Grading System for Superior Vena Cava Syndrome
• Grade 0 - Asymptomatic - Radiographic superior vena cava obstruction in the absence of symptoms
• Grade 1 - Mild - Edema in head or neck (vascular distention), cyanosis, plethora
• Grade 2 - Moderate - Edema in head or neck with functional impairment (mild dysphagia, cough, mild or moderate impairment of head, jaw or eyelid movements, visual disturbances caused by ocular edema)
• Grade 3 - Severe - Mild or moderate cerebral edema (headache, dizziness) or mild/moderate laryngeal edema or diminished cardiac reserve (syncope after bending)
• Grade 4 - Life-threatening - Significant cerebral edema (confusion, obtundation) or significant laryngeal edema (stridor) or significant hemodynamic compromise (syncope without precipitating factors, hypotension, renal insufficiency)
• Grade 5 - Fatal - Death
#Superior #VenaCava #Syndrome #SVC #diagnosis #grading #vascular
Rockwood Clinical Frailty Score
There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use.
1 Very Fit – People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.
2 Well – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.
3 Managing Well – People whose medical problems are well controlled, but are not regularly active beyond routine walking.
4 Vulnerable – While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.
5 Mildly Frail – These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.
6 Moderately Frail – People need help with all outside activities and with keeping house. Inside, they
often have problems with stairs and need help with bathing and might need minimal assistance (cuing,
standby) with dressing.
7 Severely Frail – Completely dependent for personal care, from whatever cause (physical or
cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).
8 Very Severely Frail – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
9. Terminally Ill - Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.
#Diagnosis #Geriatrics #Clinical #Frailty #Scale #Score #CFS #Rockwood
Fluid Responsiveness and Fluid Tolerance Testing - OnePager Summary
Fluid resuscitation can be beneficial when required or harmful in excess. Methods to predict fluid responsiveness enable parsimonious administration of fluids, resulting in reduced fluid shorter duration pf vasopressors and lower risk of renal failure.
Fluid responsive (FR) - a 10-15% increase in cardiac output (CO) when fluid administered; fluid responsiveness does not mean fluid is "needed" only the CO will increase with volume.
Arterial Line:
• Pulse Pressure Variation (PPV): Variation in pulse pressure (PPV) with the respiratory cycle suggests fluid responsiveness due to heart lung interactions.
• Pulse Contour Cardiac Output: Analysis of the waveform can be used to estimate stroke volume variation (SW) or cardiac output (CO) using proprietary formulas.
Central Venous Line:
• Central Venous Pressure (CVP): Measures CVP as a surrogate for RV filling pressure.
Pulmonary Artery Catheter:
• Thermodilution CO/CI: Thermodilution measurement of CO via a PAC, which can be either continuous (via heating) or intermittent (via cold saline injection).
• PAOP/PCWP: PAOP/PCWP approximates LAP.
• Mixed Venous O2 Saturation (SvO2): An increase in SvO2 suggests improved CO, however high baseline Sv02 does not preclude FR.
Point of Care Ultrasound:
• IVC Size & Distensibility: IVC size reflects RA pressure, similar to CVP. Thus measuring the IVC size & phasic variation with respiration might predict FR.
• LV End Diastolic Area (LVEDA): Measure the cross sectional area of the LV at the end of diastole (reflects adequate filling); "kissing papillary muscles" is the extreme
• LVOT VTI: Measure outflow of blood from the LV. Variability in VTI is analogous to PPV, absolute values can be compared before/after a challenge maneuver.
• Carotid VTI: Similar to L VOT VTI but easier to measure carotid facilitating repeat measurements.
Minimally Invasive:
• BIOREACTANCE/NICOM: Detection of blood flow in the chest by application of an external electric field. Averages blood flow over 8-30 seconds. Combine with a challenge (PLR, microbolus) to measure ΔSV.
• END TIDAL CO2: An increase cardiac output causes increases delivery of CO2 to the lungs, increasing exhaled CO2.
• PULSE OXIMETRY WAVEFORM ANALYSIS: Analysis of the plethysmographic waveform is analogous to PPV measurement using arterial line: a high degree of respiratory variation predicts FR.
• PULMONARY A vs B-LINE PATTERN: Sonographic lung changes precede other signs of volume overload. An A-line predominant lung US pattern suggests fluid tolerance (FT).
Challenges:
• PASSIVE LEG RAISE (PLR): Positioning a patient flat (00), then raising legs to 450) quickly (30-90 sec) returns a reservoir of ~300 ml of venous blood to the central circulation.
• MINI-BOLUS & MICRO BOLUS: Observing the hemodynamic response to the rapid infusion of a small volume 50-100m!) of fluid can predict the response to a larger bolus
• HIGH PEEP CHALLENGE: For patients on MV increasing PEEP can identify FR by identifying a decrease in MAP.
• END EXPIRATORY OCCLUSION (EEO): For MV patients, each breath increases intrathoracic pressure & impedes venous return. Interrupting MV at end expiration transiently increases preload. Decrease in CO during a 15 sec expiratorv hold maneuver predicts FR
by Nick Mark MD @nickmmark
#Fluid #Responsiveness #Tolerance #testing #diagnosis #criticalcare #comparison #challenges #management
