regression analyses demonstrated that after adjusting for age, the average CVP after revascularisation and average systolic BP in the first 24-h post-transplant were not associated with eGFR in the first month post-transplant.

Targeted intraoperative and postoperative fluid and haemodynamic characteristics were achieved but did not correlate with early graft function.

Patients in critical condition who require mechanical ventilation experience intricate interactions between their respiratory and cardiovascular systems. These complex interactions are crucial for clinicians to understand as they can significantly influence therapeutic decisions and patient outcomes. A deep understanding of heart-lung interactions is essential, particularly under the stress of mechanical ventilation, where the right ventricle plays a pivotal role and often becomes a primary concern. Positive pressure ventilation, commonly used in mechanical ventilation, impacts right and left ventricular pre- and afterload as well as ventricular interplay. The right ventricle is especially susceptible to these changes, and its function can be critically affected, leading to complications such as right heart failure. Clinicians must be adept at recognizing and managing these interactions to optimize patient care. This perspective will analyze this matter comprehensively, covering the pathophysiology of these interactions, the monitoring of heart-lung dynamics using the latest methods (including ECHO), and management and treatment strategies for related conditions. In particular, the analysis will delve into the efficacy and limitations of various treatment modalities, including pharmaceutical interventions, nuanced ventilator management strategies, and advanced devices such as extracorporeal membrane oxygenation (ECMO). Each approach will be examined for its impact on optimizing right ventricular function, mitigating complications, and ultimately improving patient outcomes in the context of mechanical ventilation.

Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for right-heart catheterization. PH is independently associated with adverse outcomes in CKD, raising the possibility that early detection and appropriate management of PH might improve outcomes in at-risk patients. Among patients with PH, the prevalence of CKD stages 3 and 4 is estimated to be as high as 36%, and CKD is also independently associated with adverse outcomes. However, the complex, heterogenous pathophysiology and clinical profile of CKD-PH requires further characterization. CKD is often associated with elevated left ventricular filling pressure and volume overload, which presumably leads to pulmonary vascular stiffening and post-capillary PH. By contrast, a distinct subgroup of patients at high risk is characterized by elevated pulmonary vascular resistance and right ventricular dysfunction in the absence of pulmonary venous hypertension, which may represent a right-sided cardiorenal syndrome defined in principle by hypervolaemia, salt avidity, low cardiac output and normal left ventricular function. Current understanding of CKD-PH is limited, despite its potentially important ramifications for clinical decision making. In particular, whether PH should be considered when determining the suitability and timing of kidney replacement therapy or kidney transplantation is unclear. More research is urgently needed to address these knowledge gaps and improve the outcomes of patients with or at risk of CKD-PH.

Purpose The relationship between the height of the V wave in the central venous pressure (CVP) waveform and the severity of tricuspid regurgitation (TR) is well known. Their diagnostic ability is unconfirmed. This study explored CVP waveform variations with TR. Methods All patients who underwent preoperative echocardiography and CVP waveform measurements before surgery at our institution were included. Indices were created to capture each feature of the CVP waveform. The median value for each case was obtained and statistically analyzed according to the severity of TR. A deep learning technique, Transformer, was used to handle the complex features of CVP waveforms. Results This study included 436 cases. The values for C wave - Y descent, X descent - Y descent, and V wave - Y descent differed significantly in the Jonckheere-Terpstra test (p = 0.0018, 0.027, and 0.077, respectively). The area under the receiver operating characteristic (ROC) curve (AUC) for X descent - Y descent in two groups, none to moderate TR and severe TR, was 0.83 (95% confidence interval (CI) [0.68, 0.98]). For Transformer, the accuracy of the validation dataset was 0.97. Conclusions The shape of the CVP waveform varied with the severity of TR in a large dataset.

Maintaining adequate preload during kidney transplantation (KT) is important for graft function. We evaluated whether a high or low normal target for a dynamic preload index of stroke volume variation (SVV) would impact graft function during living donor KT.

We compared haemodynamic management algorithms using two different targets of SVV: SVV6% group (n = 30) versus SVV12% group (n = 30). Crystalloids were administered to achieve SVV less than the assigned target. Neutrophil gelatinase-associated lipocalin (NGAL) level at the end of surgery was compared. We also compared the incidence of delayed graft function (DGF), daily serum creatinine level and glomerular filtration rate (GFR) until 2 weeks postoperatively.

The total amount of crystalloids administered was significantly different between the SVV6% and SVV12% groups (median [interquartile range] 2,250 [1,700-3,600] vs. 1,350 [1,050-1,900], P < 0.001). There was no significant difference in NGAL level at the end of the operation between the SVV6% and SVV12% groups (395 [234-560] vs. 518 [346-654], P = 0.115). The incidence of DGF was not significantly different, and there was no significant difference in the postoperative serum creatinine levels or GFR between the groups.

Our randomised trial demonstrated that an SVV target of either 6% or 12% could be adequate as a preload management target for postoperative graft function during living donor KT. However, given the low incidence of DGF in living donor KT and type II error, our study should be interpreted carefully and further studies for deceased donor KT are required.

The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups.

Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01).

Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.

Objective.Cardiac Index (CI) is a key physiologic parameter to ensure end organ perfusion in the pediatric intensive care unit (PICU). Determination of CI requires invasive cardiac measurements and is not routinely done at the PICU bedside. To date, there is no gold standard non-invasive means to determine CI. This study aims to use a novel non-invasive methodology, based on routine continuous physiologic data, called Pulse Arrival Time (PAT) as a surrogate for CI in patients with normal Ejection Fraction (EF).Approach.Electrocardiogram (ECG) and photoplethysmogram (PPG) signals were collected from beside monitors at a sampling frequency of 250 samples per second. Continuous PAT, derived from the ECG and PPG waveforms was averaged per patient. Pearson's correlation coefficient was calculated between PAT and CI, PAT and heart rate (HR), and PAT and EF.Main Results.Twenty patients underwent right heart cardiac catheterization. The mean age of patients was 11.7 ± 5.4 years old, ranging from 11 months old to 19 years old, the median age was 13.4 years old. HR in this cohort was 93.8 ± 17.0 beats per minute. The average EF was 54.4 ± 9.6%. The average CI was 3.51 ± 0.72 l min-1m-2, with ranging from 2.6 to 4.77 l min-1m-2. The average PAT was 0.31 ± 0.12 s. Pearson correlation analysis showed a positive correlation between PAT and CI (0.57,p< 0.01). Pearson correlation between HR and CI, and correlation between EF and CI was 0.22 (p= 0.35) and 0.03 (p= 0.23) respectively. The correlation between PAT, when indexed by HR (i.e. PAT × HR), and CI minimally improved to 0.58 (p< 0.01).Significance.This pilot study demonstrates that PAT may serve as a valuable surrogate marker for CI at the bedside, as a non-invasive and continuous modality in the PICU. The use of PAT in clinical practice remains to be thoroughly investigated.

The assessment of hemodynamic status in polytrauma patients is an important principle of the primary survey of trauma patients, and screening for ongoing hemorrhage and assessing the efficacy of resuscitation is vital in avoiding preventable death and significant morbidity in these patients. Invasive procedures may lead to various complications and the IVC ultrasound measurements are increasingly recognized as a potential noninvasive replacement or a source of adjunct information.

The study aimed to determine if repeated ultrasound assessment of the inferior vena cava (diameter, collapsibility (IVC- CI) in major trauma patients presenting with collapsible IVC before resuscitation and after the first hour of resuscitation will predict total intravenous fluid requirements at first 24 h.

The current study was conducted on 120 patients presented to the emergency department with Major blunt trauma (having significant injury to two or more ISS body regions or an ISS greater than 15). The patients(cases) group (shocked group) (60) patients with signs of shock such as decreased blood pressure < 90/60 mmHg or a more than 30% decrease from the baseline systolic pressure, heart rate > 100 b/m, cold, clammy skin, capillary refill > 2 s and their shock index above0.9. The control group (non-shocked group) (60) patients with normal blood pressure and heart rate, no other signs of shock (normal capillary refill, warm skin), and (shock index ≤ 0.9). Patients were evaluated at time 0 (baseline), 1 h after resucitation, and 24 h after 1st hour for:(blood pressure, pulse, RR, SO2, capillary refill time, MABP, IVCci, IVCmax, IVCmin).

Among 120 Major blunt trauma patients, 98 males (81.7%) and 22 females (18.3%) were included in this analysis; hypovolemic shocked patients (60 patients) were divided into two main groups according to IVC diameter after the first hour of resuscitation; IVC repleted were 32 patients (53.3%) while 28 patients (46.7%) were IVC non-repleted. In our study population, there were statistically significant differences between repleted and non-repleted IVC cases regarding IVCD, DIVC min, IVCCI (on arrival) (after 1 h) (after 24 h of 1st hour of resuscitation) ( p-value < 0.05) and DIVC Max (on arrival) (after 1 h) (p-value < 0.001). There is no statistically significant difference (p-value = 0.075) between repleted and non-repleted cases regarding DIVC Max (after 24 h).In our study, we found that IVCci0 at a cut-off point > 38.5 has a sensitivity of 80.0% and Specificity of 85.71% with AUC 0.971 and a good 95% CI (0.938 - 1.0), which means that IVCci of 38.6% or more can indicate fluid responsiveness. We also found that IVCci 1 h (after fluid resuscitation) at cut-off point > 28.6 has a sensitivity of 80.0% and Specificity of 75% with AUC 0.886 and good 95% CI (0.803 - 0.968), which means that IVCci of 28.5% or less can indicate fluid unresponsiveness after 1st hour of resuscitation. We found no statistically significant difference between repleted and non-repleted cases regarding fluid requirement and amount of blood transfusion at 1st hour of resuscitation (p-value = 0.104).

Repeated bedside ultrasonography of IVCD, and IVCci before and after the first hour of resuscitation could be an excellent reliable invasive tool that can be used in estimating the First 24 h of fluid requirement in Major blunt trauma patients and assessment of fluid status.

Acute circulatory failure is commonly encountered in critically ill patients, that requires fluid administration as the first line of treatment. However, only 50% of patients are fluid-responsive. Identification of fluid responders is essential to avoid the harmful effects of overzealous fluid therapy. Electrical cardiometry (EC) is a non-invasive bedside tool and has proven to be as good as transthoracic echocardiography (TTE) to track changes in cardiac output. We aimed to look for an agreement between EC and TTE for tracking changes in cardiac output in adult patients with acute circulatory failure before and after the passive leg-raising maneuver.

Prospective comparative study, conducted at a Tertiary Care Teaching Hospital.

We recruited 125 patients with acute circulatory failure and found 42.4% (53 out of 125) to be fluid-responsive. The Bland-Altman plot analysis showed a mean difference of 2.08 L/min between EC and TTE, with a precision of 3.8 L/min. The limits of agreement (defined as bias ± 1.96SD), were -1.7 L/min and 5.8 L/min, respectively. The percentage of error between EC and TTE was 56% with acceptable limits of 30%.

The percentage error beyond the acceptable limit suggests the non-interchangeability of the two techniques. More studies with larger sample sizes are required to establish the interchangeability of EC with TTE for tracking changes in cardiac output in critically ill patients with acute circulatory failure.

Sharma S, Ramachandran R, Rewari V, Trikha A. Evaluation of Electrical Cardiometry to Assess Fluid Responsiveness in Patients with Acute Circulatory Failure: A Comparative Study with Transthoracic Echocardiography. Indian J Crit Care Med 2024;28(7):650-656.

Background: The likelihood of a patient being preload responsive-a state where the cardiac output or stroke volume (SV) increases significantly in response to preload-depends on both cardiac filling and function. This relationship is described by the canonical Frank-Starling curve. Research Question: We hypothesize that a novel method for phenotyping hypoperfused patients (ie, the "Doppler Starling curve") using synchronously measured jugular venous Doppler as a marker of central venous pressure (CVP) and corrected flow time of the carotid artery (ccFT) as a surrogate for SV will refine the pretest probability of preload responsiveness/unresponsiveness. Study Design and Methods: We retrospectively analyzed a prospectively collected convenience sample of hypoperfused adult emergency department (ED) patients. Doppler measurements were obtained before and during a preload challenge using a wireless, wearable Doppler ultrasound system. Based on internal jugular and carotid artery Doppler surrogates of CVP and SV, respectively, we placed hemodynamic assessments into quadrants (Qx) prior to preload augmentation: low CVP with normal SV (Q1), high CVP and normal SV (Q2), low CVP and low SV (Q3) and high CVP and low SV (Q4). The proportion of preload responsive and unresponsive assessments in each quadrant was calculated based on the maximal change in ccFT (ccFTΔ) during either a passive leg raise or rapid fluid challenge. Results: We analyzed 41 patients (68 hemodynamic assessments) between February and April 2021. The prevalence of each phenotype was: 15 (22%) in Q1, 8 (12%) in Q2, 39 (57%) in Q3, and 6 (9%) in Q4. Preload unresponsiveness rates were: Q1, 20%; Q2, 50%; Q3, 33%, and Q4, 67%. Interpretation: Even fluid naïve ED patients with sonographic estimates of low CVP have high rates of fluid unresponsiveness, making dynamic testing valuable to prevent ineffective IVF administration.

Central venous pressure (CVP) serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume, venous compliance, cardiac output, and orthostasis. Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance. Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances. Elevated CVP can lead to fluid accumulation in the interstitial space, impairing venous return and reducing cardiac preload. While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate, they carry risk of complications and their usage has not shown clinical improvement. Ultrasound-based assessment of the internal jugular vein (IJV) offers real-time, non-invasive measurement of static and dynamic parameters for estimating CVP. IJV parameters, including diameter and ratio, has demonstrated good correlation with CVP. Despite significant advancements in non-invasive CVP measurement, a reliable tool is yet to be found. Present methods can offer reasonable guidance in assessing CVP, provided their limitations are acknowledged.

In the intensive care unit (ICU) patients, fluid overload and congestion are associated with worse outcomes. Because of the heterogeneity of ICU patients, we hypothesized that there may exist different endotypes of congestion. The aim of this study was to identify endotypes of congestion and their association with outcomes.

We conducted an unsupervised hierarchical clustering analysis on 145 patients admitted to ICU to identify endotypes. We measured several parameters related to clinical context, volume status, filling pressure, and venous congestion. These parameters included NT-proBNP, central venous pressure (CVP), the mitral E/e' ratio, the systolic/diastolic ratio of hepatic veins' flow velocity, the mean diameter of the inferior vena cava (IVC) and its variations, stroke volume changes following passive leg raising, the portal vein pulsatility index, and the venous renal impedance index.

Three distinct endotypes were identified: (1) "hemodynamic congestion" endotype (n = 75) with moderate alterations of ventricular function, increased CVP and left filling pressure values, and moderate fluid overload; (2) "volume overload congestion" endotype (n = 50); with normal cardiac function and filling pressure despite high positive fluid balance (fluid overload); (3) "systemic congestion" endotype (n = 20) with severe alterations of left and right ventricular functions, increased CVP and left ventricular filling pressure values. These endotypes vary significantly in ICU admission reasons, acute kidney injury rates, mortality, and length of ICU/hospital stay.

Our analysis revealed three unique congestion endotypes in ICU patients, each with distinct pathophysiological features and outcomes. These endotypes are identifiable through key ultrasonographic characteristics at the bedside.

NCT04680728.

Background: Remote dielectric sensing (ReDS) systems can estimate the amount of lung fluid non-invasively and easily without expert techniques. The correlation between the elevated ReDS value and other modalities that estimate pulmonary congestion has been validated. The clinical implications of lower ReDS values, which may indicate hypovolemia, remain unknown. Methods: A total of 138 patients who were hospitalized for various cardiovascular-related problems and underwent ReDS value measurements at the index discharge in a blinded manner to the attending clinicians were eligible for inclusion. Patients with ReDS values > 30%, indicating the presence of pulmonary congestion, were excluded. The prognostic impact of lower ReDS values on all-cause readmission after index discharge was evaluated. Results: A total of 97 patients were included. The median age was 78 years, and 48 were men. The median ReDS value at index discharge was 26% (23%, 27%). A lower ReDS value correlated with smaller inferior vena cava maximum diameters (r = 0.46, p < 0.001) and higher blood urea nitrogen/creatinine ratios (r = -0.35, p < 0.001). A lower ReDS value (≤25%) was associated with a risk of all-cause readmissions with an unadjusted hazard ratio of 2.68 (95% confidence interval 1.09-6.59, p = 0.031) and an adjusted hazard ratio of 2.30 (95% confidence interval 0.92-5.78, p = 0.076). Its calculated cutoff of 25% significantly stratified the cumulative incidence of the primary outcome (36% versus 17%, p = 0.038). Conclusions: A lower ReDS value may indicate hypovolemia and be associated with the risk of all-cause readmission in patients hospitalized for cardiovascular diseases.

Acute kidney injury (AKI) is a complex and life-threatening condition with multifactorial etiologies, ranging from ischemic injury to nephrotoxic exposures. Management is founded on treating the underlying cause of AKI, but supportive care-via fluid management, vasopressor therapy, kidney replacement therapy (KRT), and more-is also crucial. Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors, some of which may be more kidney-protective than others. Initiation of KRT is controversial, and studies have not consistently demonstrated any benefit to early start dialysis. There are no targeted pharmacotherapies for AKI itself, but some do exist for complications of AKI; additionally, medications become a key aspect of AKI management because changes in renal function and dialysis support can lead to issues with both toxicities and underdosing. This review will cover existing literature on these and other aspects of AKI treatment. Additionally, this review aims to identify gaps and challenges and to offer recommendations for future research and clinical practice.

Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids' impact on blood pressure changes.

This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning.

Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann's solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500-600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts.

This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.

Delayed graft function (DGF) is a common post-operative complication with potential long-term sequelae for many kidney transplant recipients, and hemodynamic factors and fluid status play a role. Fixed perioperative fluid infusions are the standard of care, but more recent evidence in the non-transplant population has suggested benefit with goal-directed fluid strategies based on hemodynamic targets. We searched MEDLINE, EMBASE, Cochrane Controlled Trials Registry and Google Scholar through December 2022 for randomized controlled trials comparing risk of DGF between goal-directed and conventional fluid therapy in adults receiving a living or deceased donor kidney transplant. Effect estimates were reported with odds ratios (OR) and pooled using random effects meta-analysis. We identified 4 studies (205 participants) that met the inclusion criteria. The use of goal-directed fluid therapy had no significant effect on DGF (OR 1.37 95% CI, 0.34-5.6; p = 0.52; I2 = 0.11). Subgroup analysis examining effects among deceased and living kidney donation did not reveal significant differences in the effects of fluid strategy on DGF between subgroups. Overall, the strength of the evidence for goal-directed versus conventional fluid therapy to reduce DGF was of low certainty. Our findings highlight the need for larger trials to determine the effect of goal-directed fluid therapy on this patient-centered outcome.

Despite the high perioperative risk profile, international guidelines for anesthesia and intensive care unit (ICU) care in pediatric kidney transplantation do not exist. Optimizing hemodynamics can be challenging in these patients, while scientific data to guide decisions in hemodynamic monitoring, hemodynamic targets, and perioperative fluid management are lacking. The limited annual number of pediatric kidney transplantations, even in reference centers, necessitates the urge for international collaboration to share knowledge and develop research and guidelines. The aim of this study was to collect data on current perioperative anesthesia and ICU care practices in pediatric kidney transplantation.

An international survey with an anonymized link was sent from a validated electronic data capture system (Castor). Inclusion criteria were: medical doctor in anesthesia, (ICU), or pediatric nephrology working in a pediatric kidney transplantation specialized center; and signed informed consent. Data were analyzed using descriptive statistics.

Thirty-three records were analyzed. Responders were anesthesiologists (58%), pediatric nephrologists (30%), and pediatric intensivists (12%), representing 13 countries worldwide. About half of the centers (48%) performed more than 10 pediatric kidney transplantations a year. Perioperative hemodynamic support was guided by intra-arterial blood pressure (88%), central venous pressure (CVP; 88%), and cardiac output (CO; 39%). The most variation was seen in the hemodynamic targets CVP and CO, fluid administration, and inotrope/vasopressor use. The protocolized use of furosemide (46%) and mannitol (61%) also varied between centers. Postoperative care for the youngest recipients occurred in the pediatric intensive care unit at all centers.

The results of this survey reveal a large variation in anesthesia and ICU care in pediatric kidney transplantation centers worldwide, particularly in CVP and CO targets, hemodynamic therapy, and the use of furosemide and mannitol. These data identify areas for further research and can be a starting point for international research collaboration and guideline development.

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions.   Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient's physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Current recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission.

Multicenter, prospective cross-sectional observational study conducted in three medical-surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected.

Ninety patients were included. Median age was 63 [45-71] years old, and median SOFA score was 9 [7-11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR-). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR- groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals.

Venous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

Develop a signal quality index (SQI) for the widely available peripheral venous pressure waveform (PVP). We focus on the quality of the cardiac component in PVP. We model PVP by the adaptive non-harmonic model. When the cardiac component in PVP is stronger, the PVP is defined to have a higher quality. This signal quality is quantified by applying the synchrosqueezing transform to decompose the cardiac component out of PVP, and the SQI is defined as a value between 0 and 1. A database collected during the lower body negative pressure experiment is utilized to validate the developed SQI. All signals are labeled into categories of low and high qualities by experts. A support vector machine (SVM) learning model is trained for practical purpose. The developed signal quality index coincide with human experts' labels with the area under the curve 0.95. In a leave-one-subject-out cross validation (LOSOCV), the SQI achieves accuracy 0.89 and F1 0.88, which is consistently higher than other commonly used signal qualities, including entropy, power and mean venous pressure. The trained SVM model trained with SQI, entropy, power and mean venous pressure could achieve an accuracy 0.92 and F1 0.91 under LOSOCV. An exterior validation of SQI achieves accuracy 0.87 and F1 0.92; an exterior validation of the SVM model achieves accuracy 0.95 and F1 0.96. The developed SQI has a convincing potential to help identify high quality PVP segments for further hemodynamic study. This is the first work aiming to quantify the signal quality of the widely applied PVP waveform.

Hypotension often occurs following the induction of general anesthesia in elderly patients undergoing surgery and can lead to severe complications. This study assessed the effect of carotid corrected flow time (FTc) combined with perioperative fluid therapy on preventing hypotension after general anesthesia induction in elderly patients.

The prospective cohort study was divided into two parts. The first part (Part I) consisted of 112 elderly patients. Carotid FTc was measured using Color Doppler Ultrasound 5 min before anesthesia induction. Hypotension was defined as a decrease of greater than 30% in systolic blood pressure (SBP) or a decrease of greater than 20% in mean arterial pressure (MAP) from baseline, or an absolute SBP below 90 mmHg and MAP below 60 mmHg within 3 min after induction of general anesthesia. The predictive value of carotid FTc was determined using receiver operating characteristic (ROC) curve. The second part (Part II) consisted of 65 elderly patients. Based on the results in Part I, elderly patients with carotid FTc below the optimal cut-off value received perioperative fluid therapy at a volume of 8 ml/kg of balanced crystalloids (lactated Ringer's solution) in 30 min before induction. The effect of carotid FTc combined with perioperative fluid therapy was assessed by comparing observed incidence of hypotension after induction.

The area under the ROC for carotid FTc to predict hypotension after induction was 0.876 [95% confidence interval (CI) 0.800-0.952, P <0.001]. The optimal cut-off value was 334.95 ms (sensitivity of 87.20%; specificity of 82.20%). The logistic regression analysis revealed that carotid FTc is an independent predictor for post-induction hypotension in elderly patients. The incidence of post-induction hypotension was significantly lower ( P <0.001) in patients with carotid FTc less than 334.95 ms who received perioperative fluid therapy (35.71%) compared to those who did not (92.31%).

Carotid FTc combined with the perioperative fluid therapy could significantly reduce the incidence of hypotension after the induction of general anesthesia in elderly patients.

Clinical evaluation of central venous pressure is difficult, depends on experience, and is often inaccurate in patients with chronic advanced heart failure. We assessed the ultrasound-assessed internal jugular vein (JV) distensibility by ultrasound as a noninvasive tool to identify patients with normal right atrial pressure (RAP ≤7 mm Hg) in this population.

We measured JV distensibility as the Valsalva-to-rest ratio of the vein diameter in a calibration cohort (N=100) and a validation cohort (N=101) of consecutive patients with chronic heart failure with reduced ejection fraction who underwent pulmonary artery catheterization for advanced heart failure therapies workup.

A JV distensibility threshold of 1.6 was identified as the most accurate to discriminate between patients with RAP ≤7 versus >7 mm Hg (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.64-0.84]) and confirmed in the validation cohort (receiver operating characteristic, 0.82 [95% CI, 0.73-0.92]). A JV distensibility ratio >1.6 had predictive positive values of 0.86 and 0.94, respectively, to identify patients with RAP ≤7 mm Hg in the calibration and validation cohorts. Compared with patients from the calibration cohort with a high JV distensibility ratio (>1.6; n=42; median RAP, 4 mm Hg; pulmonary capillary wedge pressure, 11 mm Hg), those with a low JV distensibility ratio (≤1.6; n=58; median RAP, 8 mm Hg; pulmonary capillary wedge pressure, 22 mm Hg; P<0.0001 for both) were more likely to die or undergo a left ventricular assist device implant or heart transplantation (event rate at 2 years: 42.7% versus 18.2%; log-rank P=0.034).

Ultrasound-assessed JV distensibility identifies patients with chronic advanced heart failure with normal RAP and better outcomes.

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03874312.

Several monitors have been developed that measure stroke volume (SV) in a beat-to-beat manner. Accordingly, Stroke volume variation (SVV) induced by positive pressure ventilation is widely used to predict fluid responsiveness.

The purpose of this study was to compare the ability of two different methods to predict fluid responsiveness using SVV, stroke volume variation by esCCO (esSVV) and stroke volume variation by FloTrac/VigileoTM (flSVV).

esSVV, flSVV, and stroke volume index (SVI) by both monitoring devices of 37 adult patients who underwent laparotomy surgery, were measured. Receiver operating characteristic (ROC) analysis was performed.

The area under the ROC curve (AUC) of esSVV was significantly higher than that of flSVV (p= 0.030). esSVV and flSVV showed cutoff values of 6.1% and 10% respectively, to predict an increase of more than 10% in SVI after fluid challenge. The Youden index for esSVV was higher than flSVV, even with a cutoff value between 6% and 8%.

Since esSVV and flSVV showed significant differences in AUC and cutoff values, the two systems were not comparable in predicting fluid responsiveness. Furthermore, it seems that SVV needs to be personalized to accurately predict fluid responsiveness for each patient.

Renal transplantation is a complex surgical procedure requiring meticulous anesthetic planning to ensure patient safety and optimal graft function. In this comprehensive review, we examined various aspects of anesthesia management during renal transplantation, including preoperative, intraoperative, and postoperative care. Preoperative optimization involves the identification and management of risks to mitigate perioperative complications. Treatment with erythropoiesis-stimulating agents is recommended to correct anemia in transplant recipients with hemoglobin levels below 9-10 g/dl. Intraoperative management focuses on hemodynamic monitoring, maintenance of intravascular volume, and careful selection of anesthetic techniques. Neuromuscular monitoring and the appropriate use of neuromuscular blocking and reversal agents are considered essential. Further, hemodynamic goals include maintaining the mean arterial pressure within the range of 80-110 mmHg. In addition, attention should be paid to perioperative glycemic control, temperature management, and diuretic use. In postoperative management, multimodal analgesia and the prevention of postoperative delirium contribute to optimal recovery. The implementation of enhanced recovery after surgery principles can further improve outcomes. Collaborative efforts among surgical teams, anesthesiologists, and healthcare professionals are crucial for achieving successful renal transplantation outcomes.

Finding a simple and reliable method to predict and assess fluid responsiveness has long been of clinical interest.

To investigate the predictive value of a ventilator disconnection (DV) test combined with the pulse contour-derived cardiac output (PiCCO) index on fluid responsiveness for patients in shock.

Thirty-two patients were chosen for the study. Patients who were in shock, received mechanical ventilation, and met the inclusion criteria were selected. Patients were divided into a fluid-responsive group (14 patients) and fluid-unresponsive group (18 patients) based on whether the increase in cardiac index (Δ CI) was > 10% or not, respectively, following the fluid challenge test. Changes in heart rate, pulse oximeter-measured oxygen saturation, mean arterial pressure (MAP), and CI before and after passive leg raising (PLR), DV, and fluid challenge tests were observed. We used Pearson's correlation coefficient to analyze an increase in the MAP (Δ MAP) and Δ CI before and after the PLR, DV, and fluid challenge tests; the sensitivity and specificity of the Δ MAP and Δ CI in the PLR and DV tests for predicting fluid response were also analyzed by plotting the receiver operating characteristic (ROC) curves.

CI results in the PLR and DV tests, as well as the fluid challenge test, were significantly higher in the fluid-responsive group compared with before the test (P< 0.05). The Δ CI before and after the PLR, DV, and fluid challenge tests were positively correlated among patients in the fluid-responsive group. The area under the ROC curve for the post-PLR test CI and the post-DV CI for predicting fluid responsiveness was 0.869 (95% confidence interval (CI) [0.735-1.000, P= 0.000]) and 0.937 (95% CI [0.829-1.000, P= 0.000]), respectively, in patients in the fluid-responsive group. The sensitivity and specificity of the post-DV CI for predicting fluid responsiveness in all patients was 100.0% and 88.9%, respectively, using a 5% increase as the cut-off value.

Application of DV, combined with PiCCO, has a high predictive value for fluid responsiveness among patients in shock.

Background and objectives The quest for an accurate and reliable non-invasive method of assessing cardiac output in critically ill patients is still ongoing. Carotid artery Doppler is a promising non-invasive, reproducible, and feasible bedside monitor. So we compared the change in cardiac output derived from arterial pressure waveforms (pulse contour analysis) with that from carotid artery Doppler-derived measurements, in post-major elective abdominal surgery patients. Materials and methods We conducted a prospective observational study in 30 adult post-major elective abdominal surgery patients admitted to the Gastroenterology and Liver Transplant intensive care unit postoperatively on mechanical ventilator support, who were found to be fluid responsive clinically on passive leg raise (PLR) test. Demographics and vasopressor support were recorded. Hemodynamic parameters including heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), cardiac output (CO) using arterial pulse contour analysis (Vigileo monitor/FloTrac® sensor; Edwards Lifesciences, Irvine, California, United States), and carotid blood flow (CBF) were recorded on the baseline, pre- and post- PLR, and post fluid bolus administration. Balanced salt solution at the rate of 6ml/kg over 20 minutes was given as a fluid bolus. Results Of the 30 patients who were included in the study, 16 patients (53.3%) were on vasopressor support, mean (± SD) age of the patients was 52.93 (± 8.13) years. There was a significant increase in the SBP (mmHg) pre- to post-PLR, that is, 112.2±15.57 and 118.7±14.96, respectively (p-value = 0.001). Also from pre-PLR to post-fluid bolus administration, the increase in SBP was significant, 112.2±15.57 and 121.93±13.96, respectively (p-value = 0.001). The change in cardiac output measured using Vigileo and CBF from pre- to post-PLR (7.66±1.45 to 9.14±1.76, p< 0.001 for Vigileo and 8.10±1.66 to 9.72±1.99, p<0.001 for CBF) and pre-PLR to post fluid administration (7.66±1.45 to 9.39±1.77, p< 0.001 for Vigileo and 8.10±1.66 to 10.31±2.26, p< 0.001 for CBF) were significant. There was a positive correlation between the change in cardiac output as measured from arterial pulse contour analysis technique (Vigileo) and that measured from CBF (r=0.884) pre- and post-PLR. There was a significant correlation between cardiac output measurements derived from two techniques, before PLR, after PLR, and after fluid expansion (p< 0.001 for each variable). The change in cardiac output before PLR and after fluid expansion was also correlated by both the techniques (correlation coefficient being, r=0.781). Conclusion There was a significant positive correlation of the CO (absolute and change) measurements pre- and post-interventions (that is, PLR and fluid bolus administration) as made by pulse contour analysis (Vigileo) and by CBF in post-surgical patients. Pulse wave Doppler of CBF could be used as a surrogate for invasive measures of CO measurement for prediction of fluid responsiveness in this subgroup. Further larger studies can be performed to validate the same.

Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.

Growing insights into the pathophysiology of acute cardiorenal syndrome (CRS) in acute decompensated heart failure have indicated that not every rise in creatinine is associated with adverse outcomes. Detection of persistent volume overload and diuretic resistance associated with creatinine rise may identify patients with true acute CRS. More in-depth phenotyping is needed to identify pathologic processes in renal arterial perfusion, venous outflow, and microcirculatory-interstitial-lymphatic axis alterations that can contribute to acute CRS. Recently, various novel device-based interventions designed to target different pathophysiologic components of acute CRS are in early feasibility and proof-of-concept studies. However, appropriate trial endpoints that reflect improvement in cardiorenal trajectories remain elusive and highly debated. In this review the authors describe the variety of physiological derangements leading to acute CRS and the opportunity to individualize the management of acute CRS with novel renal assist devices that can target specific components of these alterations.

Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.

Objective  Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods  This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses  All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results  The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p  < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p  = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion  The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.