The “CHEOPS” bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts’ opinion

Sanfilippo, Filippo; Messina, Antonio; Scolletta, Sabino; Bignami, Elena; Morelli, Andrea; Cecconi, Maurizio; Landoni, Giovanni; Romagnoli, Stefano

doi:10.1016/j.accpm.2023.101283

Cited by 11 publications

(2 citation statements)

References 94 publications

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“…[65][66][67] Considering all the pitfalls described for the assessment of DD in critically ill patients, we consider a more holistic approach to the dias-tolic function in the ICU more valuable. Experienced clinicians should integrate the hemodynamic information (based not only on echocardiographic variables) with other data from like lung ultrasound (LUS), the venous excess ultrasound (VExUS), and the ventriculo-arterial coupling, 68,69 to better stratify critically ill patients according to their pathophysiologic profile and prognostic impact. Briefly, LUS has been confirmed to be a rapid, noninvasive, and reproducible bedside tool to estimate the extravascular lung water, 70 and it is turning into a key component for determining the presence of pulmonary edema and estimating its severity in different clinical contexts 71,72 ; hence, it could help to understand whether there is a clinically relevant impact of increased LA pressure.…”

Section: Future Diagnostic Approaches To Lvdd and La Pressure In Icumentioning

confidence: 99%

“…Proposed algorithm for diastolic dysfunction classification and management for the critically ill patient. PALS-peak atrial longitudinal strain; VExUS-venous excess ultrasound; CHEOPS68 -Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable.…”

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Diastology in the intensive care unit: Challenges for the assessment and future directions

Gonzalez,

Santonocito,

Maybauer

et al. 2024

Echocardiography

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Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

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Section: Future Diagnostic Approaches To Lvdd and La Pressure In Icumentioning

confidence: 99%

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confidence: 99%

Diastology in the intensive care unit: Challenges for the assessment and future directions

Gonzalez,

Santonocito,

Maybauer

et al. 2024

Echocardiography

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Inferior vena cava distensibility during pressure support ventilation: a prospective study evaluating interchangeability of subcostal and trans‑hepatic views, with both M‑mode and automatic border tracing

Zawadka,

Santonocito,

Dezio

et al. 2024

J Clin Monit Comput

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The Inferior Vena Cava (IVC) is commonly utilized to evaluate fluid status in the Intensive Care Unit (ICU),with more recent emphasis on the study of venous congestion. It is predominantly measured via subcostal approach (SC) or trans-hepatic (TH) views, and automated border tracking (ABT) software has been introduced to facilitate its assessment. Prospective observational study on patients ventilated in pressure support ventilation (PSV) with 2 × 2 factorial design. Primary outcome was to evaluate interchangeability of measurements of the IVC and the distensibility index (DI) obtained using both M-mode and ABT, across both SC and TH. Statistical analyses comprised Bland–Altman assessments for mean bias, limits of agreement (LoA), and the Spearman correlation coefficients. IVC visualization was 100% successful via SC, while TH view was unattainable in 17.4% of cases. As compared to the M-mode, the IVC-DI obtained through ABT approach showed divergences in both SC (mean bias 5.9%, LoA -18.4% to 30.2%, ICC = 0.52) and TH window (mean bias 6.2%, LoA -8.0% to 20.4%, ICC = 0.67). When comparing the IVC-DI measures obtained in the two anatomical sites, accuracy improved with a mean bias of 1.9% (M-mode) and 1.1% (ABT), but LoA remained wide (M-mode: -13.7% to 17.5%; AI: -19.6% to 21.9%). Correlation was generally suboptimal (r = 0.43 to 0.60). In PSV ventilated patients, we found that IVC-DI calculated with M-mode is not interchangeable with ABT measurements. Moreover, the IVC-DI gathered from SC or TH view produces not comparable results, mainly in terms of precision.

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The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study

Sanfilippo,

Uryga,

Ball

et al. 2024

Neurocrit Care

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Background Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts. Methods The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO2). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs. Results Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8 mm Hg) and reduced CPP (ΔCPP = −12.8 mm Hg) and mean arterial pressure (difference in mean arterial pressure = −5.2 mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O2 = 4 mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO2 marginally decreased (ΔrSO2 = −0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = −0.1 cm; p < 0.001) with a tendency toward increased RV basal diameter (p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP (p = 0.040) and a larger RV basal diameter (p = 0.034) at baseline. Conclusions In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM’s impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.

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The “CHEOPS” bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts’ opinion

Cited by 11 publications

References 94 publications

Diastology in the intensive care unit: Challenges for the assessment and future directions

Diastology in the intensive care unit: Challenges for the assessment and future directions

Inferior vena cava distensibility during pressure support ventilation: a prospective study evaluating interchangeability of subcostal and trans‑hepatic views, with both M‑mode and automatic border tracing

The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study

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