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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 references 58

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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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            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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              Monitoring Changes in Hepatic Venous Velocities Flow after a Fluid Challenge Can Identify Shock Patients Who Lack Fluid Responsiveness

              Background: Evaluating the hemodynamic status and predicting fluid responsiveness are important in critical ultrasound assessment of shock patients. Transthoracic echocardiography with noninvasive diagnostic parameters allows the assessment of volume responsiveness. This study aimed to assess the hemodynamic changes in the liver and systemic hemodynamic changes during fluid challenge and during passive leg raising (PLR) by measuring hepatic venous flow (HVF) velocity. Methods: This is an open-label study in a tertiary teaching hospital. Shock patients with hypoperfusion who required fluid challenge were selected for the study. Patients 21% indicated no fluid responsiveness, with a sensitivity of 100%, a specificity of 71.2%, and an area under the receiver operating characteristic curve of 0.918. Conclusions: During fluid expansion, hepatic venous S-wave velocity can be used to monitor CO, whether or not it is increasing. ΔMHV D ≥21% indicated a lack of fluid responsiveness, thus helping to decide when to stop infusions.
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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
                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
                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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