Physiology and clinical utility of the peripheral venous waveform

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Abstract

The peripheral venous system serves as a volume reservoir due to its high compliance and can yield information on intravascular volume status. Peripheral venous waveforms can be captured by direct transduction through a peripheral catheter, non-invasive piezoelectric transduction, or gleaned from other waveforms such as the plethysmograph. Older analysis techniques relied upon pressure waveforms such as peripheral venous pressure and central venous pressure as a means of evaluating fluid responsiveness. Newer peripheral venous waveform analysis techniques exist in both the time and frequency domains, and have been applied to various clinical scenarios including hypovolemia (i.e. hemorrhage, dehydration) and volume overload.

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Most cited references 27

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Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense.

Paul E Marik, Rodrigo Cavallazzi (2013)

Despite a previous meta-analysis that concluded that central venous pressure should not be used to make clinical decisions regarding fluid management, central venous pressure continues to be recommended for this purpose. To perform an updated meta-analysis incorporating recent studies that investigated indices predictive of fluid responsiveness. A priori subgroup analysis was planned according to the location where the study was performed (ICU or operating room). MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Clinical trials that reported the correlation coefficient or area under the receiver operating characteristic curve (AUC) between the central venous pressure and change in cardiac performance following an intervention that altered cardiac preload. From 191 articles screened, 43 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, and included healthy controls (n = 1) and ICU (n = 22) and operating room (n = 20) patients. Data were abstracted on study characteristics, patient population, baseline central venous pressure, the correlation coefficient, and/or the AUC between central venous pressure and change in stroke volume index/cardiac index and the percentage of fluid responders. Meta-analytic techniques were used to summarize the data. Overall 57% ± 13% of patients were fluid responders. The summary AUC was 0.56 (95% CI, 0.54-0.58) with no heterogenicity between studies. The summary AUC was 0.56 (95% CI, 0.52-0.60) for those studies done in the ICU and 0.56 (95% CI, 0.54-0.58) for those done in the operating room. The summary correlation coefficient between the baseline central venous pressure and change in stroke volume index/cardiac index was 0.18 (95% CI, 0.1-0.25), being 0.28 (95% CI, 0.16-0.40) in the ICU patients, and 0.11 (95% CI, 0.02-0.21) in the operating room patients. There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned.

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Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre.

M Cannesson, O Desebbe, P Rosamel … (2008)

Respiratory variations in pulse oximetry plethysmographic waveform amplitude (DeltaPOP) can predict fluid responsiveness in mechanically ventilated patients but cannot be easily assessed at the bedside. Pleth variability index (PVI) is a new algorithm allowing for automated and continuous monitoring of DeltaPOP. We hypothesized that PVI can predict fluid responsiveness in mechanically ventilated patients under general anaesthesia. Twenty-five patients were studied after induction of general anaesthesia. Haemodynamic data [cardiac index (CI), respiratory variations in arterial pulse pressure (DeltaPP), DeltaPOP, and PVI] were recorded before and after volume expansion (500 ml of hetastarch 6%). Fluid responsiveness was defined as an increase in CI > or =15%. Volume expansion induced changes in CI [2.0 (sd 0.9) to 2.5 (1.2) litre min(-1) m(-2); P 14% before volume expansion discriminated between responders and non-responders with 81% sensitivity and 100% specificity. There was a significant relationship between PVI before volume expansion and change in CI after volume expansion (r=0.67; P<0.01). PVI, an automatic and continuous monitor of DeltaPOP, can predict fluid responsiveness non-invasively in mechanically ventilated patients during general anaesthesia. This index has potential clinical applications.

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A Systematic Review of the Relationship between Blood Loss and Clinical Signs

Rodolfo Pacagnella, João Souza, Jill Durocher … (2013)

Introduction This systematic review examines the relationship between blood loss and clinical signs and explores its use to trigger clinical interventions in the management of obstetric haemorrhage. Methods A systematic review of the literature was carried out using a comprehensive search strategy to identify studies presenting data on the relationship of clinical signs & symptoms and blood loss. Methodological quality was assessed using the STROBE checklist and the general guidelines of MOOSE. Results 30 studies were included and five were performed in women with pregnancy-related haemorrhage (other studies were carried in non-obstetric populations). Heart rate (HR), systolic blood pressure (SBP) and shock index were the parameters most frequently studied. An association between blood loss and HR changes was observed in 22 out of 24 studies, and between blood loss and SBP was observed in 17 out of 23 studies. An association was found in all papers reporting on the relationship of shock index and blood loss. Seven studies have used Receiver Operating Characteristic Curves to determine the accuracy of clinical signs in predicting blood loss. In those studies the AUC ranged from 0.56 to 0.74 for HR, from 0.56 to 0.79 for SBP and from 0.77 to 0.84 for shock index. In some studies, HR, SBP and shock index were associated with increased mortality. Conclusion We found a substantial variability in the relationship between blood loss and clinical signs, making it difficult to establish specific cut-off points for clinical signs that could be used as triggers for clinical interventions. However, the shock index can be an accurate indicator of compensatory changes in the cardiovascular system due to blood loss. Considering that most of the evidence included in this systematic review is derived from studies in non-obstetric populations, further research on the use of the shock index in obstetric populations is needed.

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Journal

Journal ID (nlm-ta): JRSM Cardiovasc Dis

Journal ID (iso-abbrev): JRSM Cardiovasc Dis

Journal ID (publisher-id): CVD

Journal ID (hwp): spcvd

Title: JRSM Cardiovascular Disease

Publisher: SAGE Publications (Sage UK: London, England )

ISSN (Electronic): 2048-0040

Publication date (Electronic): 28 October 2020

Publication date Collection: Jan-Dec 2020

Volume: 9

Electronic Location Identifier: 2048004020970038

Affiliations

[1 ]Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA

[2 ]Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, Nashville TN, USA

[3 ]Department of Anesthesiology, Division of Pediatric Anesthesiology, Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville TN, USA

[4 ]Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville TN, USA

[5 ]Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

Author notes

[*]Devin Chang, Vanderbilt University Medical Center, Vanderbilt University, S111 Medical Center North, 21st Ave South, Nashville, TN 37212, USA. Email: devin.j.chang@ 123456vanderbilt.edu

Author information

Devin Chang https://orcid.org/0000-0001-7943-5469

Monica Polcz https://orcid.org/0000-0001-8744-5982

Article

Publisher ID: 10.1177_2048004020970038

DOI: 10.1177/2048004020970038

PMC ID: 7605016

PubMed ID: 33194174

SO-VID: 21a9bacc-1645-4249-9e60-c857082377a8

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Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License ( https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

History

Date received : 5 June 2020

Date revision received : 1 October 2020

Date accepted : 11 October 2020

Funding

Funded by: National Institutes of Health, FundRef https://doi.org/10.13039/100000002;

Award ID: 5F32HL140849-02,

Award ID: R01HL148244

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cover-date January-December 2020

typesetter ts2

Keywords: peripheral venous pressure,waveform analysis,vascular,hemodynamic monitoring

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Keywords: peripheral venous pressure, waveform analysis, vascular, hemodynamic monitoring

Physiology and clinical utility of the peripheral venous waveform

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Vascular Biology

Most cited references 27

Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense.

Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre.

A Systematic Review of the Relationship between Blood Loss and Clinical Signs

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