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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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Non Invasive Bedside Assessment of Right Atrial Pressure; Scanning into the Future Mahwash Saeed, Jacques Rizkallah, Megan Jack, Leigh Anne Shafer, James Tam
disclosures • None.
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 • 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 • 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 • PVC, IVC collapse • The relative accuracy of these techniques, compared to one another, and their application by trainees of varying experience remains uncertain
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 • 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
Methods • Inclusion Criteria • Patients receiving scheduled echo at St Boniface Hospital in Winnipeg, MB • Patient able to give informed consent
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
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
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
PPV and NPV of Specific Exam Techniques in Obese Patients (BMI >30)
Results • Of the physical exam maneuvers for detecting elevated RAP, the JVP was the most sensitive at 86% • This improved with clinical experience
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
Results • The BME showed 100% sensitivity for detecting increased RAP
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
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 St Boniface Echo staff Photo models: • Rosalie Grant • DrAnjalaChelvanathan • Dr Ali Bagherli • D Shelley Zieroth
Acknowledgements • Dr Jacques Rizkallah • Dr James Tam • Megan Jack