Circulatory response to volume expansion and transjugular intrahepatic portosystemic shunt in refractory ascites: Relationship with diastolic dysfunction
Daniela FilìCalogero FallettaAngelo LucaCesar Hernandez BaravogliaFrancesco ClemenzaRoberto MiragliaCesare ScardullaFabio TuzzolinoGiovanni VizziniBruno GridelliJaime Bosch
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Pulmonary wedge pressure
Cardiac index
Portosystemic shunt
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Central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) are insensitive preload markers and sometimes misleading. The introduction of the pulse contour method for monitoring of continuous cardiac output enabled the real-time quantification of stroke volume variation (SVV). Studies evaluating the accuracy of this parameter as a measure of preload responsiveness are still limited and conflicting results have been published in cardiac surgical patients. The aim of this study was to reevaluate the predictive value of SVV regarding cardiac responsiveness to fluid therapy and to compare it with the standard preload variables in a clinical setting in the ICU after cardiac surgery.The assessment of cardiac responsiveness to fluid therapy (HAES-steril 6% 10 mL * Body Mass Index) was performed in 92 ventilated coronary artery surgical patients after arrival in the ICU. After the fluid load, detailed hemodynamic measurements were performed. A 'responder' was defined as a patient with a gain in stroke volume index (SVI) of 5% or more from baseline value to the volume challenge.Post hoc analysis showed that there were 47 responders to the fluid challenge and 45 non-responders. Hemodynamic data before the fluid therapy show that stroke volume variation in the responders group was significantly higher than in the non-responders groups (9.7 +/- 4.3% versus 7.6 +/- 3.0%, P = 0.01). The receiver operating characteristic curves for the baseline values of CVP, PCWP and SVV were constructed for illustrative purposes. The area under the curve for baseline values of SVV was significantly higher than random guess (area = 0.65, p < 0.05), indicative for the value of SVV as a marker of cardiac responsiveness to fluid therapy. The static preload parameters CVP and PCWP had no predictive value.SVV as measured with the LiDCO system is a better functional marker of cardiac responsiveness to fluid therapy than the static parameters CVP and PCWP.
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In the postoperative management of cardiac surgery patients, pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) are the most commonly used parameters of preload. However, these pressure parameters are easily affected by ventricular compliance, positive end-expiratory pressure and other factors. The aim of this study was to evaluate whether right ventricular end-diastolic volume index (RVEDVI) reflects cardiac output or ventricular preload in patients after cardiac surgery during postoperative management.We performed measurements in 31 patients postoperatively in the intensive care unit every 1 or 2 hours using a modified thermodilution catheter.There were 999 measured hemodynamic data sets and the measurement duration was 47 +/- 21 hours (mean +/- SD). RVEDVI was 119 +/- 32 ml/m(2), cardiac index (CI) was 2.7 +/- 0.7 L/min/m(2), and PCWP was 11 +/- 4 mmHg. A significant correlation was found between RVEDVI, CVP and CI in 15 of 31 patients, and between PCWP and CI in 4 of 22 patients. In 33% of cases, CVP showed a negative correlation with CI, whereas 7% showed a negative correlation between RVEDVI and CI.RVEDVI was a significant index during the postoperative management after cardiac surgery.
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Hepatic venous pressure gradient (HVPG) is an independent predictor of variceal rebleeding in patients with cirrhosis.After pharmacological and/or endoscopic therapy, the use of a transjugular intrahepatic portosystemic shunt (TIPS) may be necessary in HVPG non-responders, but not in responders.Thus, HVPG measurement may be incorporated into the treatment algorithm for acute variceal bleeding, which further identifies the candidates that should undergo early insertion of TIPS or maintain the traditional pharmacological and/or endoscopic therapy.The potential benefits are to reduce the cost and prevent TIPS-related complications.
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To investigate the changes in hemodynamics and oxygen metabolism of different Child-grade patients during orthotopic liver transplantation (OLT) without veno-venous bypass.Forty patients with end-stage liver disease undergoing non veno-venous OLT under general anesthesia were enrolled in this research. Swan-Ganz catheter was placed in the pulmonary artery via right internal jugular vein and right radial artery was cannulated to monitor mean pulmonary artery pressure (mPAP) and artery blood pressure (ABP) continuously. Pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) were also recorded. Cardiac output (CO) was recorded at several time points, such as, 30 min after induction (T1), when inferior vena cava and portal vein were clamped (T2), 30 min after portal vein was clamped (T3), 10 min after unclamping of portal vein (T4), 60 min after graft reperfusion (T5) and at the end of the operation (T6). Blood samples were taken from radial and pulmonary artery for blood gas analysis and hemodynamic parameters, such as, cardiac index (CI), stroke volume index (SVI), pulmonary vascular resistance index (PVRI), and system vascular resistance index (SVRI); oxygen delivery (DO2) and oxygen consumption (VO2) were also calculated at these time points.(1) The mPAP values were much higher in group C than in group A or B at all time points. CVP was significantly increased at T1 or T2 in group C as compared with those points of Child's B or C. PCWP was increased significantly after unclamping of portal vein in all three groups and was much higher at several points in Child's C than in Child's A or B. The SVRI value of T1 and the PVRI value of T3 were much lower in group C than those points in group A and the value of SVRI/PVRI was less than normal except at T3 point. And blood gas analysis elucidated that PaO2 was higher than 400 mm Hg at any points. (2) Oxygen consumption was significantly decreased during the operation due to less blood supply and was reverted to normal at the end point of the operation in all patients. Oxygen delivery was all at least 1,000 mL/min during OLT and there was no significant difference between different groups or different points.The hemodynamic state of high cardiac output with low peripheral resistance deteriorated when patients' Child-grade shifted from A to C. VO2 was less than normal value during OLT until the end point.
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Background: To evaluate the left heart function, left atrial pressure(LAP) has been monitored directly via LA catheter and indirectly via Swan-Ganz catheter. But indirect pressure monitor cannot often reflect the LAP precisely. We compared the LAP via LA catheter with central venous pressure(CVP), diastolic pulmonary artery pressure(DPAP) and pulmonary capillary wedge pressure(PCWP) by Swan-Ganz catheter. Methods: Eleven cardiac-surgical patients whose LAP measurements were needed for clinical management were the subjects of this study. The CVP, DPAP and PCWP by Swan-Ganz catheter, and LAP were measured just after cardiopulmonary bypass, just after sternal closure, after 6 hours and 18 hours from the end of operation. And we divided them into two groups which consisted below 35 mmHg(group I) and over 35 mmHg(group II) of systolic pulmonary artery pressure(SPAP), and compared two groups. Results: In group I, the LAP, CVP, DPAP and PCWP was 11.7±3.9 mmHg, 10.5±3.9 mmHg, 12.5±5.1 mmHg and 12.5±4.4 mmHg respectively, and correlation coefficiency of LAP with CVP, DPAP and PCWP was 0.7478, 0.7128 and 0.9002 respectively(p<0.05). In the group II, the LAP, CVP, DPAP and PCWP was 16.5±3.2 mmHg, 12.8±2.9 mmHg, 23.4±3.8 mmHg and 20.8±4.7 mmHg respectively and there was no correlation between LAP, CVP, DPAP and PCWP. Conclusion: The Swan-Ganz catheterization for the estimation of LAP is useful in the patients without pulmonary hypertension, but in the patient with pulmonary hypertension, CVP, DPAP and PCWP do not reflect the LAP.(Korean J Anesthesiol 1996; 30: 172~177)
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To delineate the indications for pulmonary arterial pressure monitoring, the relationship between central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) was examined in 30 patients with coronary-artery disease and ventricular dysfunction (ejection fractions ranging from 0.26 to 0.84) prior to, during, and after coronary-artery surgery. For each patient, 30 simultaneous measurements of CVP and PCWP were made during a 36-hour period that included the awake state, the anesthetized state with and without surgery, before and after pericardiotomy, before and after cardiopulmonary bypass, and one, four, eight, and 24 hours after operation. At each point, changes in filling pressures were acutely induced by changing body position to alter venous return. The CVPs ranged from 0 to 19 torr, and the PCWPs from 0 to 31 torr. The CVP and the PCWP correlated well (r = 0.89) during all measurement periods for patients who had ejection fractions greater than 0.50 without angiographically demonstrable ventricular dyssynergy preoperatively. Changes in CVP (delta CVP) and PCWP (delta PCWP) over the 35-hour period also correlated well (r = 0.94). Normality (abnormality) of the CVP was predictive of normality (abnormality) of the PCWP for more than 96 per cent of the 450 data points. On the other hand, for patients with ejection fractions less than 0.40 or with hyssynergy, the CVP did not correlate with the PCWP (r = 0.24), and delta CVP did not correlate with delta PCWP (r = 0.04). Normality (abnormality) of the CVP was predictive of normality (abnormality) of the PCWP for less than 62 per cent of the 450 data points. This study has defined subclasses of patients with coronary-artery disease for whom pulmonary arterial pressure monitoring is indicated prior to, during, and following coronary-artery surgery.
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Objective:To investigate the changes in hemodynamics in end stage liver failure patients after liver transplantation.Methods:Five patients with liver transplantation were included in this study.SwanGanz catheters were inserted and central venous pressure (CVP),mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP),cardiac output (CO),mean arterial pressure (MAP),systemic vascular resistance index (SVRI),pulmonary vascular resistance index (PVRI),heart rate (HR) were measured from 1 to 3 days after the operation.Results:MAP,PCWP,and CVP decreased and HR increased after the admission to ICU,and then they were increased within 3 days.Cardiac index(CI) showed no marked changes within 3 days.SVRI and PVRI were decreased at the admission,and then were improved in the next 3 days.Conclusions:In end stage liver failure patients with liver transplantation,the hemodynamics is unstable,indicating hypovolemia.It is necessary to calculate the volume deficit and determine the resuscitation volume.
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Introduction Cardiac surgery with cardiopulmonary bypass (CPB) is a recognized trigger of systemic inflammatory response, usually related to postoperative acute lung injury (ALI).As an attempt to dampen inflammatory response, steroids have been perioperatively administered to patients.Macrophage migration inhibitory factor (MIF), a regulator of the endotoxin receptor, is implicated in the pathogenesis of ALI.We have previously detected peak circulating levels of MIF, 6 hours post CPB.Experimental data have shown that steroids may induce MIF secretion by mononuclear cells.This study aims to correlate levels of MIF assayed 6 hours post CPB to the intensity of postoperative pulmonary dysfunction, analysing the impact of perioperative steroid administration. MethodsWe included patients submitted to cardiac surgery with CPB, electively started in the morning, performed by the same team under a standard technique except for the addition of methylprednisolone (15 mg/kg) to the CPB priming solution for patients from group MP (n = 37), but not for the remaining patients -group NS (n = 37).MIF circulating levels were assayed at the anesthesia induction, 3, 6, and 24 hours after CPB.A standard weaning protocol with fast track strategy was adopted, and indicators of organ dysfunction and therapeutic intervention were registered during the first 72 hours postoperative.Results Levels of MIF assayed 6 hours post CPB correlated directly to the postoperative duration of mechanical ventilation (P = 0.014, rho = 0.282) and inversely to PaO 2 /FiO 2 ratio (P = 0.0021, rho = -0.265).No difference in MIF levels was noted between the groups.The duration of mechanical ventilation was higher (P = 0.005) in the group MP (7.92 ± 6.0 hours), compared with the group NS (4.92 ± 3.6 hours). ConclusionCirculating levels of MIF assayed 6 hours post CPB are correlated to postoperative pulmonary performance.Immunosuppressive doses of methylprednisolone did not affect circulating levels of MIF and may be related to prolonged mechanical ventilation.
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