Simultaneous venous–arterial Doppler during preload augmentation: illustrating the Doppler Starling curve

Kenny, Jon‐Émile S.; Gibbs, Stanley O.; Eibl, Joseph K.; Eibl, Andrew M; Yang, Zhen; Johnston, Delaney; Munding, Chelsea E.; Elfarnawany, Mai; Lau, Vivian C; Kemp, Benjamin O; Nalla, Bhanu; Atoui, Rony

doi:10.1186/s13089-023-00330-9

Cited by 5 publications

(3 citation statements)

References 50 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Often venous and arterial ultrasound measures described above are performed in isolation, however, it has been argued that they should be assessed in tandem by a wireless, wearable Doppler device. 13 – 16 Simultaneous Doppler ultrasound of the jugular vein (ie, CVP surrogate) and carotid artery (ie, SV surrogate) create a “Doppler Starling curve” 15 , 16 which roughly resembles the canonical “Frank-Starling” curve, but can be noninvasively derived at the bedside. By dichotomizing jugular venous Doppler morphology into “low” and “high” CVP surrogates and ccFT into “low” and “normal” SV surrogates, the Doppler Starling curve is divided into 4 quadrants that phenotype hypoperfused patients.…”

Section: Introductionmentioning

confidence: 99%

Simultaneous Venous-Arterial Doppler Ultrasound During Early Fluid Resuscitation to Characterize a Novel Doppler Starling Curve: A Prospective Observational Pilot Study

Kenny,

Prager,

Rola

et al. 2024

J Intensive Care Med

Self Cite

View full text Add to dashboard Cite

Background: The likelihood of a patient being preload responsive—a state where the cardiac output or stroke volume (SV) increases significantly in response to preload—depends on both cardiac filling and function. This relationship is described by the canonical Frank-Starling curve. Research Question: We hypothesize that a novel method for phenotyping hypoperfused patients (ie, the “Doppler Starling curve”) using synchronously measured jugular venous Doppler as a marker of central venous pressure (CVP) and corrected flow time of the carotid artery (ccFT) as a surrogate for SV will refine the pretest probability of preload responsiveness/unresponsiveness. Study Design and Methods: We retrospectively analyzed a prospectively collected convenience sample of hypoperfused adult emergency department (ED) patients. Doppler measurements were obtained before and during a preload challenge using a wireless, wearable Doppler ultrasound system. Based on internal jugular and carotid artery Doppler surrogates of CVP and SV, respectively, we placed hemodynamic assessments into quadrants (Qx) prior to preload augmentation: low CVP with normal SV (Q1), high CVP and normal SV (Q2), low CVP and low SV (Q3) and high CVP and low SV (Q4). The proportion of preload responsive and unresponsive assessments in each quadrant was calculated based on the maximal change in ccFT (ccFTΔ) during either a passive leg raise or rapid fluid challenge. Results: We analyzed 41 patients (68 hemodynamic assessments) between February and April 2021. The prevalence of each phenotype was: 15 (22%) in Q1, 8 (12%) in Q2, 39 (57%) in Q3, and 6 (9%) in Q4. Preload unresponsiveness rates were: Q1, 20%; Q2, 50%; Q3, 33%, and Q4, 67%. Interpretation: Even fluid naïve ED patients with sonographic estimates of low CVP have high rates of fluid unresponsiveness, making dynamic testing valuable to prevent ineffective IVF administration.

show abstract

Section: Introductionmentioning

confidence: 99%

Simultaneous Venous-Arterial Doppler Ultrasound During Early Fluid Resuscitation to Characterize a Novel Doppler Starling Curve: A Prospective Observational Pilot Study

Kenny,

Prager,

Rola

et al. 2024

J Intensive Care Med

Self Cite

View full text Add to dashboard Cite

show abstract

“…Importantly, patients with low VExUS may not be fluid-responsive. The combination of normal venous pressure and fluid unresponsiveness is termed “dynamic fluid intolerance” because venous congestion is uncovered with a dynamic maneuver such as a passive leg raise (PLR) ( 6 , 15 ). When dynamic fluid intolerance is present, venous congestion is initially absent, but develops with fluid loading ( 15 ).…”

Section: Introductionmentioning

confidence: 99%

“…The combination of normal venous pressure and fluid unresponsiveness is termed “dynamic fluid intolerance” because venous congestion is uncovered with a dynamic maneuver such as a passive leg raise (PLR) ( 6 , 15 ). When dynamic fluid intolerance is present, venous congestion is initially absent, but develops with fluid loading ( 15 ). Accordingly, resuscitation protocols that focus only on static venous measures are limited.…”

Section: Introductionmentioning

confidence: 99%

Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond–Forrester Classification

Kenny,

Prager,

Rola

et al. 2023

Critical Care Explorations

Self Cite

View full text Add to dashboard Cite

Point of care ultrasound (POCUS) is a first-line tool to assess hemodynamically unstable patients, however, there is confusion surrounding intertwined concepts such as: “flow,” “congestion,” “fluid responsiveness (FR),” and “fluid tolerance.” We argue that the Frank–Starling relationship is clarifying because it describes the interplay between “congestion” and “flow” on the x-axis and y-axis, respectively. Nevertheless, a single, simultaneous assessment of congestion and flow via POCUS remains a static approach. To expand this, we propose a two-step process. The first step is to place the patient on an ultrasonographic Diamond–Forrester plot. The second step is a dynamic assessment for FR (e.g., passive leg raise), which individualizes therapy across the arc of critical illness.

show abstract

Optimising flow without congestion using the venous‐arterial Doppler enhanced resuscitation framework

Kenny,

Rola

2024

Australas J Ultrason Med

View full text Add to dashboard Cite

IntroductionUltrasonography as a guide for intravenous (IV) fluid therapy is increasingly accepted within the spheres of acute care. Initial investigations and protocols often focused on measures of arterial flow as an objective approach for personalising organ ‘perfusion.’ More recently, and with literature associating excessive IV fluid with adverse outcomes, venous ultrasound as a measure of organ ‘congestion’ is taking hold. Yet, arterial (i.e., ‘perfusion’) and venous (i.e., ‘congestion’) Doppler ultrasound measures are often performed separately and can be time‐consuming, especially for novices.MethodsWe report a case, wherein venous and arterial Doppler were simultaneously measured using a wireless, wearable ultrasound as a means to optimise flow without congestion.ResultsBefore IV volume expansion, the patient had Doppler measures consistent with low central venous pressure (CVP) and stroke volume (SV). Following IV volume expansion, venous Doppler remained the same; however, carotid corrected flow time (ccFT) increased significantly.ConclusionA framework for venous‐arterial Doppler enhanced resuscitation (VADER) can be used to guide IV volume in patients at risk for venous congestion.

show abstract

Simultaneous venous–arterial Doppler during preload augmentation: illustrating the Doppler Starling curve

Cited by 5 publications

References 50 publications

Simultaneous Venous-Arterial Doppler Ultrasound During Early Fluid Resuscitation to Characterize a Novel Doppler Starling Curve: A Prospective Observational Pilot Study

Simultaneous Venous-Arterial Doppler Ultrasound During Early Fluid Resuscitation to Characterize a Novel Doppler Starling Curve: A Prospective Observational Pilot Study

Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond–Forrester Classification

Optimising flow without congestion using the venous‐arterial Doppler enhanced resuscitation framework

Contact Info

Product

Resources

About