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

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


Overall patient characteristics
Overall Patient Characteristics


Overall patient characteristics1
Overall Patient Characteristics





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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