Point-of-Care Echocardiography Improves Assessment of Volume Status in Cirrhosis and Hepatorenal Syndrome

Huggins, J. Terrill; Doelken, Peter; Walters, Christian; Rockey, Don C.

doi:10.1097/maj.0000000000000458

Cited by 5 publications

(10 citation statements)

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“…Physical examination and invasive measurements, such as central venous pressure, often do not reflect intravascular volume status. Point-of-care echocardiography can be effective in guiding the timing of large volume abdominal paracentesis and optimizing the hemodynamic status in decompensated cirrhotic patients with AKI, which in turn can improve venous return and promote recovery of renal function[ 254 ].…”

Section: Body Fluid Balance In Severe Chronic or Acute Illnessmentioning

confidence: 99%

Fluid balance concepts in medicine: Principles and practice

Roumelioti¹,

Glew²,

Khitan³

et al. 2018

WJN

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The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.

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Section: Body Fluid Balance In Severe Chronic or Acute Illnessmentioning

confidence: 99%

Fluid balance concepts in medicine: Principles and practice

Roumelioti¹,

Glew²,

Khitan³

et al. 2018

WJN

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“…Ultrasound can be used to reliably detect increases in volume following successful resuscitation. [39][40][41][42] Finally, patients with acute decompensated heart failure require strict intravascular fluid monitoring. Krishnan et al [43] showed that providers could use ultrasound evaluation of the IVC diameter to predict a patient's response to diuretics independent of his/her baseline renal function.…”

Section: Assessment Of Corrected Fl Ow Timementioning

confidence: 99%

The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients

Pourmand¹,

Pyle²,

Yamane³

et al. 2019

World Journal of Emergency Medicine

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BACKGROUND: Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefi t from volume resuscitation. DATA RESOURCES: We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient's cardiovascular ability to respond to intravenous fl uid administration using ultrasound. RESULTS: Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients. CONCLUSION: Ultrasound in combination with passive leg raise is a non-invasive, costand time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.

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“…In case of critically ill patients with liver disease who present with shock, a screening evaluation is performed by the primary physician to determine the specific flow dynamics of the hypotensive state, but an expert cardiology evaluation is essential to manage a cardiac condition contributing to multifactorial shock. The use of TTE is to determine intravascular volume status using inferior vena cava (IVC) dynamics, differentiate between pre-renal acute kidney injury (AKI) and hepatorenal syndrome (HRS) and evaluate the preload during transfusion of blood components 4 –7 Critical care POC ultrasound (POCUS) consists of a combination of skills including abdominal ultrasound, thoracic ultrasonography (lungs and pleural), vascular ultrasonography and critical care TTE. 8,9 There is increasing evidence and cost-effectiveness analysis that telemedicine in the liver intensive care unit (Tele-ICU) and liver transplantation can improve patient-centric care while protecting health care personnel.…”

Section: Introductionmentioning

confidence: 99%

“…30,31 In patients with cirrhosis, an IVCCI >40% best correlates with CVP <10 mmHg and such patients are usually fluid depleted. 4 Even in patients with AKI, it has been shown that IVC guided fluids lead to better renal outcomes at 48 hrs. 32 Table 2 shows a simple bedside volume status assessment tool which we developed for use in our Liver Unit using the IVC dynamics.…”

Section: Introductionmentioning

confidence: 99%

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Premkumar

Kajal

Kulkarni

et al. 2021

J Intensive Care Med

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Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

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Point-of-Care Echocardiography Improves Assessment of Volume Status in Cirrhosis and Hepatorenal Syndrome

Cited by 5 publications

References 0 publications

Fluid balance concepts in medicine: Principles and practice

Fluid balance concepts in medicine: Principles and practice

The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

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