MAHWASH SAEED, JACQUES RIZKALLAH, MEGAN JACK, LEIGH ANNE SHAFER, JAMES TAM Non Invasive Bedside...
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Transcript of MAHWASH SAEED, JACQUES RIZKALLAH, MEGAN JACK, LEIGH ANNE SHAFER, JAMES TAM Non Invasive Bedside...
Mahwash Saeed, Jacques Rizkallah, Megan Jack, Leigh Anne Shafer, James Tam
Non Invasive Bedside Assessment of Right Atrial Pressure;
Scanning into the Future
disclosures
• None.
Right Atrial Pressure
• Noninvasive bedside physical examination of volume status is a common clinical skill taught to medical students early in their training
• Right atrial pressure (RAP) is used as a surrogate for central venous pressure and overall volume status
RAP: Evaluation
• Noninvasive evaluation of RAP can be achieved by the following techniques:
• Jugular Venous Pressure (JVP)
• Peripheral Venous Collapse (PVC)
• Ultrasound visualization of the inferior vena cava (IVC)
JVP: Limitations
• The JVP examination is a practical clinical tool, however it can be very difficult to assess in certain individuals
• obesity • anomalous venous anatomy• connective tissue diseases• venous scarring from catheter insertion
• In such patients, alternative methods may be helpful, although not systematically validated
RAP Estimation: Alternative Techniques
•PVC, IVC collapse
• The relative accuracy of these techniques, compared to one another, and their application by trainees of varying experience remains uncertain
Objectives
• We compared the utility of the JVP, PVC, and bedside mini echo (BME) as non-invasive RAP clinical predictive tools amongst trainees of varying experience
Methods
• A 2nd year medical student, 2nd year medical resident, and 2nd year cardiology fellow examined patients presenting for outpatient and inpatient echocardiogram at a tertiary care hospital
Methods
• Inclusion Criteria
• Patients receiving scheduled echo at St Boniface Hospital in Winnipeg, MB
• Patient able to give informed consent
Methods
• Exclusion Criteria
• Patients with intravenous catheters (IV) or recent IV insertions within the last 2 weeks in the right arm or neck veins
• Patients with a history of intravenous drug use
• Patients who could not give informed consent, including those with language barrier
Methods
• Patients were examined for JVP and PVC by all three examiners
• BME (without JVP/PVC) was utilized (after 10 hours of instruction) by the student in another group of patients
• Bedside RAP estimates were then compared to measurements from a complete echo study by a trained sonographer read by a level 3 echocardiologist
JVP
Peripheral Vein Collapse
Anthem Sign
BEDSIDE MINI ECHO
Methods
• All patients underwent their regularly scheduled two dimensional echocardiographic examination
• The echo technologist and staff echocardiographer interpreting the study were not involved in the clinical assessment of the patients
• Assessment of the IVC by the echocardiographer was used as the gold standard for RAP estimates
Overall Patient Characteristics
Overall Patient Characteristics
SENSITIVITY OF PHYSICAL EXAM TECHNIQUES
Examiner 1
MED STUDEN
T(N= 217)
Examiner 2
MED RESIDEN
T(N= 58)
Examiner 3
CARDIO FELLOW(N= 49)
Examiner 1
BME
(N= 43)
P-Value
Sensitivity for detecting
increased CVP
JVP
PVCAnthem Sign
BME
13%
15%21%
n/a
53%
8%15%
n/a
86%
50%38%
n/a
n/a
n/an/a
100%
<0.01
0.020.35
n/a
PPV and NPV of Specific Exam Techniques
Examiner 1
MED STUDENT(N= 217
Examiner 2
MED RESIDEN
T(N= 58)
Examiner 3
CARDIO FELLOW(N= 49)
Examiner 1
BME
(N= 43)
PPV
JVPPVC
AnthemBME
39%35%39%n/a
47%25%29%n/a
44%38%50%n/a
n/an/an/a40%
NPV
JVPPVC
AnthemBME
75%73%74%n/a
75%71%72%n/a
91%80%78%n/a
n/an/an/a100%
PPV and NPV of Specific Exam Techniques in Obese Patients (BMI >30)
Results
• Of the physical exam maneuvers for detecting elevated RAP, the JVP was the most sensitive at 86%
• This improved with clinical experience
Results
• The PVC/anthem sign more useful for the early learner who has not mastered the JVP yet
• There was consistency in the sensitivity of the anthem sign which hints towards ease of use and reproducibility
Results
• The BME showed 100% sensitivity for detecting increased RAP
Conclusions
•The JVP was the most sensitive physical exam technique
•There may be an adjunctive role for the PVC and Anthem sign
• Helpful for early learner and in obese patients
Conclusions
• BME estimate of CVP is at least comparable to physical examination assessment and may require less instruction
• The use of BME in medical training should be further evaluated and encouraged
SCANNING INTO THE FUTURE…
Acknowledgements
St Boniface Echo staff
Photo models:• Rosalie Grant• Dr Anjala Chelvanathan• Dr Ali Bagherli• D Shelley Zieroth
Acknowledgements
• Dr Jacques Rizkallah• Dr James Tam• Megan Jack