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Intraoperative TTE inferior vena cava monitoring in elderly orthopaedic patients with cardiac disease and spinal-induced hypotension

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Abstract

Objective To address the role of transthoracic echocardiography in inferior vena cava (IVC) monitoring in the management of haemodynamically unstable elderly patients subjected to lower limb orthopaedic surgery under spinal anesthesia. Possible implications in the postoperative care unit (PACU) length of stay (LOS) are investigated. Methods 41 elderly patients with cardiac diseases were recruited. Patients experiencing intraoperative haemodynamic instability (diastolic blood pressure ≤ 60 mmHg) were divided into two groups according to right atrial pressure (RAP), (RAP < 5 mmHg and RAP between 5 and 10 mmHg) as measured by inferior vena cava collapsibility index (IVCCI). Haemodynamic instability was treated with normal saline infused at a constant rate supplemented by phenylephrine (PHE) infusions titrated to normal blood pressure values. Intraoperatively comparisons of peak PHE infusion rates and all episodes of hypotension, including in the PACU, were recorded among groups. The patients’ PACU LOS and associated factors were assessed. Results The intraoperative peak PHE infusion rate and the incidence of haemodynamic instability in the postoperative period were significantly higher in patients with RAP < 5 mmHg. The total PHE consumption was also higher in patients with RAP < 5 mmHg postoperatively. The primary risk factor for a prolonged stay in PACU, as determined by multiple regression analysis was RAP. Conclusions Patients with high dynamic collapsibility of the IVC may require aggressive treatment to restore their haemodynamic status. Additionally, intraoperative levels of RAP, as measured by IVCCI, can act as a predictor for increased LOS in the PACU.

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Abbreviations

ACC:

American college of cardiology

AHA:

American heart association

BMI:

Body mass index

CVP:

Central venous pressure

DBP:

Diastolic blood pressure

EF:

Ejection fraction

E:

Expiration

HR:

Heart rate

IVC:

Inferior vena cava

I:

Inspiration

IVCCI:

Inferior vena cava collapsibility index

LV:

Left ventricle

LOS:

Length of stay

NYHA:

New York heart association

PACU:

Post-anesthesia care unit

PHE:

Phenylephrine

PONV:

Postoperative nausea and vomiting

RAP:

Right atrial pressures

RV:

Right ventricle

TAPSE:

Tricuspid annular plane systolic excursion

TTE:

Transthoracic echocardiography

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Authors and Affiliations

  1. Second Department of Anesthesiology, Athens University Medical School, Athens, Greece

    Theodosios Saranteas, Dimitrios Manikis & Georgia Kostopanagiotou

  2. First Department of Orthopaedics, Athens University Medical School, Athens, Greece

    Andreas F. Mavrogenis

  3. Second Department of Cardiology, Athens University Medical School, Athens, Greece

    Fotios Panou

  4. Department of Anesthesiology, The Ohio State University, Weaxner Medical Center, Columbus, OH, USA

    Thomas Papadimos

  5. 14, Kerdillion Str, Gerakas, Athens, Greece

    Theodosios Saranteas

Authors
  1. Theodosios Saranteas
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  2. Dimitrios Manikis
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  3. Thomas Papadimos
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  4. Andreas F. Mavrogenis
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  5. Georgia Kostopanagiotou
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  6. Fotios Panou
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Correspondence to Theodosios Saranteas.

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No benefits have been or will be received from a commercial party related directly or indirectly to the subject matter of this article. We wish also to confirm that there is no financial support for this work that could have influenced its outcome.

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Saranteas, T., Manikis, D., Papadimos, T. et al. Intraoperative TTE inferior vena cava monitoring in elderly orthopaedic patients with cardiac disease and spinal-induced hypotension. J Clin Monit Comput 31, 919–926 (2017). https://doi.org/10.1007/s10877-016-9922-9

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  • DOI: https://doi.org/10.1007/s10877-016-9922-9

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