Achikam Oren-Grinberg

Bio: Achikam Oren-Grinberg is an academic researcher from Beth Israel Deaconess Medical Center. The author has contributed to research in topics: Perioperative & Cardiopulmonary resuscitation. The author has an hindex of 11, co-authored 24 publications receiving 803 citations. Previous affiliations of Achikam Oren-Grinberg include Harvard University & Medical University of South Carolina.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Perioperative Ultrasound Training in Anesthesiology: A Call to Action.

Abstract: The purpose of this position paper is to define the scope of perioperative ultrasound (US), review the current status of US training practices during anesthesiology residency, and suggest the recommendations for current and future trainees on how to obtain perioperative US proficiency We define per

The PiCCO Monitor.

Abstract: Hemodynamic optimization is a complex task requiring, among other things, monitoring of arterial and venous pressures, urine output, acid-base balance, and oxygen content/delivery. These parameters, however, reflect the overall circulatory state and not the basic physiologic determinants of cardiac output (CO), which include preload, afterload, and contractility. To help determining these basic physiologic determinants, the pulmonary artery catheter (PAC) has been used by clinicians for almost 4 decades where it became the mainstay of patient monitoring in the operating room and in the intensive care unit (ICU) setting. It provides direct information on pressure variables such as pulmonary artery pressure, pulmonary artery occlusion pressure, and central venous pressure. It can also provide flow-related data such as CO and mixed venous oxygen saturation. Despite its extensive use, the clinical value of data obtained from pulmonary artery catheters remains unproven. Therefore, an alternative approach to the PAC monitoring has been proposed—the functional hemodynamic monitoring. This approach focuses on the effects of positive pressure ventilation on left ventricular (LV) output; positive pressure ventilation induces phasic changes in LV stroke volume through similar cyclic changes in venous return. This is a ‘‘normal’’ phenomenon for all patients ventilated with positive pressure ventilation, and can be advantageous in situations of hypovolemia.

Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned?

Abstract: Intracranial hypertension, defined as an intracranial pressure (ICP) >20 mmHg for a period of more than 5 min, worsens neurologic outcome in traumatic brain injury (TBI). While several mechanisms contribute to poor outcome, impaired cerebral perfusion appears to be a highly significant common denominator. Management guidelines from the Brain Trauma Foundation recommend measuring ICP to guide therapy. In particular, hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce ICP. Currently, mannitol (20%) is considered the gold standard hyperosmolar agent. However, HTS is increasingly used in this setting. This review sought to compare the efficacy of mannitol to HTS in severe TBI.The PubMed database was used to systematically search for articles comparing mannitol to HTS in severe TBI. The following medical subject headings were used: HTS, sodium lactate, mannitol, ICP, intracranial hypertension, and TBI. We included both prospective and retrospective randomized controlled studies of adult patients with intracranial hypertension as a result of severe TBI who received hyperosmolar therapy.Out of 45 articles, seven articles were included in our review: 5 were prospective, randomized trials; one was a prospective, nonrandomized trial; and one was a retrospective, cohort study.While all seven studies found that both mannitol and HTS were effective in reducing ICP, there was heterogeneity with regard to which agent was most efficacious.

Focused critical care echocardiography.

Abstract: Objective Portable ultrasound is now used routinely in many intensive care units (ICUs) for various clinical applications. Echocardiography performed by non-cardiologists, both transesophageal (TEE) and transthoracic (TTE), has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on Focused Critical Care Echocardiography (FCCE) for the management of critically ill patients.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients—part Ii: Cardiac Ultrasonography

Abstract: Objective:To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.Methods:Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the “levels” of quality of evidence into high (A), mod

Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study*

Abstract: Objective: Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients. Design: Prospective randomized study. Setting: Medical intensive care unit of a tertiary medical center. Patients: Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470). Interventions: We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index. Measurements and Main Results: No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p<.05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p<.05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians. Conclusions: The present data suggested that ultrasoundguided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients. (Crit Care Med 2011; 39:1607‐1612)

Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis

Abstract: We performed a systematic review and meta-analysis of studies investigating the passive leg raising (PLR)-induced changes in cardiac output (CO) and in arterial pulse pressure (PP) as predictors of fluid responsiveness in adults. MEDLINE, EMBASE and Cochrane Database were screened for relevant original and review articles. The meta-analysis determined the pooled area under the ROC curve, the sensitivity, specificity and threshold for the PLR test when assessed with CO and PP. Twenty-one studies (991 adult patients, 995 fluid challenges) were included. CO was measured by echocardiography in six studies, calibrated pulse contour analysis in six studies, bioreactance in four studies, oesophageal Doppler in three studies, transpulmonary thermodilution or pulmonary artery catheter in one study and suprasternal Doppler in one study. The pooled correlation between the PLR-induced and the fluid-induced changes in CO was 0.76 (0.73–0.80). For the PLR-induced changes in CO, the pooled sensitivity was 0.85 (0.81–0.88) and the pooled specificity was 0.91 (0.88–0.93). The area under the ROC curve was 0.95 ± 0.01. The best threshold was a PLR-induced increase in CO ≥10 ± 2 %. For the PLR-induced changes in PP (8 studies, 432 fluid challenges), the pooled sensitivity was 0.56 (0.49–0.53), the pooled specificity was 0.83 (0.77–0.88) and the pooled area under the ROC curve was 0.77 ± 0.05. Sensitivity and subgroup analysis were consistent with the primary analysis. PLR-induced changes in CO very reliably predict the response of CO to volume expansion in adults with acute circulatory failure. When PLR effects are assessed by changes in PP, the specificity of the PLR test remains acceptable but its sensitivity is poor.