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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

Non Invasive Bedside Assessment of Right Atrial Pressure;

Scanning into the Future

Mahwash Saeed, Jacques Rizkallah,

Megan Jack, Leigh Anne Shafer, James Tam

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
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
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
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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