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Anthony J Dean - One of the best experts on this subject based on the ideXlab platform.

  • diagnosing heart failure among acutely dyspneic patients with cardiac inferior vena cava and lung ultrasonography
    American Journal of Emergency Medicine, 2013
    Co-Authors: Kenton L Anderson, Katherine Y Jenq, Matthew J Fields, Nova Panebianco, Anthony J Dean
    Abstract:

    Abstract Background Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, Intravascular Volume Status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. Methods This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. Results One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). Conclusion In this study, US was 100% specific for the dx of ADHF.

  • the interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients
    Academic Emergency Medicine, 2011
    Co-Authors: Matthew J Fields, Katherine Y Jenq, Nova Panebianco, Paul A Lee, Dustin G Mark, Anthony J Dean
    Abstract:

    ACADEMIC EMERGENCY MEDICINE 2011; 18:98–101 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives:  Inferior vena cava ultrasound (IVC-US) is a noninvasive bedside tool to assess Intravascular Volume Status. This study set out to investigate the interrater reliability of IVC-US by bedside clinician sonographers and determine whether alternative methods of IVC-US such as B-mode and visual estimation are equally reliable to traditional M-mode. Methods:  A convenience sample of adult emergency department (ED) patients was prospectively enrolled. Each patient underwent IVC-US by two different emergency physicians (EPs), each of whom first performed visual estimation of IVC percent collapse and of Volume Status, followed by caliper measurements in M-mode and B-mode. EPs were blinded to patient data and to the other sonographer’s results. For each technique, interrater reliability was determined between the two EPs’ assessments using intraclass correlation coefficients (ICC) for continuous data and Cohen’s weighted kappa for categorical data. In addition, analysis was performed on M-mode diameter measurements to determine the relationship between sonographer and patient characteristics on interrater reliability. Results:  Five EPs performed 92 US exams on 46 patients. Using M-mode, the ICC for maximum IVC diameter was 0.81 (95% confidence interval [CI] = 0.67 to 0.89), and for minimum diameter was 0.77 (95% CI = 0.62 to 0.87). There were no statistically significant differences between the caliper methods used for IVC measurements (M-mode diameter, B-mode diameter, or B-mode area). Agreement for visually estimated IVC collapse (0.60, 95% CI = 0.36 to 0.76) was similar to agreement for calculated M-mode IVC collapse index (0.52, 95% CI = 0.27 to 0.71). Cohen’s weighted kappa for Volume Status based on visual estimation of IVC filling (size, shape, and collapse) was 0.64 (95% CI = 0.53 to 0.73). ICC values for M-mode diameter measurements were significantly higher in studies involving patients who were noneuvolemic and studies in which sonographers had each performed at least five prior IVC-US. Conclusions:  Emergency physicians’ US measurements of IVC diameter have a high degree of interrater reliability. IVC percent collapse by visual estimation or based on caliper measurements have lower, but still moderate to good reliability. The use of the visual estimation technique should be considered by clinicians who have learned to obtain measured parameters of IVC filling because it is equally reliable to traditional M-mode and can be performed more rapidly.

  • the interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients
    Academic Emergency Medicine, 2011
    Co-Authors: Matthew J Fields, Nova L Panebianco, Katherine Y Jenq, Dustin G Mark, Anthony J Dean
    Abstract:

    OBJECTIVES: Inferior vena cava ultrasound (IVC-US) is a noninvasive bedside tool to assess Intravascular Volume Status. This study set out to investigate the interrater reliability of IVC-US by bedside clinician sonographers and determine whether alternative methods of IVC-US such as B-mode and visual estimation are equally reliable to traditional M-mode. METHODS: A convenience sample of adult emergency department (ED) patients was prospectively enrolled. Each patient underwent IVC-US by two different emergency physicians (EPs), each of whom first performed visual estimation of IVC percent collapse and of Volume Status, followed by caliper measurements in M-mode and B-mode. EPs were blinded to patient data and to the other sonographer's results. For each technique, interrater reliability was determined between the two EPs' assessments using intraclass correlation coefficients (ICC) for continuous data and Cohen's weighted kappa for categorical data. In addition, analysis was performed on M-mode diameter measurements to determine the relationship between sonographer and patient characteristics on interrater reliability. RESULTS: Five EPs performed 92 US exams on 46 patients. Using M-mode, the ICC for maximum IVC diameter was 0.81 (95% confidence interval [CI]=0.67 to 0.89), and for minimum diameter was 0.77 (95% CI=0.62 to 0.87). There were no statistically significant differences between the caliper methods used for IVC measurements (M-mode diameter, B-mode diameter, or B-mode area). Agreement for visually estimated IVC collapse (0.60, 95% CI=0.36 to 0.76) was similar to agreement for calculated M-mode IVC collapse index (0.52, 95% CI=0.27 to 0.71). Cohen's weighted kappa for Volume Status based on visual estimation of IVC filling (size, shape, and collapse) was 0.64 (95% CI=0.53 to 0.73). ICC values for M-mode diameter measurements were significantly higher in studies involving patients who were noneuvolemic and studies in which sonographers had each performed at least five prior IVC-US. CONCLUSIONS: Emergency physicians' US measurements of IVC diameter have a high degree of interrater reliability. IVC percent collapse by visual estimation or based on caliper measurements have lower, but still moderate to good reliability. The use of the visual estimation technique should be considered by clinicians who have learned to obtain measured parameters of IVC filling because it is equally reliable to traditional M-mode and can be performed more rapidly.

  • intensivist use of hand carried ultrasonography to measure ivc collapsibility in estimating Intravascular Volume Status correlations with cvp
    Journal of The American College of Surgeons, 2009
    Co-Authors: Peter S Stawicki, James N Kirkpatrick, Benjamin M Braslow, Nova L Panebianco, Vicente H Gracias, Geoffrey E Hayden, Anthony J Dean
    Abstract:

    Background Volume Status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic Status of SICU patients, focusing on correlations between IVC-CI and CVP. Study Design Prospective evaluation of hemodynamic Status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and ≥25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. Results Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges ( 0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although 40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP Conclusions Measurements of IVC-CI by INBU can provide a useful guide to noninvasive Volume Status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low ( 0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.

Karim Bendjelid - One of the best experts on this subject based on the ideXlab platform.

  • respiratory change in ecg wave amplitude is a reliable parameter to estimate Intravascular Volume Status
    Journal of Clinical Monitoring and Computing, 2013
    Co-Authors: Raphael Giraud, Nils Siegenthaler, Denis R Morel, Jacquesandre Romand, Laurent Brochard, Karim Bendjelid
    Abstract:

    Electrocardiogram (ECG) is a standard type of monitoring in intensive care medicine. Several studies suggest that changes in ECG morphology may reflect changes in Volume Status. The "Brody effect", a theoretical analysis of left ventricular (LV) chamber size influence on QRS-wave amplitude, is the key element of this phenomenon. It is characterised by an increase in QRS-wave amplitude that is induced by an increase in ventricular preload. This study investigated the influence of changes in Intravascular Volume Status on respiratory variations of QRS-wave amplitudes (ΔECG) compared with respiratory pulse pressure variations (ΔPP), considered as a reference standard. In 17 pigs, ECG and arterial pressure were recorded. QRS-wave amplitude was measured from the Biopac recording to ensure that in all animals ECG electrodes were always at the same location. Maximal QRS amplitude (ECGmax) and minimal QRS amplitude (ECGmin) were determined over one respiratory cycle. ΔECG was calculated as 100 × [(ECGmax - ECGmin)/(ECGmax + ECGmin)/2]. ΔECG and ΔPP were simultaneously recorded. Measurements were performed at different time points: during normovolemic conditions, after haemorrhage (25 mL/kg), and following re-transfusion (25 mL/kg) with constant tidal Volume (10 mL/kg) and respiration rate (15 breath/min). At baseline, ΔPP and ΔECG were both <12 %. ΔPP were significantly correlated with ΔECG (r(2) = 0.89, p < 0.001). Volume loss induced by haemorrhage increased significantly ΔPP and ΔECG. Moreover, during this state, ΔPP were significantly correlated with ΔECG (r(2) = 0.86, p < 0.001). Re-transfusion significantly decreased ΔPP and ΔECG, and ΔPP were significantly correlated with ΔECG (r(2) = 0.90, p < 0.001). The observed correlations between ΔPP and ΔECG at each time point of the study suggest that ΔECG is a reliable parameter to estimate the changes in Intravascular Volume Status and provide experimental confirmation of the "Brody effect."

Wesley E Ely - One of the best experts on this subject based on the ideXlab platform.

  • radiographic measures of Intravascular Volume Status the role of vascular pedicle width
    Current Opinion in Critical Care, 2006
    Co-Authors: Russell R Miller, Wesley E Ely
    Abstract:

    Purpose of reviewA valid, low-cost, high-yield instrument to assess Intravascular Volume Status in critically ill patients does not exist. The portable chest X-ray is a common part of any intensivist's or chest clinician's daily rounds.Recent findingsA simple, objective, valid measure of intravascul

  • using the chest radiograph to determine Intravascular Volume Status the role of vascular pedicle width
    Chest, 2002
    Co-Authors: Wesley E Ely, Edward F Haponik
    Abstract:

    Due to concerns about the efficacy and safety of using pulmonary artery catheterization to evaluate hemodynamic Status, noninvasive diagnostic testing has gained increased importance. This article focuses on both the supportive evidence and the limitations of applying the vascular pedicle width (VPW), which is the mediastinal silhouette of the great vessels, as an aid in the assessment of patients' Intravascular Volume Status. The objective measurement of the VPW obtained from either upright or supine chest radiographs (CXRs which are often already available though not fully utilized) can increase the accuracy of the clinical and radiographic assessment of Intravascular Volume Status by 15 to 30%, and this value may be even higher when VPW is used serially within the same patient. Regardless of the presence or absence of pulmonary edema, the best VPW cutoff for differentiating a high vs normal to low Intravascular Volume Status is 70 mm. Patients with a VPW of > 70 mm coupled with a cardiothoracic ratio of > 0.55 are more than three times more likely to have a pulmonary artery occlusion pressure > 18 mm Hg than are patients without these radiographic findings. We suggest a management algorithm for utilizing the VPW, and whether or not such an approach will offer superior patient outcomes requires prospective investigation. Reappraisal of the VPW and other roentgenographic signs should be incorporated into newly implemented studies of the Swan-Ganz catheter, ICU echocardiography, portable CT scans, and other costlier technologies. While such investigations may refine the optimum application of the portable CXR, conventional and digital supine radiographs should retain an important role in the diagnosis and management of critically ill patients. Lastly, the measurement of the VPW should be incorporated into the training of chest clinicians and radiologists.

  • radiologic determination of Intravascular Volume Status using portable digital chest radiography a prospective investigation in 100 patients
    Critical Care Medicine, 2001
    Co-Authors: Wesley E Ely, Alle Smith, Caroline Chiles, Suzanne L Aquino, Tom S Harle, Gregory W Evans, Edward F Haponik
    Abstract:

    ObjectiveTo answer the following questions: Can the digital chest roentgenogram (CXR) be used to differentiate patients’ Volume Status? Do clinical data alter radiologists’ accuracy in interpreting the digital CXR?DesignProspective cohort study.SettingNine adult intensive care units of a tertiary ca

Edward F Haponik - One of the best experts on this subject based on the ideXlab platform.

  • vascular pedicle width in acute lung injury correlation with Intravascular pressures and ability to discriminate fluid Status
    Critical Care, 2011
    Co-Authors: Todd W Rice, Edward F Haponik, Caroline Chiles, Lorraine B Ware, Arthur P Wheeler, Gordon R Bernard, Jay Steingrub, Duncan R Hite, Michael A Matthay, Patrick Wright
    Abstract:

    Introduction: Conservative fluid management in patients with acute lung injury (ALI) increases time alive and free from mechanical ventilation. Vascular pedicle width (VPW) is a non-invasive measurement of Intravascular Volume Status. The VPW was studied in ALI patients to determine the correlation between VPW and Intravascular pressure measurements and whether VPW could predict fluid Status. Methods: This retrospective cohort study involved 152 patients with ALI enrolled in the Fluid and Catheter Treatment Trial (FACTT) from five NHLBI ARDS (Acute Respiratory Distress Syndrome) Network sites. VPW and central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) from the first four study days were correlated. The relationships between VPW, positive end-expiratory pressure (PEEP), cumulative fluid balance, and PAOP were also evaluated. Receiver operator characteristic (ROC) curves were used to determine the ability of VPW to detect PAOP <8 mmHg and PAOP ≥18 mm Hg. Results: A total of 71 and 152 patients provided 118 and 276 paired VPW/PAOP and VPW/CVP measurements, respectively. VPW correlated with PAOP (r = 0.41; P < 0.001) and less well with CVP (r = 0.21; P = 0.001). In linear regression, VPW correlated with PAOP 1.5-fold better than cumulative fluid balance and 2.5-fold better than PEEP. VPW discriminated achievement of PAOP <8 mm Hg (AUC = 0.73; P = 0.04) with VPW ≤67 mm demonstrating 71% sensitivity (95% CI 30 to 95%) and 68% specificity (95% CI 59 to 75%). For discriminating a hydrostatic component of the edema (that is, PAOP ≥18 mm Hg), VPW ≥72 mm demonstrated 61.4% sensitivity (95% CI 47 to 74%) and 61% specificity (49 to 71%) (area under the curve (AUC) 0.69; P = 0.001). Conclusions: VPW correlates with PAOP better than CVP in patients with ALI. Due to its only moderate sensitivity and specificity, the ability of VPW to discriminate fluid Status in patients with acute lung injury is limited and should only be considered when Intravascular pressures are unavailable.

  • using the chest radiograph to determine Intravascular Volume Status the role of vascular pedicle width
    Chest, 2002
    Co-Authors: Wesley E Ely, Edward F Haponik
    Abstract:

    Due to concerns about the efficacy and safety of using pulmonary artery catheterization to evaluate hemodynamic Status, noninvasive diagnostic testing has gained increased importance. This article focuses on both the supportive evidence and the limitations of applying the vascular pedicle width (VPW), which is the mediastinal silhouette of the great vessels, as an aid in the assessment of patients' Intravascular Volume Status. The objective measurement of the VPW obtained from either upright or supine chest radiographs (CXRs which are often already available though not fully utilized) can increase the accuracy of the clinical and radiographic assessment of Intravascular Volume Status by 15 to 30%, and this value may be even higher when VPW is used serially within the same patient. Regardless of the presence or absence of pulmonary edema, the best VPW cutoff for differentiating a high vs normal to low Intravascular Volume Status is 70 mm. Patients with a VPW of > 70 mm coupled with a cardiothoracic ratio of > 0.55 are more than three times more likely to have a pulmonary artery occlusion pressure > 18 mm Hg than are patients without these radiographic findings. We suggest a management algorithm for utilizing the VPW, and whether or not such an approach will offer superior patient outcomes requires prospective investigation. Reappraisal of the VPW and other roentgenographic signs should be incorporated into newly implemented studies of the Swan-Ganz catheter, ICU echocardiography, portable CT scans, and other costlier technologies. While such investigations may refine the optimum application of the portable CXR, conventional and digital supine radiographs should retain an important role in the diagnosis and management of critically ill patients. Lastly, the measurement of the VPW should be incorporated into the training of chest clinicians and radiologists.

  • radiologic determination of Intravascular Volume Status using portable digital chest radiography a prospective investigation in 100 patients
    Critical Care Medicine, 2001
    Co-Authors: Wesley E Ely, Alle Smith, Caroline Chiles, Suzanne L Aquino, Tom S Harle, Gregory W Evans, Edward F Haponik
    Abstract:

    ObjectiveTo answer the following questions: Can the digital chest roentgenogram (CXR) be used to differentiate patients’ Volume Status? Do clinical data alter radiologists’ accuracy in interpreting the digital CXR?DesignProspective cohort study.SettingNine adult intensive care units of a tertiary ca

Warren Pavey - One of the best experts on this subject based on the ideXlab platform.

  • determinants of urinary output response to iv furosemide in acute kidney injury a pharmacokinetic pharmacodynamic study
    Critical Care Medicine, 2016
    Co-Authors: Benjamin I Silbert, Jeffrey Lipman, Jason A Roberts, Tomas Corcoran, David J R Morgan, Warren Pavey
    Abstract:

    Objectives: This study assessed the determinants of urinary output response to furosemide in acute kidney injury; specifically, whether the response is related to altered pharmacokinetics or pharmacodynamics. Design: Prospective cohort. Setting: Tertiary ICU. Patients: Thirty critically ill patients with acute kidney injury without preexisting renal impairment or recent diuretic exposure. Intervention: A single dose of IV furosemide. Measurements and Main Results: Baseline markers of Intravascular Volume Status were obtained prior to administering furosemide. Six-hour creatinine clearance, hourly plasma/urinary furosemide concentrations, and hourly urinary output were used to assess furosemide pharmacokinetics/pharmacodynamics parameters. Of 30 patients enrolled, 11 had stage-1 (37%), nine had stage-2 (30%), and 10 had stage-3 (33%) Acute Kidney Injury Network acute kidney injury. Seventy-three percent were septic, 47% required norepinephrine, and 53% were mechanically ventilated. Urinary output doubled in 20 patients (67%) following IV furosemide. Measured creatinine clearance was strongly associated with the amount of urinary furosemide excreted and was the only reliable predictor of the urinary output after furosemide (area under the receiver-operating-characteristic curve, 0.75; 95% CI, 0.57-0.93). In addition to an altered pharmacokinetics (p < 0.01), a reduced pharmacodynamics response to furosemide also became important when creatinine clearance was reduced to less than 40 mL/min/1.73 m 2 (p = 0.01). Acute kidney injury staging and markers of Intravascular Volume, including central venous pressure, brain-natriuretic-peptide concentration, and fractional urinary sodium excretion were not predictive of urinary output response to furosemide. Conclusions: The severity of acute kidney injury, as reflected by the measured creatinine clearance, alters both pharmacokinetics and pharmacodynamics of furosemide in acute kidney injury, and was the only reliable predictor of the urinary output response to furosemide in acute kidney injury.