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      Doppler Interrogation of the Femoral Vein in the Critically Ill Patient: The Fastest Potential Acoustic Window to Diagnose Right Ventricular Dysfunction?

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Objectives:

          To report the use of common femoral vein Doppler interrogation as a simple technique to diagnose right ventricular dysfunction.

          Design:

          Case report.

          Setting:

          Cardiac surgical ICU.

          Patients:

          Postoperative cardiac surgical patients.

          Interventions:

          Common femoral pulsed-wave and color Doppler examination associated with hepatic, portal, and renal venous Doppler measurement were obtained in both patients and before and after treatment in patient number 1. In addition, right ventricular pressure waveform examination was obtained in patient number 2.

          Measurements and Main Results:

          The technique to obtain common femoral venous Doppler is described. Two cases of patients presenting with right ventricular dysfunction and fluid overload with portal and renal venous congestion in the perioperative period undergoing complex multivalvular cardiac surgery are presented. Hemodynamic waveform monitoring was performed alongside echocardiographic, hepatic, and renal venous flow Doppler assessment, and spectral Doppler profiles of the common femoral veins were examined. Those findings were useful in confirming our diagnosis and guiding our response to treatment. An algorithm was developed and tested on two additional hemodynamically unstable patients.

          Conclusions:

          Doppler examination of the common femoral vein is a simple, fast, and noninvasive technique that could be useful to rule in the presence of right ventricular dysfunction with venous congestion and help guide the management of such patients.

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          Most cited references58

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          Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system

          Background Organ congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery. This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. Five prototypes of venous excess ultrasound (VExUS) grading system combining multiple ultrasound markers were developed. Results The association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing. A total of 706 ultrasound assessments were analyzed. We found that defining severe venous congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (≥ 2 cm) showed the strongest association with the development of subsequent AKI compared with other combinations (HR: 3.69 CI 1.65–8.24 p = 0.001). The association remained significant after adjustment for baseline risk of AKI and vasopressor/inotropic support (HR: 2.82 CI 1.21–6.55 p = 0.02). Furthermore, this severe VExUS grade offered a useful positive likelihood ratio (+LR: 6.37 CI 2.19–18.50) when detected at ICU admission, which outperformed central venous pressure measurements. Conclusions The combination of multiple POCUS markers may identify clinically significant venous congestion.
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            Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure

            This study clarified the characteristics of intrarenal Doppler ultrasonography (IRD) profiles and their prognostic implications in heart failure (HF).
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              Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study

              Background Acute kidney injury (AKI) after cardiac surgery is associated with adverse outcomes. Venous congestion can impair kidney function, but few tools are available to assess its impact at the bedside. The objective of this study was to determine whether portal flow pulsatility and alterations in intrarenal venous flow assessed by Point‐Of‐Care ultrasound are associated with AKI after cardiac surgery. Methods and Results This single‐center prospective cohort study recruited patients undergoing cardiac surgery with cardiopulmonary bypass. Hepatic and renal Doppler ultrasound assessments were performed before surgery, at the intensive care unit admission, and daily for 3 days after surgery. The primary statistical analysis was performed using proportional hazards model for time‐dependent variables. Among the 145 patients included, 49 patients (33.8%) developed AKI after cardiac surgery. The detection of portal flow pulsatility was associated with an increased risk of AKI (hazard ratio: 2.09, confidence interval, 1.11–3.94, P=0.02), as were severe alterations of intrarenal venous flow (hazard ratio: 2.81, confidence interval, 1.42–5.56, P=0.003). These associations remained significant in multivariable models. The addition of these markers to preoperative risk factors and central venous pressure measurement at intensive care unit admission improved the prediction of AKI. (Continuous net reclassification improvement: 0.364, confidence interval, 0.081–0.652 for portal Doppler and net reclassification improvement: 0.343, confidence interval, 0.081–0.628 for intrarenal Doppler) Conclusions Portal flow pulsatility and intrarenal flow alterations are markers of venous congestion and are independently associated with AKI after cardiac surgery. These tools might offer valuable information to develop strategies aimed at treating or preventing congestive cardiorenal syndrome after cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02831907.
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                Author and article information

                Journal
                Crit Care Explor
                CC9
                Critical Care Explorations
                Lippincott Williams & Wilkins (Hagerstown, MD )
                2639-8028
                28 September 2020
                October 2020
                : 2
                : 10
                : e0209
                Affiliations
                [1 ]Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
                [2 ]Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada.
                [3 ]Department of Anesthesiology, Université de Montréal, Montreal, QC, Canada.
                [4 ]Department of Nursing, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada.
                [5 ]Department of Medicine, Nephrology Division, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada.
                [6 ]Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie, Quebec City, QC, Canada.
                [7 ]Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
                [8 ]Department of Cardiac Surgery and Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
                [9 ]Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada.
                [10 ]Department of Radiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
                Author notes
                For information regarding this article, E-mail: andre.denault@ 123456umontreal.ca
                Article
                00011
                10.1097/CCE.0000000000000209
                7523763
                33063023
                f027c616-2e34-48a7-830c-652746361cb4
                Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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                bedside ultrasound,common femoral vein,right ventricular dysfunction,venous congestion

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