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