Respiratory Variation in Femoral Vein Diameter Has Moderate Accuracy as a Marker of Fluid Responsivity in Mechanically Ventilated Septic Shock Patients

Ultrasound (US) is considered the first step in evaluation of patients with shock; respiratory variation of the inferior vena cava (inferior vena cava collapsibility [IVCc]) is an important measurement in this scenario that can be impaired by patient condition or technical skills. The main objective of this study was to evaluate if respiratory variation of the femoral vein (femoral vein collapsibility [FVc]), which is easier to visualize, can adequately predict fluid responsiveness in septic shock patients. Forty-five mechanically ventilated septic shock patients in a mixed clinical–surgical, 30-bed intensive care unit were enrolled in this study. All patients underwent assessments of FVc, IVCc and cardiac output using a portable US device. The passive leg raising test was used to evaluate fluid responsiveness. FVc presented an area under the receiver operating characteristic curve of 0.678 (95% confidence interval: 0.519–0.837, p = 0.044) with a cutoff point of 17%, yielding a sensitivity of 62% and specificity of 65% in predicting fluid responsiveness. IVCc had greater diagnostic accuracy compared with FVc, with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval: 0.563–0.903, p = 0.024) and a cutoff point of 29%, yielding a sensitivity of 47% and specificity of 86%. In conclusion, FVc has moderate accuracy when employed as an indicator of fluid responsiveness in spontaneously mechanically ventilated septic shock patients.     

Congenital absence of portal vein in the fetus: a case report.

Congenital absence of portal vein (CAPV) is a rare abnormality, which may be associated with other abnormalities. We report a case of prenatal diagnosis of absent portal vein confirmed on postnatal ultrasonography and computed tomography scan. The ultrasound features of CAPV include dilated intra-abdominal segment of umbilical vein, dilated inferior vena cava and the presence of hyperechogenic areas in the liver. Blood coming from the umbilical vein directly drains into the inferior vena cava. The dilated intra-abdominal segment of the umbilical vein shows high velocity pulsatile flow, resembling that of ductus venosus. These findings should prompt a careful search for the portal vein and any associated anomalies.     

Echocardiographic measurement of fluid responsiveness

PURPOSE OF REVIEW: Fluid responsiveness is a relatively new concept. It enables the efficacy of volume expansion to be predicted before use, rather than assessed afterwards, thus avoiding inappropriate fluid infusion. Echocardiography is a fantastic noninvasive tool which can directly visualize the heart and assess cardiac function. Its use was long limited by the absence of accurate indices to diagnose hypovolemia and predict the effect of volume expansion. In the last few years, several French teams have used echocardiography to develop new parameters of fluid responsiveness, taking advantage of its ability to monitor cardiac function beat by beat during the respiratory cycle. RECENT FINDINGS: In mechanically ventilated patients perfectly adapted to the respirator, respiratory variations in superior and inferior vena cava diameters and in left ventricular stroke volume have been validated as parameters of fluid responsiveness. In our opinion, the collapsibility index of the superior vena cava is the most reliable of these parameters, but does require transesophageal echocardiography. SUMMARY: Echocardiography has been widely demonstrated to predict fluid responsiveness accurately. This is now a complete and noninvasive tool able to accurately determine hemodynamic status in circulatory failure.     

Evaluation of Intravascular Volume Using the Internal Jugular Vein Cardiac Collapse Index in the Emergency Department: A Preliminary Prospective Observational Study

A non-invasive method for assessment of intravascular volume for optimal fluid administration is needed. We here conducted a preliminary study to confirm whether cardiac variation in the internal jugular vein (IJV), evaluated by ultrasound, predicts fluid responsiveness in patients in the emergency department. Patients who presented to the emergency department between August 2019 and March 2020 and required infusions were enrolled. We recorded a short-axis video of the IJV, respiratory variability in the inferior vena cava and stroke volume variations using the ClearSight System (Edwards Lifesciences, Irvine, CA, USA) before infusion of 500 mL of crystalloid fluid. Cardiac variations in the cross-sectional area of the IJV were measured by speckle tracking. Among the 148 patients enrolled, 105 were included in the final analysis. Fluid responsiveness did not correlate with the cardiac collapse index (13.6% vs. 16.8%, p = 0.24), but correlated with stroke volume variations (12.5% vs. 15.6%, p = 0.026). Although it is a simple correction, the cardiac collapse index correlated with stroke volume corrected by age (r = 0.25, p = 0.01), body surface area (r = 0.33, p = 0.002) and both (r = 0.35, p = 0.001). Cardiac variations in the IJV did not predict fluid responsiveness in the emergency department, but may reflect stroke volume.     

经颈静脉介入治疗不同类型急性髂股静脉血栓

目的 评价经颈静脉介入治疗不同类型急性髂股静脉血栓形成(IF-VT)的疗效.方法 38例急性IF-VT患者来自徐州医学院附属医院,全部经颈静脉插管行尿激酶溶栓治疗.结果 左侧IF-VT或伴血栓蔓延至下腔静脉16例;左侧IF-VT伴左髂总静脉闭塞17例;左侧IF-VT合并左髂总静脉狭窄或闭塞伴血栓蔓延至下腔静脉3例;双侧IF-VT伴左髂总静脉狭窄或闭塞2例.血栓完全溶解33例,部分溶解5例.20例随访2～18个月,血栓复发2例.结论 经颈静脉介入治疗不同类型急性IF-VT是一种安全、有效的治疗方法.     

A case of successfully treated inferior vena cava injury

The inferior vena cava (IVC) is the most frequently injured retroperitoneal vascular structure. Despite the improvements in preoperative care and operation techniques, mortality rates for inferior vena cava injuries are still high due to delayed or inadequate volume recussitation, difficulty of diagnosis and technical problems in repair. A 1.5-cm sized wound at the IVC was primarly repaired by suturing. Because of appropriate and successful perioperative blood and fluid resuscitation, the patient was able to survive. We report a case of successfully treated IVC injury caused by a gunshot.     

下腔静脉离断产前超声诊断

目的 探讨胎儿下腔静脉离断产前超声声像图特征和有效诊断切面,以提高其产前超声诊断准确率.方法 回顾性分析我院2006年1月至2010年5月诊断的10例下腔静脉离断胎儿(其中7例经引产后尸体解剖证实)产前超声声像图,与正常超声声像图对比,总结其产前超声声像图特征及有效切面.结果 10例下腔静脉离断胎儿,9例合并严重心内结构畸形,7例合并心外结构畸形(其中5例合并内脏反位).本组10例下腔静脉离断胎儿产前超声声像图均表现为四腔心切面异常(奇静脉扩张)、上腹部横切面异常(正常下腔静脉不能显示)、胸腹部斜冠状切面异常[离断的下腔静脉异位连接于奇(半奇)静脉并穿过膈肌连于腔静脉]及右心房纵切面异常(肝上段下腔静脉入右心房,肾上段肝段间的下腔静脉缺失并离断).结论 下腔静脉离断常合并心内、外结构畸形.下腔静脉离断胎儿在四腔心切面、上腹部横切面、胸腹部斜冠状切面及右心房纵切面上均有特征性超声声像图表现.识别下腔静脉离断特征性超声声像图表现可明显提高其产前超声检出率和诊断准确率.     

Clinical integrated ultrasound of the thorax including causes of shock in nontraumatic critically ill patients. A practical approach

A rapid identification of the causes of hemodynamic instability or cardiac arrest is crucial for correct treatment. In a critical care setting, ultrasound seems to be an ideal tool for a rapid diagnosis. A multiple-goal problem-based approach represents the main peculiarity of emergency ultrasound and may be considered an extension of physical examination. The integration of data that can rapidly be obtained from the heart, lung, inferior vena cava, abdomen and leg vein examination are often essential for the diagnosis and treatment in critically ill patients. The role and potentiality of integrated ultrasound in cardiac arrest, shock/hypotension and severe dyspnea are considered in this article.     

下腔静脉滤器在下肢深静脉血栓溶栓治疗中的应用

目的：探讨经导管溶栓治疗下肢深静脉血栓中下腔静脉滤器的应用价值。方法：采用经导管溶栓治疗下肢深静脉血栓10例,术前经健侧股静脉置人下腔静脉滤器于肾静脉平面下方的下腔静脉内,并观察有无肺栓塞症状。结果：10例均成功置人,无肺栓塞发生。9例下肢静脉血栓症状和体征消失,1例下肢肿胀减轻。结论：经导管溶栓治疗下肢深静脉血栓前置人下腔静脉滤器,能有效预防肺栓塞。     

Embryogenetic malformations of the inferior vena cava, and their manifestations in adults

Five male patients with congenital anomalies of the inferior vena cava aged 20 to 43 were examined. The diagnosis and the level of aplasia were established on the basis of complex instrumental examination (duplex scanning of inferior extremity veins, pelvic veins, and retroperitoneal veins; computed and magnetic resonance tomography of the abdominal cavity; pelvic phlebography; retrograde cavagraphy). Together with inferior vena cava anomalies, other malformations such as pulmonary arterial stenosis or duplication of renal collector system were diagnosed in two patients. In three or 60% of the patients the disease had first manifested by the clinical picture of peripheral thrombosis (shin and femoral edema); fever, chill and subsequent edema of both legs had been first manifestations in two patients. Aplasia of the infrarenal segment of the inferior vena cava was revealed in two patients; in other two patients aplasia of the infrarenal, renal, and partly suprarenal segments of this magistral vessel was found; in one patient the whole vein was aplastic except a small part of the suprarenal segment, where the hepatic veins and the right suprapolar renal vein flew into. To establish an early diagnosis of a congenital inferior vena cava anomaly, the protocol of examination of patients with venous diseases should include ultrasound mapping of the suprarenal and infrarenal segments of the vena cava; in cases of agenesia it should include computed and magnetic resonance tomography and retrograde cavagraphy.     

Assessment of indices of preload and volume responsiveness

PURPOSE OF REVIEW: To summarize the relevant peer-reviewed publications over the past year that addressed issues of when to give (or not give) fluid to the critically ill patient. RECENT FINDINGS: Clinical data from several studies underscore the inability of measures of ventricular filling to assess either preload or preload responsiveness. Whereas less invasive monitoring techniques than pulmonary arterial catheterization demonstrate better discrimination with estimates of both preload and preload responsiveness. Measuring dynamic changes in stroke volume, descending aortic flow, and both superior and inferior vena caval diameters during ventilation provides good predictive value in defining preload responsiveness. One study demonstrated that resuscitation protocols keyed to esophageal flow measures improved outcome in postoperative cardiac surgery patients. SUMMARY: Preload is not preload responsiveness. Functional measures of preload responsiveness exist and are superior to traditional measures of filling pressures in driving resuscitation in critically ill patients.     

Paramètres dynamiques non invasifs prédictifs de l'efficacité d'un remplissage vasculaire

Circulatory failure treatment needs to assess blood volume status, in order to detect a hypovolemia requiring blood volume expansion. Unfortunately, significant fluid responsiveness occurs in only 40–70% of critical care patients after blood volume expansion, suggesting the inability of central venous pressure, pulmonary wedge pressure or conventional echocardiographic parameters to detect hypovolemia and to predict fluid responsiveness. In this way, new dynamic echocardiographic parameters have recently been proposed in mechanically ventilated patients, using the heart lung interactions, such as respiratory changes of aortic blood flow velocity, and of diameters of superior and inferior vena cava. Echocardiography Doppler allows now to completely investigate hemodynamic status in critical care patients.     

Évaluation de la volémie par échocardiographie à l’aide des interactions cardiopulmonaires

Circulatory failure treatment needs to assess blood volume status, in order to detect an hypovolemia requiring blood volume expansion. Unfortunately, significant fluid responsiveness occurs in only 40 to 70% of critical care patients after blood volume expansion, suggesting the inability of central venous pressure, pulmonary wedge pressure or conventional echocardiographic parameters to detect hypovolemia and to predict fluid responsiveness. In this way, new dynamic echocardiographic parameters have recently been proposed in mechanically ventilated patients, using the heart lung interactions, such as respiratory changes of aortic blood flow velocity and of diameters of both superior and inferior vena cava. Echocardiography Doppler allows now for complete investigation of the hemodynamic status in critical care patients.     

经股静脉穿刺置入PICC管5例临床研究

目的:探讨上腔静脉狭窄和穿刺困难无法将PICC管置入上腔静脉患者经其他静脉置管的方法.方法:对5例无法将PICC管置入上腔静脉的患者给予正确、全面评估,并与医生讨论、制定开通静脉通路的方案,向患者及家属详细说明目的与方法,征得患者及家属的同意,严格消毒穿刺部位皮肤,选择患者右侧股静脉穿刺置入三向瓣膜单腔PICC管.结果:本组5例均一次穿刺成功置入PICC管至下腔静脉,其中2例分别留置导管110d、63d后病情好转拔管;1例留置导管18d后因病重死亡而拔管;1例留置导管已90d,1例在层流病房内置管后目前均正常使用.本组均无静脉炎、导管相关性感染、堵管及深静脉血栓形成等并发症发生.结论:时上腔静脉狭窄和穿刺困难无法将PICC管置入上腔静脉的患者,经股静脉穿刺置入PICC管是开通静脉通路的有效方法.     

时间—空间关联成像联合高分辨力血流显像技术显示孕中期胎儿奇静脉

目的探讨应用时间—空间关联成像(STIC)联合高分辨力血流显像(HD)技术显示孕中期胎儿奇静脉的可行性。方法选取2013年3~11月期间进行胎儿畸形筛查的200例孕妇,随机分为两组,研究组100例应用STIC联合HD技术在胎儿胸腹部正中旁矢状切面显示奇静脉,通过图像旋转等后处理,观察奇静脉与胸主动脉关系,奇静脉弓的形态及奇静脉弓汇入上腔静脉的位置及方式。对照组100例应用二维超声联合CDFI技术对胎儿奇静脉进行显示。结果 1研究组100例胎儿共96例成功显示了奇静脉,显示成功率为96%,对照组100例胎儿共85例成功显示了奇静脉,显示成功率为85%。研究组优于对照组,P﹤0.05。2根据与脊柱的相对位置关系对奇静脉分型,奇静脉脊柱右侧型、中间型及左侧型所占比例分别为26.0%、33.9%及40.1%。3奇静脉与胸主动脉并行,至上腔静脉水平后向前弯曲形成弓形,汇入上腔静脉。41例下腔静脉肝段离断,奇静脉明显扩张,内径与胸主动脉相当。结论 STIC联合HD技术显示孕中期奇静脉可行,可观察奇静脉内径及走形,奇静脉弓的形态及汇入上腔静脉的位置及方式等,对导致奇静脉扩张的疾病如下腔静脉离断等具有提示诊断作用;该方法对奇静脉的显示率优于传统的二维超声联合CDFI。     

Coagulability and fibrinolytic changes during veno-venous bypass in liver transplantation

In clinical liver transplantation, a venous bypass that rechannels the blood flow from the inferior vena cava and portal vein to the superior vena cava has been used to maintain the venous return. However, the usage of mechanical shunt has given rise to derangements of blood coagulability and fibrinolysis. Therefore, changes of coagulability and fibrinolysis during the venous bypass were examined in dogs using a centrifugal pump (Bio-Pump), and the effect of gabexate mesilate for coagulation were studied. Venous bypass from the inferior vena cava and the portal vein to the external jugular vein was performed in mongrel dogs (group A: bypass without pump, group B: bypass with the Bio-Pump, group C: bypass with the Bio-Pump and the addition of gabexate mesilate). In group A, blood pressure gradually decreased, but in groups B and C it maintained the pre-bypass level. All results of coagulation parameters and fibrinolytic measurements of group B were not significantly different from those of group A; only partial thromboplastin time was prolonged in group B. However, this prolongation was effectively prevented by the addition of gabexate mesilate in group C.     

上腔静脉置换术中体外静脉-静脉压差式转流的临床应用探讨

目的评价体外静脉-静脉压差式转流在上腔静脉置换术中的临床应用价值。方法选取2004年-2006年我院实施上腔静脉切除人造血管重建术无神经系统合并症的患者。术中应用体外静脉-静脉压差式转流。术中持续监测动脉血压、颈内静脉压。于转流前、转流后、阻断后5min、15min、40min及开放后5min、1h经颈内静脉、桡动脉同时抽血行血气分析。术毕随访呼唤睁眼时间及神经系统相关并发症。结果术中动脉血压无变化。阻断期间颈内静脉压升高,平均动脉压与颈内静脉压差及颈内静脉氧饱和度（SjvO2）下降。开放后上述三者均迅速恢复至基础水平。所有患者术毕呼唤睁眼,无神经系统并发症发生,痊愈出院。结论体外静脉-静脉压差式转流操作简单、无污染、可控性好,易维持稳定的血流动力学,改善了脑的血液灌注,是一种安全有效的脑保护临床措施。     

Use of hand-held ultrasonography to confirm the correct placement of a central venous catheter tip

To avoid severe complications resulting from malpositioning of a central venous catheter, removal and recannulation of the catheter may be necessary, thus wasting medical equipment and increasing stress on the patient. Therefore, central venous catheters should be inserted correctly the first time. We tested whether real-time hand-held ultrasound-guided confirmation of the location of the tip of a central venous catheter inserted from the femoral vein could reduce the rate of malpositioning. Catheters were inserted using conventional methods for 65 patients, and using ultrasound guidance for 29 patients. For the latter group, when a central venous catheter was inserted, the ultrasound examiner first identified its tip located dorsal to the liver in the inferior vena cava and then fixed the catheter in position. We considered a central venous catheter to be malpositioned when its tip appeared in neither the inferior vena cava nor the right atrium–inferior vena cava junction in X-rays. Flexed or inverted catheters were also considered to be malpositioned. We compared the malpositioning rates for the ultrasound and conventional groups. Malpositioning was identified for two (6.9%) patients in the ultrasound group and 19 (29.2%) patients in the conventional group. The relative risk of ultrasound-guided versus conventional catheter insertion was 0.23 (95% confidence interval, 0.09–0.62). Our data suggest that real-time ultrasound monitoring is useful for avoiding malpositioning of central venous catheters inserted from the femoral vein.     

超声在急性下肢深静脉血栓形成局部置管溶栓中的应用价值

目的 探讨超声在急性下肢深静脉血栓形成（DVT）患者局部置管溶栓中的应用价值.方法 38例急性下肢DVT患者,术前经健侧股静脉或颈内静脉置入下腔静脉滤器.在超声定位和引导下,穿刺患侧腘静脉,置入溶栓导管.微泵持续注入尿激酶,24～48 h后超声监测.结果 超声定位下穿刺针均顺利进入腘静脉;超声引导下溶栓导管均被置入血栓合适位置,38例超声引导全部成功.治疗过程中,根据血栓消融情况,4例在超声引导下调整了溶栓导管位置.经过2～7 d溶栓治疗后行超声检查,33例基本治愈,4例好转,1例无效.无一例发生大出血和肺栓塞.结论 超声检查在急性下肢DVT患者局部置管溶栓术前诊断、术中引导、术后指导用药及疗效评估方面具有一定临床应用价值.     

下腔静脉滤器置入术在下肢深静脉血栓治疗中的应用

目的：探讨下腔静脉滤器在治疗下肢深静脉血栓中的应用价值。方法：19例下肢深静脉血栓患者，经股静脉或颈静脉途径成功置入下腔静脉滤器，随访4～36个月。结果：无致死性肺动脉栓塞发生，无滤器移位，l例患者术后2个月时出现下腔静脉血栓形成。结论：下腔静脉滤器置入方法简单，安全，可有效防止肺动脉栓塞的发生，但应严格掌握适应证。