Central venous pressure and ultrasonographic measurement correlation and their associations with intradialytic adverse events in hospitalized patients: A prospective observational study.

PURPOSE: To investigate correlation of central venous pressure (CVP) with ultrasonographic measurement of central veins, along with association between these variables and occurrence of intradialytic adverse events in hospitalized patients. MATERIALS AND METHODS: Patients requiring hemodialysis via dialysis catheter were prospectively enrolled. CVP measurements through catheter, internal jugular vein aspect ratio, subclavian vein collapsibility, inferior vena cava (IVC) maximal diameter, and IVC collapsibility were recorded before and after hemodialysis. Predictive accuracy of ultrasonographic measurements in discriminating high versus low CVP and their association with intradialytic adverse events were evaluated. Area under receiver operating characteristic curves (AUCs) were calculated. RESULTS: Fifty-nine patients were enrolled. Median (interquartile range) pre- and post-dialysis CVPs were 8 (4-13)mmHg and 6 (3-10)mmHg, respectively (P<0.01). In pre-dialysis, IVC collapsibility had the highest AUC (0.79, P<0.01) to predict CVP >8mmHg. In post-dialysis, IVC maximal diameter had the highest AUC (0.86, P<0.01) to predict CVP ≤4mmHg. Fifteen patients (25%) had adverse events. Neither pre-dialytic CVP nor ultrasonographic variables were associated with occurrence of adverse events. CONCLUSIONS: Highest accuracy in predicting low and high CVP was observed with ultrasonographic assessment of IVC diameter and collapsibility. Adverse events were not predicted by pre-dialytic CVP or ultrasonographic measurements.

Unplanned transfers to the intensive care unit: the role of the shock index.

BACKGROUND: Unplanned (unexpected) transfers to the intensive care unit (ICU) are typically preceded by physiologic instability. However, trends toward instability may be subtle and not accurately reflected by changes in vital signs. The shock index (SI) (heart rate/systolic blood pressure as an indicator of left ventricular function, reference value of 0.54) may be a simple alternative means to predict clinical deterioration. OBJECTIVE: To assess the association of the SI with unplanned ICU transfers. DESIGN: Retrospective case-control study. SETTING: Academic medical center. PATIENTS: Fifty consecutive general medical patients with unplanned ICU transfers between 2003 and 2004 and 50 matched controls admitted to the same general medical unit between 2002 and 2004. MEASUREMENTS: Demographic data and vital signs abstracted from chart review. RESULTS: The SI was associated with unplanned ICU transfer at values of 0.85 or greater (P < 0.02; odds ratio, 3.0) and there was a significant difference between the median of worst shock indices of cases and controls (0.87 vs. 0.72; P < 0.005). There was no significant difference in age, race, admission ward, or Charlson Comorbidity Index, but hospital stay for cases was significantly longer (mean [standard deviation, SD], 14.8 [9.7] days vs. 5.7 [6.3] days; P < 0.001). CONCLUSIONS: SI is associated with unplanned transfers to the ICU from general medical units at values of 0.85 or greater. Future studies will determine whether SI is more accurate than simple vital signs as an indicator of clinical decline. If so, it may be a useful trigger to activate medical emergency or rapid response teams (RRTs).

Sequelae of a left-sided parietal stroke: posterior alien hand syndrome.

Posterior alien hand syndrome is a new addition to a poorly understood group of movement disorders. Historically, anatomical lesions causing uncontrolled limb movement and a feeling of foreignness were found to be located in the corpus callosum or frontal lobe. Recent case reports, however, demonstrate the typical symptoms of alien hand syndrome with lesions located in the parietal/occipital lobes. Disturbance of normal function in these regions tends to produce less complex motor activity, such as hand levitation, along with a sensory component characterized by feeling of estrangement. We discuss a patient who presented with unusual symptoms following an outpatient procedure and was found to have posterior alien hand syndrome.

Diagnostic accuracy of a simple ultrasound measurement to estimate central venous pressure in spontaneously breathing, critically ill patients.

BACKGROUND: Early goal-directed therapy for severe sepsis or septic shock improves outcomes but requires placement of a central venous catheter to measure central venous pressure (CVP), which may delay timely resuscitation and cause catheter-related complications. In addition, nonintensivists may not start early aggressive fluid resuscitation because of difficulty estimating CVP and concerns for inadvertent volume overload. OBJECTIVE: To determine if the CVP target of 8 to 12 mm Hg can be accurately assessed using noninvasive ultrasound to measure the internal jugular vein aspect ratio (height/width). DESIGN: Prospective observational study. SETTING: Two academic medical centers. PARTICIPANTS: Nineteen euvolemic volunteers and a convenience sample of 44 spontaneously breathing, critically ill patients. MEASUREMENTS: Ultrasound imaging of internal jugular vein aspect ratio; invasive CVP measurement in critically ill patients. RESULTS: For the volunteers, mean (standard deviation [SD]) aspect ratio of both the right and left internal jugular vein was 0.82 (0.07). Bland-Altman analysis indicated moderate intraobserver and interobserver agreement. Aspect ratio was similar for right and left sides and between men and women. In the critically ill patients, ultrasound accurately estimated a CVP of 8 mm Hg; area under the receiver operating characteristics curve was 0.84. For an invasively measured CVP of <8 mm Hg, the likelihood ratio for a positive ultrasound test (aspect ratio <0.83) was 3.5 and for a negative test (aspect ratio > or =0.83) was 0.30. CONCLUSIONS: In this exploratory study, noninvasive ultrasound imaging of internal jugular vein aspect ratio accurately estimated a CVP of 8 mm Hg in spontaneously breathing, critically ill patients.

Home alone: assessing mobility independence before discharge.

Hospitalists are often confronted with discharge planning responsibility and decisions for elderly patients who live alone. The absence of an in-home helper (spouse, partner, or care-giver) reduces the margin of safety and resilience to any new debility. Research has documented that during hospital stays elderly patients tend to become deconditioned, even if there is no new specific neurologic or motor deficit. In the patient whose pre-hospital mobility independence is not robust, and perhaps marginally compensated, inpatient stays for any diagnosis may result in critical decrements in mobility independence. The present study is an effort to design a bedside tool for the hospitalist by which to discern, or screen, for such debility. The tool is a hierarchical performance test we named I-MOVE (Independent Mobility Validation Examination). It is a quick series of bedside mobility requests to demonstrate capability of fundamental movements critical to independent living. We describe manner in which I-MOVE can be performed. Moreover, we describe the face validity and the high interrater reliability (> 0.90 intra-class correlation coefficient) of two RNs who independently administered and scored I-MOVE for 41 patients on a General Medical Care Unit. Although not yet studied in correlation with outcomes, nor with validated mobility assessment tools, we believe I-MOVE can serve as a useful extension of the nurse's assessment, or the Hospitalist's physical examination. Discerning the continued capability of mobility independence is a desirable, on-going insight for discharge planning of the elderly patient who resides alone.