Jugular vein distensibility predicts fluid responsiveness in septic patients.

INTRODUCTION: The purpose of the study was to verify the efficacy of using internal jugular vein (IJV) size and distensibility as a reliable index of fluid responsiveness in mechanically ventilated patients with sepsis. METHODS: Hemodynamic data of mechanically ventilated patients with sepsis were collected through a radial arterial indwelling catheter connected to continuous hemodynamic monitoring system (Most Care®, Vytech Health, Padova, Italy), including cardiac index (CI) (L/min/M(2)), heart rate (beats/min), mean arterial pressure (MAP) (mmHg), central venous pressure (CVP) (mmHg) and arterial pulse pressure variation (PPV), coupled with ultrasound evaluation of IJV distensibility (%), defined as a ratio of the difference between IJV maximal antero-posterior diameter during inspiration and minimum expiratory diameter to minimum expiratory diameter x100. Patients were retrospectively divided into two groups; fluid responders (R), if CI increase of more than or equal to 15% after a 7 ml/kg crystalloid infusion, and non-responders (NR) if CI increased more than 15%. We compared differences in measured variables between R and NR groups and calculated receiver-operator-characteristic (ROC) curves of optimal IJV distensibility and PPV sensitivity and specificity to predicting R. We also calculated a combined inferior vena cava distensibility-PPV ROC curve to predict R. RESULTS: We enrolled 50 patients, of these, 30 were R. Responders presented higher IJV distensibility and PPV before fluid challenge than NR (P <0.05). An IJV distensibility more than 18% prior to volume challenge had an 80% sensitivity and 85% specificity to predict R. Pairwise comparison between IJV distensibility and PPV ROC curves revealed similar ROC area under the curve results. Interestingly, combining IJV distensibility more than 9.7% and PPV more than 12% predicted fluid responsiveness with a sensitivity of 100% and specificity of 95%. CONCLUSION: IJV distensibility is an accurate, easily acquired non-invasive parameter of fluid responsiveness in mechanically ventilated septic patients with performance similar to PPV. The combined use of IJV distensibility with left-sided indexes of fluid responsiveness improves their predictive value.

Beta-adrenergic antagonists improve oxygen saturation in acute pulmonary edema: a case series in the prehospital setting.

The use of beta-adrenergic antagonists in acute heart failure is controversial. In this case series, we report the use of intravenous atenolol, a short-acting cardioselective beta-adrenergic antagonist, to treat acute pulmonary edema in the prehospital setting. Four patients with a documented history of cardiac disease and one patient with unknown cardiac issues experienced severe respiratory distress and presented with pulmonary edema; the local emergency medical service was utilized. In all of the patients, the saturation of peripheral oxygen (SpO2) was severely low, and the patients were rapidly treated with oxygen, diuretics, morphine, and nitrates. However, only a small increase in oxygen saturation was observed. Intravenous atenolol was administered and led to a dramatic increase in SpO2. In our case series, we observed the positive effect of early treatment with short-acting beta-adrenergic antagonists on the recovery of rapid oxygen delivery in severely hypoxemic patients.