Point of care transthoracic echocardiography for the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and left ventricular dysfunction : Inferior vena cava and post-spinal anesthesia hypotension in elderly patients

Nefeli Moschovaki, Theodosios Saranteas, Elen Spiliotaki, Dimitrios Giannoulis, Dimitrios Anagnostopoulos, Christina Talliou, Orestis Milionis, Panagiotis Briassoulis, Konstantinos Katogiannis, Thomas Papadimos, Nefeli Moschovaki, Theodosios Saranteas, Elen Spiliotaki, Dimitrios Giannoulis, Dimitrios Anagnostopoulos, Christina Talliou, Orestis Milionis, Panagiotis Briassoulis, Konstantinos Katogiannis, Thomas Papadimos

Abstract

In elderly patients with cardiac diseases, changes in cardiovascular physiology diminish cardiovascular reserve and predispose to hemodynamic instability after spinal anesthesia; hence, such patients could be at risk of postoperative complications. Additionally, transthoracic echocardiography (TTE) is used in clinical practice to evaluate cardiovascular hemodynamics. Therefore, we hypothesized that echocardiographic measurements could display significant diagnostic power in the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and reduced left ventricular ejection fraction (LV-EF). Therefore, sixty-one elderly orthopedic-trauma patients were recruited. Prior to spinal anesthesia a TTE examination was performed. The LV-EF, the stroke volume index (SVI), the peripheral vascular resistance (PVR), the LV filling pressures (E/Em ratio), the right ventricular function [tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV) and fractional area change (FAC)], as well as inferior vena cava (IVC) measurements, such as IVCCI (collapsibility index of the IVC) and dIVCmax (maximum diameter of IVC)-to-IVCCI ratio were assessed. Twenty-six out of sixty-one patients manifested hypotension. Preoperative dIVCmax-to-IVCCI ratio demonstrated the greatest performance amongst echocardiographic indices in predicting post - spinal anesthesia hypotension. The dIVCmax-to-IVCCI ratio < 48 had significantly higher diagnostic power than IVCCI > 0.28, FAC > 42, E/Em ratio < 9 and SVI < 32 (receiver operator characteristic curve analysis). The gray zone for the dIVCmax-to-IVCCI ratio (40-49) showed the lowest number of inconclusive measurements among echocardiographic variables. The preoperative dIVCmax-to-IVCCI ratio could be a reliable echocardiographic index to predict post - spinal anesthesia hypotension in elderly patients with left ventricular dysfunction.

Keywords: Echocardiography; Inferior vena cava; Post - spinal anesthesia hypotension.

Conflict of interest statement

The authors declare no competing interests.

The authors declare no conflicts of interest.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
TTE-non-invasive hemodynamic monitoring of the heart. a Biplane Simpson’s method of disks with automated measurements of LV volumes for the calculation of stroke volume and ejection fraction of the LV. b RV focused view: From the 4 chambers view, the transducer was moved laterally and rotated until the maximum diameter of the base is visualized. To measure the Fractional Area Shortening, the endocardial borders of the RV are traced to assess the RV area both in diastole and systole. c and d Subcostal view of IVC at expiration and inspiration. 2CH = 2 chambers view, 4CH = 4 chambers view, RV = right ventricle, LV = left ventricle, IVC = inferior vena cava
Fig. 2
Fig. 2
Flow diagram of patients’ cohort development. LV = left ventricle, RV = right ventricle, IVC = inferior vena cava, PACU = post-anesthesia care unit
Fig. 3
Fig. 3
Diagnostic performance of dIVCmax-to-IVCCI ratio (ROC-AUC) with respect to (a) right ventricle (FAC and IVCCI) and (b) left ventricle (SVI and E/Em ratio) echocardiographic variables, respectively. IVCCI = inferior vena cava collapsibility index, dIVCmax = maximum diameter of IVC at expiration, FAC = fractional area change, SVI = stroke volume index, E = peak velocity flow in early diastole, Em = the average of peak velocities in early diastole of lateral and septal mitral annulus
Fig. 4
Fig. 4
Plots of sensitivity and specificity showing the predictive ability and gray zones of the dIVCmax-to-IVCCI ratio. Gray zone plot is created using the sensitivity and specificity of the dIVCmax-to-IVCCI ratio to predict post-spinal hypotension (y-axis) against the dIVCmax-to-IVCCI ratio measurements (x-axis). The gray zone was delimited between the 90% sensitivity and the 90% specificity cutoff points on the two sigma curves. IVCCI = inferior vena cava collapsibility index, dIVCmax = maximum diameter of IVC at expiration
Fig. 5
Fig. 5
Interobserver agreement of various echocardiographic variables. IVCCI = inferior vena cava collapsibility index, dIVCmax = maximum diameter of IVC at expiration, FAC = fractional area change, SVI = stroke volume index, E = peak velocity flow in early diastole, Em = the average of peak velocities in early diastole of lateral and septal mitral annulus

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