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Determination of vascular waterfall phenomenon by bedside measurement of mean systemic filling pressure and critical closing pressure in the intensive care unit

Maas, JJ and De Wilde, RB and Aarts, LP and Pinsky, MR and Jansen, JR (2012) Determination of vascular waterfall phenomenon by bedside measurement of mean systemic filling pressure and critical closing pressure in the intensive care unit. Anesthesia and Analgesia, 114 (4). 803 - 810. ISSN 0003-2999

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BACKGROUND: Mean systemic filling pressure (Pmsf) can be determined at the bedside by measuring central venous pressure (Pcv) and cardiac output (CO) during inspiratory hold maneuvers. Critical closing pressure (Pcc) can be determined using the same method measuring arterial pressure (Pa) and CO. If Pcc > Pmsf, there is then a vascular waterfall. In this study, we assessed the existence of a waterfall and its implications for the calculation of vascular resistances by determining Pmsf and Pcc at the bedside. METHODS: In 10 mechanically ventilated postcardiac surgery patients, inspiratory hold maneuvers were performed, transiently increasing Pcv and decreasing Pa and CO to 4 different steady-state levels. For each patient, values of Pcv and CO were plotted in a venous return curve to determine Pmsf. Similarly, Pcc was determined with a ventricular output curve plotted for Pa and CO. Measurements were performed in each patient before and after volume expansion with 0.5 L colloid, and vascular resistances were calculated. RESULTS: For every patient, the relationship between the 4 measurements of Pcv and CO and of Pa and CO was linear. Baseline Pmsf was 18.7 ± 4.0 mm Hg (mean ± SD) and differed significantly from Pcc 45.5 ± 11.1 mm Hg (P < 0.0001). The difference of Pcc and Pmsf was 26.8 ± 10.7 mm Hg, indicating the presence of a systemic vascular waterfall. Volume expansion increased Pmsf (26.3 ± 3.2 mm Hg), Pcc (51.5 ± 9.0 mm Hg), and CO (5.5 ± 1.8 to 6.8 ± 1.8 L · min). Arterial (upstream of Pcc) and venous (downstream of Pmsf) vascular resistance were 8.27 ± 4.45 and 2.75 ± 1.23 mm Hg · min · L; the sum of both (11.01 mm Hg · min · L) was significantly different from total systemic vascular resistance (16.56 ± 8.57 mm Hg · min · L; P = 0.005). Arterial resistance was related to total resistance. CONCLUSIONS: Vascular pressure gradients in cardiac surgery patients suggest the presence of a vascular waterfall phenomenon, which is not affected by CO. Thus, measures of total systemic vascular resistance may become irrelevant in assessing systemic vasomotor tone. Copyright © 2012 International Anesthesia Research Society.


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Item Type: Article
Status: Published
CreatorsEmailPitt UsernameORCID
Maas, JJ
De Wilde, RB
Aarts, LP
Pinsky, MRpinsky@pitt.eduPINSKY0000-0001-6166-700X
Jansen, JR
Centers: Other Centers, Institutes, Offices, or Units > McGowan Institute for Regenerative Medicine
Date: 1 April 2012
Date Type: Publication
Journal or Publication Title: Anesthesia and Analgesia
Volume: 114
Number: 4
Page Range: 803 - 810
DOI or Unique Handle: 10.1213/ane.0b013e318247fa44
Schools and Programs: School of Medicine > Critical Care Medicine
Refereed: Yes
ISSN: 0003-2999
MeSH Headings: Aged; Aged, 80 and over; Blood Pressure; Cardiac Output; Cardiac Surgical Procedures; Central Venous Pressure; Female; Humans; Intensive Care Units; Male; Middle Aged; Vascular Resistance
Other ID: NLM NIHMS352056 [Available on 04/01/13], NLM PMC3310263 [Available on 04/01/13]
PubMed Central ID: PMC3310263
PubMed ID: 22344243
Date Deposited: 18 Oct 2012 21:13
Last Modified: 30 Jan 2020 16:56


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