William Beaubien-Souligny

Extracardiac Signs of Fluid Overload in the Critically Ill Cardiac Patient: A Focused Evaluation Using Bedside Ultrasound

Fluid balance management is of great importance in the critically ill cardiac patient. Although intravenous fluids are a cornerstone therapy in the management of unstable patients, excessive administration coupled with cardiac dysfunction leads to elevation in central venous pressure and end-organ venous congestion. Fluid overload is known to have a detrimental effect on organ function and is responsible for significant morbidity in critically ill patients. Multisystem bedside point of care ultrasound imaging can be used to assess signs of fluid overload and venous congestion in critically ill patients. In this review we describe the ultrasonographic extracardiac signs of fluid overload and how they can be used to complement clinical evaluation to individualize patient management.

Imaging portal venous flow to aid assessment of right ventricular dysfunction

Figure A) To obtain an image of portal venous flow (PVF) using transesophageal echocardiography (TEE), a view of the inferior vena cava (IVC) is obtained using a lower mid-esophageal view with the omniplane transducer at 90 (with permission of CAE Healthcare, Ville Saint-Laurent, QC, Canada). B) The TEE probe is then slowly advanced in a transgastric position while maintaining the liver under the ultrasound beam. Transducer rotation between 50 and 70 will typically align the right portal vein (PV) with the centre of the ultrasound beam. C) A normal portal vein flow velocity is 20 ± 5 cm sec with minimal pulsatility. D) Abnormal PVF in a 78-yr-old male before mitral valve repair with peak and trough velocities of 18 and 4 cm sec, respectively, resulting in a pulsatility fraction of 78%. A video of the technique to acquire an image of the portal vein can be seen in the video that is available as Electronic Supplementary Material

A Simplified Approach to Extravascular Lung Water Assessment Using Point-of-Care Ultrasound in Patients with End-Stage Chronic Renal Failure Undergoing Hemodialysis

Background: Fluid overload leading to pulmonary congestion is an important issue in patients undergoing hemodialysis. This study aimed to determine if a simplified method of extravascular lung water assessment using ultrasound provided clinically relevant information. Methods: This prospective study recruited 47 patients from a single hemodialysis center. Pulmonary ultrasound was performed before and after 2 hemodialysis sessions in 28 regions on the thorax. The B-line score was defined as the percentage regions where B-lines were present. Results: When B-lines were detected before hemodialysis, a significant relationship was found between fluid removal and the change in B-line score. Patients with a B-line score of ≥21.4% (4th quartile) after the second hemodialysis session were more likely to be hospitalized for pulmonary edema or acute coronary syndrome. Conclusions: A simplified pulmonary assessment using ultrasound provides relevant information about pulmonary congestion in hemodialysis patients and identifies patients at risk of hospitalization for heart-related problems.

Importance of Extra-Cardiac Manifestations of Right Heart Failure Using Bedside Ultrasound

Organ ischemia in the context of right ventricular dysfunction are the result of the profound hemodynamic alterations caused by a decrease in cardiac output and an elevation in central venous pressure. Performing a focused extra-cardiac ultrasound examination can reveal the impact of right ventricular failure by identifying signs of venous congestion in distal organs and might provide clinically relevant information to personalise management.

Risk of de novo infection following acute kidney injury: A retrospective cohort study

Purpose: Recent studies suggest that acute kidney injury (AKI) can affect distant organ function and increase non‐renal complications. We determined whether AKI is associated with an increased risk of incident infections. Material and methods: We conducted a one‐year single‐center retrospective cohort study, excluding patients readmitted to the ICU or for <24 h, on chronic dialysis, and kidney transplant recipients. The primary outcome was the development of incident infections analyzed by multivariate time‐dependent Cox models. Results: Of the 1001 included patients, infections were more frequent in those with AKI (62% vs. 37% without AKI; p < .001). To characterize predictors of incident infections, we excluded patients with an infection until ICU admission (n = 244). Patients with AKI presented infections more often than without AKI (44% vs. 20%; p < .001). AKI, chronic obstructive pulmonary disease, and mechanical ventilation (MV) were associated with incident infections (HR 1.62, 95%CI:1.15–2.30, HR 1.51, 95%CI 1.04–2.18 and HR 2.14, 95%CI:1.48–3.09, respectively) while age, MV, higher fluid balance, and AKI were independent predictors of mortality. Conclusions: AKI was associated with incident in‐hospital infections. However, newly occurring infections were not associated with an increased risk of mortality. Further studies are needed to understand how AKI affects distant organ function and associated clinical outcomes.

Doppler Renal Resistance Index for the Prediction of Response to Passive Leg‐Raising Following Cardiac Surgery

Doppler‐based renal resistance index (RI) can be measured at the bedside of critically ill patients. This study was designed to assess if the RI predicted an increase in cardiac output (CO) following passive leg‐raising (PLR) in patients admitted to the intensive care unit after cardiac surgery.

Noninvasive Administration of Inhaled Nitric Oxide and its Hemodynamic Effects in Patients With Acute Right Ventricular Dysfunction

OBJECTIVE The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach. DESIGN Retrospective cohort study. SETTING Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017. PARTICIPANTS All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation. INTERVENTION Noninvasive administration of iNO. MEASUREMENTS AND MAIN RESULTS Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm5 (n = 7; p < 0.001), mean pulmonary artery pressure from 28.4 to 25.3 mmHg (n = 8; p = 0.01), and central venous pressure from 17.5 to 13.1 mmHg (n = 16; p = 0.001). Indexed cardiac output increased from 2.0 to 2.6 L/min/m2 (n = 9; p = 0.004). ICU mortality was 27.78%, and median ICU length of stay was 7 (5-9) days. Two significant bleeding episodes requiring intervention and 1 acute kidney injury occurred during iNO therapy. No headache was reported. CONCLUSION Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.

Acute Kidney Injury Due to Inferior Vena Cava Stenosis After Liver Transplantation: A Case Report About the Importance of Hepatic Vein Doppler Ultrasound and Clinical Assessment

Rationale: Acute kidney injury (AKI) is a frequent complication after liver transplantation. In some patients, prompt intervention targeted at a specific etiology is of paramount importance. Presenting concerns of the patients: A 25 years old man with advanced liver cirrhosis caused by sclerosing cholangitis and autoimmune hepatitis underwent orthotopic liver transplantation. One month after surgery, severe AKI developed in conjunction with recurrent ascites and lower extremity edema. Notable clinical findings included a persistently low urinary sodium excretion, a bland urinary sediment, and an abnormally monophasic hepatic vein waveform on Doppler ultrasound. Diagnoses: Inferior vena cava stenosis. Interventions: Angioplasty with stent installation. Outcomes: Rapid improvement of renal function after stent installation. Lessons learned: The following case illustrates the importance of integrating clinical cues, ultrasound features, and laboratory findings. The combination of AKI associated with lower extremity edema, abnormal monophasic hepatic vein flow on Doppler ultrasound, and a low urinary sodium excretion after liver transplantation should evoke the possibility of inferior vena cava stenosis as the etiologic factor.