Echocardiography and Spinal Induced Hypotension.

The Role of Heart Echocardiography in the Prediction of Spinal-induced Hypotension in Elderly Patients With Reduced Left Ventricular Function.

Modern guidelines have combined both the maximum diameter of IVC at expiration (dIVC max) and the IVCCI to appreciate right atrial pressure (RAP) measurements and consequently to assess intravascular volume status. In fact, IVC diameter <2.1 cm with IVCCI >20% (quite inspiration) suggests normal RAP of 3mmHg (range, 0-5mmHg), whereas IVC diameter >2.1 cm with IVCCI<20% suggests high RAP of 15mmHg (range, 10-20mmHg). In occasions where the IVC diameter and collapse is not fit the above categories, an intermediate value of 8 mmHg (range, 5-10 mmHg) is applied. From a clinical standpoint, it is conceivable that both measurements must be measured in isolation to enable RAP assessment. To circumvent this limitation the two indices have been consolidated to dIVCmax-to-IVCCI ratio. Although this ratio has been shown high accuracy to predict spinal-induced hypotension in elderly patients with preserved ejection fraction (EF) of the left ventricle (LV), its value in patients with cardiac dysfunction and reduced LV-EF has not been investigated.

From the aforementioned, this study sets out to address the role of dIVCmax-to-IVCCI ratio in the prediction as well as in the management of hypotension after spinal anesthesia in elderly orthopaedic patients with reduced LV-EF.

Study Overview

• Status: Completed
• Conditions: Spinal Anesthetic Toxicity
• Intervention / Treatment: Other: Transthoracic echocardiography; Drug: Spinal anesthesia

Detailed Description

Methods In the present prospective study, consecutive sampling is been used to recruit elderly patients (age>70 years) hospitalized in the Attikon University Hospital of Athens. Patients is included if they sustain orthopaedic operation of the lower limb under spinal anaesthesia. This study was approved for ethics and consent by the Institutional Review Board/Ethics Committee of the authors' institution.

Patients' medical history, physical examination, ECG, and X-ray assessment are standard practice, supplemented by specific exams or tests (e.g. TTE or pro-BNP levels), are performed per the consultant cardiologist's recommendations. All patients included in our study are American Heart Association/American College of Cardiology(AHA/ACC) stage II or III with ejection fraction (EF) of the left ventricle (LV) between 35 and 50%, and their cardiac disease status always in compensated status; also, patients with right ventricle (RV) dysfunction and severe valvular diseases are not included in the study.

A standard intraoperative TTE protocol is used in all patients and included the following views: subcostal 4-chamber (SUBC), apical 4-chamber (4CH), apical 2-chamber (2CH), apical 3-chamber (3CH), parasternal long (LAX) and short axis (SAX).

All data are saved and stored digitally for off-line, postoperative analysis. The EF is determined using the biplane Simpson's method, by performing automated measurements of LV volumes in 2CH and 4CH views (GE, Auto-EF system).

The LV-EF, stroke volume index (SVI), peripheral vascular resistance (PVR), LV filling pressures (E/Em ratio), right ventricle (RV) function (tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV), fractional area change (FAC), the IVCCI and dIVCmax-to-IVCCI ratio were assessed Stroke volume (SV) and subsequent stroke volume index (SVI=SV/m2) of the LV is assessed by using automated measurements of LV volumes, according to the formula: SV= EDV-ESV, where EDV=end-diastolic LV volume and ESV=end-systolic LV volume. From these data, we also derived values for the assessment of cardiac output (CO =SV x HR), subsequent systemic vascular resistance (SVR =MAP x 80/CO), (mean arterial blood pressure=MAP, HR=heart rate).

IVC measurements include its maximum diameter at the end of expiration (dIVCmax), IVCCI during spontaneous, quiet, breathing, [(IVC maximal diameter - IVC minimal diameter)/IVC maximal diameter] and the ratio (R) of dIVCmax-to-IVCCI; the IVC diameters is measured in the long axis of the IVC and just proximal to the entry of the hepatic veins.

Anesthetic protocol and measurements. Spinal anesthesia is introduced with a single intrathecal injection of 12 to 18 mg (average15 mg plain ropivacaine, 0.75% solution) using a 22 or 25-gauge needle (pencil-point) with the patient in the lateral position. Intraoperative ECG, SPO2 and invasive arterial blood pressure (through an indwelling radial artery catheter) monitoring is used. Patients who are experiencing a MAP less than or equal to 65 mmHg, or greater than or equal to 25% reduction of its baseline preoperative value were considered hypotensive (duration of low MAP: 30sec, time-period: from spinal anesthesia induction to the end of surgery). Arterial hypotension related to blood transfusion for any reason is not considered in our statistical analysis.

Data analysis:A pilot study of 18 patients revealed a detected area under the ROC curve (AUC) of 0.89 for dIVCmax-to-IVCCI, and for IVCCI 0.74, with rank correlation between the two assays being 0.88 in positive and 0.62 in negative cases. Based on this result, a sample of 40 patients will be required to achieve a power of 80% in order to detect significant difference (at a level 0.05) between dIVCmax-to-IVCCI ratio and IVCCI (MedCalc Software, Mariakerke, Belgium). Quantitative variables and proportions are compared with the student t-test or Mann-Whitney and chi-square tests, respectively. Normality is tested by using the Kolmogorov- Smirnov test. We will assess the area under the receiver operator characteristic curve (AUC-ROC) to evaluate the diagnostic performance of echocardiographic parameters in identifying patients who experience spinal-induced hypotension. The grey zone estimation between two cut-off points will be used for clinical utility reasons.

• Study Type: Observational
• Enrollment (Actual): 61

Contacts and Locations

Study Locations

• Greece
  • Attica
    • Athens, Attica, Greece, 15562
      • Department of anesthesia ,ATTIKON UNIVERSITY HOSPITAL OF ATHENS

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 70 years to 100 years (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients is included if they sustain orthopaedic operation of the lower limb under spinal anaesthesia.

Patients' medical history, physical examination, ECG, and X-ray assessment are standard practice, supplemented by specific exams or tests (e.g. TTE or pro-BNP levels), are performed per the consultant cardiologist's recommendations. All patients included in our study were American Heart Association/American College of Cardiology(AHA/ACC) stage II or III with ejection fraction (EF) of the left ventricle (LV) between 35 and 50%, and their cardiac disease status always in compensated status

Description

Inclusion Criteria:

Orthopaedic trauma patients Reduced LV-EF (35% <EF<50%) Elderly patients

Exclusion Criteria:

• Patients with right ventricle (RV) dysfunction/patients with LV-EF<35%/
• Severe pulmonary hypertension
• Tachycardia (heart rate > 100 beats/min), atrial fibrillation.
• Patients with tricuspid and mitral regurgitation more than grade 2 and those with more than moderate valvular stenosis were excluded.
• Left ventricular dysynchrony
• TAPSE index<16 and/orTDI-tricuspid annulus<10 cm/sec and/or Fractional Area Shortening<35.

Spinal block below T-12 level Overt intraoperative haemorhage

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Hypotension group; spinal anesthesia in Hypotensive patients with low LV-EF Transthoracic echocardiography of IVC before spinal anaesthesia	Other: Transthoracic echocardiography; A standard TTE protocol is used in all patients and included the following views: subcostal 4-chamber (SUBC), apical 4-chamber (4CH), apical 2-chamber (2CH), apical 3-chamber (3CH), parasternal long (LAX) and short axis (SAX).; Other Names: TTE; Drug: Spinal anesthesia; Spinal anesthesia is introduced with a single intrathecal injection of 12 to 18 mg (15 mg average dose) plain ropivacaine (0.75% solution) using a 22 or 25-gauge needle (pencil-point) with the patient in the lateral position.; Other Names: Neuraxial block
Normotension group; spinal anesthesia IN Normotensive patients with low LV-EF Transthoracic echocardiography of IVC before spinal anaesthesia	Other: Transthoracic echocardiography; A standard TTE protocol is used in all patients and included the following views: subcostal 4-chamber (SUBC), apical 4-chamber (4CH), apical 2-chamber (2CH), apical 3-chamber (3CH), parasternal long (LAX) and short axis (SAX).; Other Names: TTE; Drug: Spinal anesthesia; Spinal anesthesia is introduced with a single intrathecal injection of 12 to 18 mg (15 mg average dose) plain ropivacaine (0.75% solution) using a 22 or 25-gauge needle (pencil-point) with the patient in the lateral position.; Other Names: Neuraxial block

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Predictive value of dIVCmax-to-IVCCI ratio	Preoperative performance of the dIVCmax-to-IVCCI ratio The main outcome will be the preoperative performance of the dIVCmax-to-IVCCI ratio to foresee the incidence of hypotension after spinal anesthesia in patients with low LV-EF	18 months

Collaborators and Investigators

• Sponsor: Attikon Hospital
• Investigators: Principal Investigator: THEODOSIOS SARANTEAS, PROFESSOR, MEDICAL SCHOOL OF ATHENS, GREECE, EU

Publications and helpful links

General Publications

• Saranteas T, Spiliotaki H, Koliantzaki I, Koutsomanolis D, Kopanaki E, Papadimos T, Kostopanagiotou G. The Utility of Echocardiography for the Prediction of Spinal-Induced Hypotension in Elderly Patients: Inferior Vena Cava Assessment Is a Key Player. J Cardiothorac Vasc Anesth. 2019 Sep;33(9):2421-2427. doi: 10.1053/j.jvca.2019.02.032. Epub 2019 Feb 22.

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2019
• Primary Completion (Actual): April 25, 2022
• Study Completion (Actual): May 5, 2022

Study Registration Dates

• First Submitted: June 26, 2019
• First Submitted That Met QC Criteria: June 27, 2019
• First Posted (Actual): June 28, 2019

Study Record Updates

• Last Update Posted (Actual): May 12, 2022
• Last Update Submitted That Met QC Criteria: May 11, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Keywords: echocardiography; spinal anesthesia; inferior vena cava
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Hypotension; Physiological Effects of Drugs; Central Nervous System Depressants; Anesthetics
• Other Study ID Numbers: 3332017

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No