Porto-splenic pulsatility in cardiac surgical patients: a promising novel and clinically useful sign of renal congestion from fluid overload.
CCCF ePoster library. Beaubien-Souligny W. Oct 26, 2015; 117311; P9
Dr. William Beaubien-Souligny
Dr. William Beaubien-Souligny
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Abstract
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P9


Topic: Case Report


Porto-splenic pulsatility in cardiac surgical patients: a promising novel and clinically useful sign of renal congestion from fluid overload.



William Beaubien-Souligny, R. Eljaiek, J. Bouchard, G. Desjardins, M. Elmi-Sarabi, A. Chronopoulos, Y. Lamarche, J. Lambert, I. El-Hamamsy, A. Denault

Nephrology, Montreal heart institute, Montreal, Canada | Intensive care, Université de Montréal, Montréal, Canada | Nephrology, Hôpital Sacré-Coeur de Montréal, Montreal, Canada | Anesthesiology, Montreal heart institute, Montreal, Canada | Anesthesiology, Université de montréal, Montreal, Canada | Intensive Care, Montreal Heart Institute, Montreal, Canada | Intensive Care, Montreal Heart Institute, Montreal, Canada | Biostatistics, Université de Montréal, Montréal, Canada | Caridac surgery, Montreal Heart Institute, Montreal, Canada | Anesthesiology, intensive care, Montreal heart institute, Montréal, Canada

Introduction: Acute kidney injury (AKI) is a frequent complication in the setting of cardiac surgery involving cardiopulmonary bypass. Fluid administration had been used to optimize cardiac output but the progressive increase in interstitial pressure can have a negative impact on organ function. In observational studies in critically ill patients, positive fluid balance has been associated with AKI.1, 2, 3 New tools are currently needed to adequately assess venous congestion in order to avoid excessive intravenous fluid administration. Portal vein pulsatility has been described as a marker of congestive heart failure and correlates with elevated RAP and worse New York Heart Association functional class.4, 5 Bedside assessment of the portal flow in a critical care setting following cardiac surgery has never been studied and could potentially be used for the early detection of hypervolemia in this setting.

Objectives: This case series describes our preliminary experience using bedside Doppler ultrasound and intra-operative transesophageal echocardiography to assess portal and splenic vein pulsatility as signs of fluid overload and AKI in patients undergoing cardiac surgery .

Methods: This is a retrospective observational study performed in patients undergoing cardiac surgery at the Montreal Heart Institute between February 2014 and February 2015. Consent is obtained from all patients pre-operatively for the use of clinical data and ultrasound images collected during the peri-operative period. Data collection was done retrospectively by reviewing intra- operative and post-operative monitoring documents. Porto-splenic venous flow ultrasound assessment was performed by anesthesiologists and intensivists with National Board Certification in TEE and critical care ultrasound certification from the ACCP. Portal and splenic pulsatility was defined as a pulsatility fraction of 30% or more. Continuous variables are presented as median and interquartile range (IQR) and compared using t-test or Mann-Whitney U test, where appropriate. Categorical variables are presented as proportions and compared using x2 test. The creatinine/net fluid balance relationship over time after pulsatility detection was assessed by linear mixed models while controlling for baseline creatinine. Quadratic relationships, interactions and the association with CVP were tested.


Results: Portal or splenic vein interrogation was performed in 14 critically ill patients including 8 males and 6 females ranging from 32 to 85 year-old. These patients underwent coronary revascularizations (n=2), cardiac transplantation (n=3), left ventricular assist device installation (n=1), tricuspid valve replacement (n=2), aortic valve replacement (n=6). Ninety-three percent of patients had AKI defined as AKIN stage 1 to 3. After splanchnic pulsatility was documented, negative fluid balance was acheived in 13 patients. The mean total fluid balance was -6.5 ± 1.8 L after splanchnic pulsatility was documented during the ICU stay, with daily fluid balance ranging between -0.39 to -2.8 L. (Table 1) In patients who did not receive CVVHDF, serum creatinine decreased by a mean of 8 umol/L per day (p=0.03) after the detection of splanchic pulsatility. During this time period, serum creatinine decreased by 6 umol/L per liter of negative fluid balance (p=0.07). There was no association or interaction found with measured CVP. A selected case is presented in Figure 2.


Conclusion:

In this case series, we described that hepatosplenic vein pulsatility using bedside ultrasound could be an important sign of fluid overload in cardiac surgery patients and could be used to individualize fluid management. This approach should be studied prospectively to assess if it could reduce the incidence and the severity of AKI in this population.



References:
  1. Payen, D., et al., A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care, 2008. 12(3): p. R74.
  2. Bouchard, J., et al., Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int, 2009. 76(4): p. 422-7.
  3. Mullens, W., et al., Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol, 2009. 53(7): p. 589-96.
  4. Duerinckx, A.J., et al., The pulsatile portal vein in cases of congestive heart failure: correlation of duplex Doppler findings with right atrial pressures. Radiology, 1990. 176(3): p. 655-8.
  5. Catalano, D., et al., Portal vein pulsatility ratio and heart failure. J Clin Ultrasound, 1998. 26(1): p. 27-31.
  6. Denault AY, C.P., Lamarche Y, Tardif JC, Vegas A., Basic transesophageal and critical care ultrasound. CRC Press, 2015.
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