Mahwash Saeed, Jacques Rizkallah, Megan Jack, Leigh Anne Shafer, James Tam
Non Invasive Bedside Assessment of Right Atrial Pressure;
Scanning into the Future
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
JVP
Peripheral Vein Collapse
Anthem Sign
BEDSIDE MINI ECHO
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
SENSITIVITY OF PHYSICAL EXAM TECHNIQUES
Examiner 1
MED STUDEN
T(N= 217)
Examiner 2
MED RESIDEN
T(N= 58)
Examiner 3
CARDIO FELLOW(N= 49)
Examiner 1
BME
(N= 43)
P-Value
Sensitivity for detecting
increased CVP
JVP
PVCAnthem Sign
BME
13%
15%21%
n/a
53%
8%15%
n/a
86%
50%38%
n/a
n/a
n/an/a
100%
<0.01
0.020.35
n/a
PPV and NPV of Specific Exam Techniques
Examiner 1
MED STUDENT(N= 217
Examiner 2
MED RESIDEN
T(N= 58)
Examiner 3
CARDIO FELLOW(N= 49)
Examiner 1
BME
(N= 43)
PPV
JVPPVC
AnthemBME
39%35%39%n/a
47%25%29%n/a
44%38%50%n/a
n/an/an/a40%
NPV
JVPPVC
AnthemBME
75%73%74%n/a
75%71%72%n/a
91%80%78%n/a
n/an/an/a100%
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
SCANNING INTO THE FUTURE…
Acknowledgements
St Boniface Echo staff
Photo models:• Rosalie Grant• Dr Anjala Chelvanathan• Dr Ali Bagherli• D Shelley Zieroth
Acknowledgements
• Dr Jacques Rizkallah• Dr James Tam• Megan Jack