Mahwash saeed jacques rizkallah megan jack leigh anne s hafer james tam
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Non Invasive Bedside Assessment of Right Atrial Pressure; Scanning into the Future. Mahwash Saeed, Jacques Rizkallah , Megan Jack , Leigh Anne S hafer, James Tam. disclosures. None. Right Atrial Pressure.

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Mahwash Saeed, Jacques Rizkallah , Megan Jack , Leigh Anne S hafer, James Tam

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Mahwash saeed jacques rizkallah megan jack leigh anne s hafer james tam

Non Invasive Bedside Assessment of Right Atrial Pressure;

Scanning into the Future

Mahwash Saeed, Jacques Rizkallah,

Megan Jack, Leigh Anne Shafer, James Tam


Disclosures

disclosures

  • None.


Right atrial pressure

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

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

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

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

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

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


Methods1

Methods

  • Inclusion Criteria

    • Patients receiving scheduled echo at

      St Boniface Hospital in Winnipeg, MB

    • Patient able to give informed consent


Methods2

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


Methods3

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


Mahwash saeed jacques rizkallah megan jack leigh anne s hafer james tam

JVP


Peripheral vein collapse

Peripheral Vein Collapse


Anthem sign

Anthem Sign


Bedside mini echo

BEDSIDE MINI ECHO


Methods4

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


Overall patient characteristics1

Overall Patient Characteristics


Mahwash saeed jacques rizkallah megan jack leigh anne s hafer james tam

SENSITIVITY OF PHYSICAL EXAM TECHNIQUES


Ppv and npv of specific exam techniques

PPV and NPV of Specific Exam Techniques


Ppv and npv of specific exam techniques in obese patients bmi 30

PPV and NPV of Specific Exam Techniques in Obese Patients (BMI >30)


Results

Results

  • Of the physical exam maneuvers for detecting elevated RAP, the JVP was the most sensitive at 86%

    • This improved with clinical experience


Results1

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


Results2

Results

  • The BME showed 100% sensitivity for detecting increased RAP


Conclusions

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


Conclusions1

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

SCANNING INTO THE FUTURE…


Acknowledgements

Acknowledgements

St Boniface Echo staff

Photo models:

  • Rosalie Grant

  • DrAnjalaChelvanathan

  • Dr Ali Bagherli

  • D Shelley Zieroth


Acknowledgements1

Acknowledgements

  • Dr Jacques Rizkallah

  • Dr James Tam

  • Megan Jack


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