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Affiliation(s)
- Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA.
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA
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Abbasi A, Azab N, Nayeemuddin M, Schick A, Lopardo T, Phillips GS, Merchant RC, Levy MM, Blaivas M, Corl KA. Change in Carotid Blood Flow and Carotid Corrected Flow Time Assessed by Novice Sonologists Fails to Determine Fluid Responsiveness in Spontaneously Breathing Intensive Care Unit Patients. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2659-2666. [PMID: 32747073 PMCID: PMC7771259 DOI: 10.1016/j.ultrasmedbio.2020.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/18/2020] [Accepted: 07/04/2020] [Indexed: 06/11/2023]
Abstract
Measurement of carotid blood flow (CBF) and corrected carotid flow time (ccFT) has been proposed as a non-invasive means of determining fluid responsiveness. We evaluated the ability of CBF and ccFT as assessed by novice sonologists to determine fluid responsiveness in intensive care unit patients. Three novice physician sonologists performed carotid ultrasounds before and after a fluid bolus and calculated changes in CBF and ccFT. Fluid responsiveness was defined as a ≥10% increase in cardiac index as measured using bioreactance. Of 112 participants, 56 (50%) were fluid responders. Changes in CBF and ccFT performed poorly at determining fluid responsiveness: 19 mL/min (area under the receiver operating characteristic curve: 0.58, 95% confidence interval: 0.47-0.68) and 6 ms (0.59, 0.46-0.65) respectively. Novice physician sonologists are unable to determine fluid responsiveness using CBF or ccFT. Further research is needed to identify the key limiting factors in using carotid ultrasound to determine fluid responsiveness.
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Affiliation(s)
- Adeel Abbasi
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | - Nader Azab
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Mohammed Nayeemuddin
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alexandra Schick
- Department of Emergency Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Thomas Lopardo
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Gary S Phillips
- Consultant, retired from the Center for Biostatistics, Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Roland C Merchant
- Brown University School of Public Health, Providence, Rhode Island, USA; Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell M Levy
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Michael Blaivas
- Department of Emergency Medicine, University of South Carolina School of Medicine, St Francis Hospital, Columbus, GA
| | - Keith A Corl
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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Bioreactance-Based Noninvasive Fluid Responsiveness and Cardiac Output Monitoring: A Pilot Study in Patients with Aneurysmal Subarachnoid Hemorrhage and Literature Review. Crit Care Res Pract 2020; 2020:2748181. [PMID: 33014461 PMCID: PMC7512079 DOI: 10.1155/2020/2748181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/05/2020] [Accepted: 09/03/2020] [Indexed: 11/22/2022] Open
Abstract
Management of volume status, arterial blood pressure, and cardiac output are core elements in approaching the patients with aneurysmal subarachnoid hemorrhage (SAH). For the prevention and treatment of delayed cerebral ischemia (DCI), euvolemia is advocated and caution is made towards the avoidance of hypervolemia. Induced hypertension and cardiac output augmentation are the mainstays of medical management during active DCI, whereas the older triple-H paradigm has fallen out of favor due to lack of demonstrable physiological or clinical benefits and serious concern for adverse effects such as pulmonary edema and multiorgan system dysfunction. Furthermore, insight into clinical hemodynamics of patients with SAH becomes salient when one considers the frequently associated cardiac and pulmonary manifestations of the disease such as SAH-associated cardiomyopathy and neurogenic pulmonary edema. In terms of fluid and volume targets, less attention has been paid to dynamic markers of fluid responsiveness despite the well-established, in the general critical care literature, superiority of these as compared to traditionally used static markers such as central venous pressure (CVP). Based on this literature and sound pathophysiologic reasoning, reliance on static markers (such as CVP) is unjustified when one attempts to assess strategies augmenting stroke volume (SV), arterial blood pressure, and oxygen delivery. There are several options for continuous bedside cardiorespiratory monitoring and optimization of SAH patients. We, here, review a noninvasive monitoring technique based on thoracic bioreactance and focusing on continuous cardiac output and fluid responsiveness markers.
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Abstract
Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.
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Affiliation(s)
- Kevin W Lobdell
- Atrium Health Cardiothoracic Surgery, Atrium Health's Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232, USA.
| | - Subhasis Chatterjee
- Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS: BCM 390, Houston, TX 77030, USA; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA. https://twitter.com/SXC71
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, Giessen 35392, Germany; Charity Medical University, Berlin, Germany. https://twitter.com/Mich_San_d
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55
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Maternal Cardiovascular Dysfunction is Associated with Hypoxic Cerebral and Umbilical Doppler Changes. J Clin Med 2020; 9:jcm9092891. [PMID: 32906735 PMCID: PMC7565559 DOI: 10.3390/jcm9092891] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 11/17/2022] Open
Abstract
We investigate the relationship between maternal cardiovascular (CV) function and fetal Doppler changes in healthy pregnancies and those with pre-eclampsia (PE), small for gestational age (SGA) or fetal growth restriction (FGR). This was a three-centre prospective study, where CV assessment was performed using inert gas rebreathing, continuous Doppler or impedance cardiography. Maternal cardiac output (CO) and peripheral vascular resistance (PVR) were analysed in relation to the uterine artery, umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PI, expressed as z-scores by gestational week) using polynomial regression analyses, and in relation to the presence of absent/reversed end diastolic (ARED) flow in the UA. We included 81 healthy controls, 47 women with PE, 65 with SGA/FGR and 40 with PE + SGA/FGR. Maternal CO was inversely related to fetal UA PI and positively related to MCA PI; the opposite was observed for PVR, which was also positively associated with increased uterine artery impedance. CO was lower (z-score 97, p = 0.02) and PVR higher (z-score 2.88, p = 0.02) with UA ARED flow. We report that maternal CV dysfunction is associated with fetal vascular changes, namely raised impedance in the fetal-placental circulation and low impedance in the fetal cerebral vessels. These findings are most evident with critical UA Doppler changes and represent a potential mechanism for therapeutic intervention.
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Joosten A, Coeckelenbergh S, Alexander B, Delaporte A, Cannesson M, Duranteau J, Saugel B, Vincent JL, Van der Linden P. Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review. BMC Anesthesiol 2020; 20:209. [PMID: 32819296 PMCID: PMC7441629 DOI: 10.1186/s12871-020-01128-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/12/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate. MAIN TEXT The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications. CONCLUSIONS The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Department of Anesthesiology & Perioperative Medicine, Bicêtre Hospital, 78, Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology & Perioperative Care, University of California San Diego, San Diego, USA
| | - Amélie Delaporte
- Department of Anesthesiology & Intensive Care, Marie Lannelongue Hospital, Paris, France
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles, Los Angeles, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Outcomes Research Consortium, Cleveland, OH USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Al-Qatatsheh A, Morsi Y, Zavabeti A, Zolfagharian A, Salim N, Z. Kouzani A, Mosadegh B, Gharaie S. Blood Pressure Sensors: Materials, Fabrication Methods, Performance Evaluations and Future Perspectives. SENSORS (BASEL, SWITZERLAND) 2020; 20:E4484. [PMID: 32796604 PMCID: PMC7474433 DOI: 10.3390/s20164484] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Abstract
Advancements in materials science and fabrication techniques have contributed to the significant growing attention to a wide variety of sensors for digital healthcare. While the progress in this area is tremendously impressive, few wearable sensors with the capability of real-time blood pressure monitoring are approved for clinical use. One of the key obstacles in the further development of wearable sensors for medical applications is the lack of comprehensive technical evaluation of sensor materials against the expected clinical performance. Here, we present an extensive review and critical analysis of various materials applied in the design and fabrication of wearable sensors. In our unique transdisciplinary approach, we studied the fundamentals of blood pressure and examined its measuring modalities while focusing on their clinical use and sensing principles to identify material functionalities. Then, we carefully reviewed various categories of functional materials utilized in sensor building blocks allowing for comparative analysis of the performance of a wide range of materials throughout the sensor operational-life cycle. Not only this provides essential data to enhance the materials' properties and optimize their performance, but also, it highlights new perspectives and provides suggestions to develop the next generation pressure sensors for clinical use.
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Affiliation(s)
- Ahmed Al-Qatatsheh
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Yosry Morsi
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Ali Zavabeti
- Department of Chemical Engineering, The University of Melbourne, Parkville VIC 3010, Australia;
| | - Ali Zolfagharian
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
| | - Nisa Salim
- Faculty of Science, Engineering, and Technology (FSET), Swinburne University of Technology, Melbourne VIC 3122, Australia; (Y.M.); (N.S.)
| | - Abbas Z. Kouzani
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Saleh Gharaie
- Faculty of Science, Engineering and Built Environment, School of Engineering, Deakin University, Waurn Ponds VIC 3216, Australia; (A.Z.); (A.Z.K.)
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Lorenzen U, Pohlmann M, Hansen J, Klose P, Gruenewald M, Renner J, Elke G. Perioperative non-invasive versus semi-invasive cardiac index monitoring in patients with bariatric surgery - a prospective observational study. BMC Anesthesiol 2020; 20:196. [PMID: 32778047 PMCID: PMC7419223 DOI: 10.1186/s12871-020-01110-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Background In morbidly obese patients undergoing laparoscopic bariatric surgery, the combination of obesity-related comorbidities, pneumoperitoneum and extreme posture changes constitutes a high risk of perioperative hemodynamic complications. Thus, an advanced hemodynamic monitoring including continuous cardiac index (CI) assessment is desirable. While invasive catheterization may bear technical difficulties, transesophageal echocardiography is contraindicated due to the surgical procedure. Evidence on the clinical reliability of alternative semi- or non-invasive cardiac monitoring devices is limited. The aim was to compare the non-invasive vascular unloading to a semi-invasive pulse contour analysis reference technique for continuous CI measurements in bariatric surgical patients. Methods This prospective observational study included adult patients scheduled for elective, laparoscopic bariatric surgery after obtained institutional ethics approval and written informed consent. CI measurements were performed using the vascular unloading technique (Nexfin®) and semi-invasive reference method (FloTrac™). At 10 defined measurement time points, the influence of clinically indicated body posture changes, passive leg raising, fluid bolus administration and pneumoperitoneum was evaluated pre- and intraoperatively. Correlation, Bland-Altman and concordance analyses were performed. Results Sixty patients (mean BMI 49.2 kg/m2) were enrolled into the study and data from 54 patients could be entered in the final analysis. Baseline CI was 3.2 ± 0.9 and 3.3 ± 0.8 l/min/m2, respectively. Pooled absolute CI values showed a positive correlation (rs = 0.76, P < 0.001) and mean bias of of − 0.16 l/min/m2 (limits of agreement: − 1.48 to 1.15 l/min/m2) between the two methods. Pooled percentage error was 56.51%, missing the criteria of interchangeability (< 30%). Preoperatively, bias ranged from − 0.33 to 0.08 l/min/m2 with wide limits of agreement. Correlation of CI was best (rs = 0.82, P < 0.001) and percentage error lowest (46.34%) during anesthesia and after fluid bolus administration. Intraoperatively, bias ranged from − 0.34 to − 0.03 l/min/m2 with wide limits of agreement. CI measurements correlated best during pneumoperitoneum and after fluid bolus administration (rs = 0.77, P < 0.001; percentage error 35.95%). Trending ability for all 10 measurement points showed a concordance rate of 85.12%, not reaching the predefined Critchley criterion (> 92%). Conclusion Non-invasive as compared to semi-invasive CI measurements did not reach criteria of interchangeability for monitoring absolute and trending values of CI in morbidly obese patients undergoing bariatric surgery. Trial registration The study was registered retrospectively on June 12, 2017 with the registration number NCT03184272.
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Affiliation(s)
- Ulf Lorenzen
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany
| | - Markus Pohlmann
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany
| | - Jonathan Hansen
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany
| | - Phil Klose
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany
| | - Jochen Renner
- Department of Anesthesiology, Helios Kliniken Schwerin, 19055, Schwerin, Germany
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus R3, 24105, Kiel, Germany.
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Continuous noninvasive pulse wave analysis using finger cuff technologies for arterial blood pressure and cardiac output monitoring in perioperative and intensive care medicine: a systematic review and meta-analysis. Br J Anaesth 2020; 125:25-37. [DOI: 10.1016/j.bja.2020.03.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/02/2020] [Accepted: 03/06/2020] [Indexed: 12/16/2022] Open
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Joosten A, Vincent JL, Saugel B. Continuous non-invasive haemodynamic monitoring in patients having surgery: Valuable tool or superfluous toy? Anaesth Crit Care Pain Med 2020; 39:417-418. [PMID: 32499128 DOI: 10.1016/j.accpm.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Alexandre Joosten
- Department of Anaesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Department of Anaesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Bernd Saugel
- Department of Anaesthesiology, Centre of Anaesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, Ohio, USA
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Fischer MO, Fiant AL, Debroczi S, Boutros M, Pasqualini L, Demonchy M, Flais F, Alves A, Gérard JL, Buléon C, Hanouz JL. Perioperative non-invasive haemodynamic optimisation using photoplethysmography: A randomised controlled trial and meta-analysis. Anaesth Crit Care Pain Med 2020; 39:421-428. [DOI: 10.1016/j.accpm.2020.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/08/2020] [Accepted: 03/08/2020] [Indexed: 12/27/2022]
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Anderson TA. Intraoperative Analgesia-Nociception Monitors: Where We Are and Where We Want To Be. Anesth Analg 2020; 130:1261-1263. [PMID: 32287133 DOI: 10.1213/ane.0000000000004473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T Anthony Anderson
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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63
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Milam AJ, Ghoddoussi F, Lucaj J, Narreddy S, Kumar N, Reddy V, Hakim J, Krishnan SH. Comparing the Mutual Interchangeability of ECOM, FloTrac/Vigileo, 3D-TEE, and ITD-PAC Cardiac Output Measuring Systems in Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2020; 35:514-529. [PMID: 32622708 DOI: 10.1053/j.jvca.2020.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to compare the mutual interchangeability of 4 cardiac output measuring devices by comparing their accuracy, precision, and trending ability. DESIGN A single-center prospective observational study. DESIGN Nonuniversity teaching hospital, single center. PARTICIPANTS Forty-four consecutive patients scheduled for elective, nonemergent coronary artery bypass grafting (CABG). INTERVENTIONS The cardiac output was measured for each participant using 4 methods: intermittent thermodilution via pulmonary artery catheter (ITD-PAC), Endotracheal Cardiac Output Monitor (ECOM), FloTrac/Vigileo System (FLOTRAC), and 3-dimensional transesophageal echocardiography (3D-TEE). MEASUREMENTS AND MAIN RESULTS Measurements were performed simultaneously at 5 time points: presternotomy, poststernotomy, before cardiopulmonary bypass, after cardiopulmonary bypass, and after sternal closure. A series of statistical and comparison analyses including ANOVA, Pearson correlation, Bland-Altman plots, quadrant plots, and polar plots were performed, and inherent precision for each method and percent errors for mutual interchangeability were calculated. For the 6 two-by-two comparisons of the methods, the Pearson correlation coefficients (r), the percentage errors (% error), and concordance ratios (CR) were as follows: ECOM_versus_ITD-PAC (r = 0.611, % error = 53%, CR = 75%); FLOTRAC_versus_ITD-PAC (r = 0.676, % error = 49%, CR = 77%); 3D-TEE versus ITD-PAC (r = 0.538, % error = 64%, CR = 67%); FLOTRAC_versus_ECOM (r = 0.627, % error = 51%, CR = 75%); 3D-TEE_versus ECOM (r = 0.423, % error = 70%, CR = 60%), and 3D-TEE_versus_FLOTRAC (r = 0.602, % error = 59%, CR = 61%). CONCLUSIONS Based on the recommended statistical measures of interchangeability, ECOM, FLOTRAC, and 3D-TEE are not interchangeable with each other or to the reference standard invasive ITD-PAC method in patients undergoing nonemergent cardiac bypass surgery. Despite the negative result in this study and the majority of previous studies, these less-invasive methods of CO have continued to be used in the hemodynamic management of patients. Each device has its own distinct technical features and inherent limitations; it is clear that no single device can be used universally for all patients. Therefore, different methods or devices should be chosen based on individual patient conditions, including the degree of invasiveness, measurement performance, and the ability to provide real-time, continuous CO readings.
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Affiliation(s)
- Adam J Milam
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Farhad Ghoddoussi
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI
| | - Jon Lucaj
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Spurthy Narreddy
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Nakul Kumar
- Department of Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Vennela Reddy
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Joffer Hakim
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI
| | - Sandeep H Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI.
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64
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Kobe J, Mishra N, Arya VK, Al-Moustadi W, Nates W, Kumar B. Cardiac output monitoring: Technology and choice. Ann Card Anaesth 2020; 22:6-17. [PMID: 30648673 PMCID: PMC6350438 DOI: 10.4103/aca.aca_41_18] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.
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Affiliation(s)
- Jeff Kobe
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Nitasha Mishra
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra K Arya
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Waiel Al-Moustadi
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Wayne Nates
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Bhupesh Kumar
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Karbing DS, Perchiazzi G, Rees SE, Jaffe MB. Journal of Clinical Monitoring and Computing 2018-2019 end of year summary: respiration. J Clin Monit Comput 2020; 34:197-205. [PMID: 31981067 PMCID: PMC7223067 DOI: 10.1007/s10877-020-00468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 11/25/2022]
Abstract
This paper reviews 28 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2018 and 2019, within the field of respiration. Papers were published covering endotracheal tube cuff pressure monitoring, ventilation and respiratory rate monitoring, lung mechanics monitoring, gas exchange monitoring, CO2 monitoring, lung imaging, and technologies and strategies for ventilation management.
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Affiliation(s)
- D S Karbing
- Respiratory and Critical Care Group (Rcare), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - G Perchiazzi
- Department of Surgical Sciences, The Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - S E Rees
- Respiratory and Critical Care Group (Rcare), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - M B Jaffe
- Cardiorespiratory Consulting, LLC, Cheshire, CT, USA
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Abstract
PURPOSE OF REVIEW Bedside cardiac output (CO) measurement is an important part of routine hemodynamic monitoring in the differential diagnosis of circulatory shock and fluid management. Different choices of CO measurement devices are available. The purpose of this review is to review the importance of CO [or stroke volume (SV)] measurement and to discuss the various methods (devices) used in determination of CO. RECENT FINDINGS CO measurement devices can be classified into two types: those use simple physical principles with minimal assumptions, and those predicting CO via mathematical modelling with a number of assumptions. Both have pros and cons, with the former being more accurate but with limited continuous monitoring capability whereas the latter less accurate but usually equipped with continuous monitoring functionality. With frequent updates in mathematical models, research data constantly become outdated in this area. Recent data suggest devices based on mathematical modelling have limited accuracies and poor precisions. SUMMARY Measurement of CO or SV is important in critically ill patients. Most devices have accuracy and reliability issues. The choice of device should depend on the purpose of measurement. For diagnostic purposes, devices based on simple physical principles, especially thermodilution and transthoracic echocardiography are more reliable due to accuracy.
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Abstract
PURPOSE OF REVIEW To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies. RECENT FINDINGS Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise. Profound understanding of the underlying mechanisms, adequate patient selection and timing, meaningful representation and software-supported interpretation of data all play an important role. Furthermore, protocol adherence and human behaviour seem to form the often missing link between a solid physiologic principle and clinically relevant outcome. Introduction of haemodynamic monitoring should therefore not be limited to theoretical and practical issues, but also involve integration strategies. By learning from others, we might be able to implement haemodynamic monitoring in such a way that it has potential to modify the course of a disease. SUMMARY The clinical success of haemodynamic monitoring goes far beyond accuracy and precision of monitoring devices. Understanding of the factors influencing the effective implementation of therapeutic strategies plays an important role in the meaningful introduction of haemodynamic monitoring.
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Eley VA, Christensen R, Guy L, Dodd B. Perioperative Blood Pressure Monitoring in Patients With Obesity. Anesth Analg 2019; 128:484-491. [PMID: 30059399 DOI: 10.1213/ane.0000000000003647] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Blood pressure monitoring plays a key part in the preoperative, intraoperative, and postoperative care of all patients. In patients with obesity, hypertension indicates increased metabolic and surgical risk and may signal the presence of significant medical comorbidities, including obstructive sleep apnea. Avoidance of hypertension postoperatively is necessary to minimize bleeding risk after surgery. Hypotension in the postoperative period may be the first sign of significant complications that require urgent management. With the problem of being overweight or obese now affecting two-thirds of adults in Western countries, the proportion of patients with obesity in perioperative environments is similarly increasing. Detection of aberrations in blood pressure is contingent on the accuracy of blood pressure measurement methods. Patients with obesity tend to have a large arm circumference and "cone-shaped arms." Standard blood pressure cuffs fit such patients poorly, and this compromises the accuracy of measurements. Alternatives to arm blood pressure cuffs, some made specifically for individuals with obesity, have been evaluated but are not widely available to clinicians. This focused narrative review will discuss the relevance of hypertension management in the care of patients with obesity, highlight the currently available methods for perioperative monitoring of blood pressure, and explore the opportunities that exist to improve the perioperative blood pressure care in patients with obesity undergoing surgical procedures.
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Affiliation(s)
- Victoria A Eley
- From the Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Rebecca Christensen
- From the Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Louis Guy
- From the Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Benjamin Dodd
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia.,Department of Surgery, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Stroke volume and cardiac output measurement in cardiac patients during a rehabilitation program: comparison between tonometry, impedancemetry and echocardiography. Int J Cardiovasc Imaging 2019; 36:447-455. [PMID: 31845049 DOI: 10.1007/s10554-019-01738-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
Given the increasing use of noninvasive techniques for the assessment of cardiac function in clinical practice, the aim of this study was to evaluate if stroke volume (SV) and cardiac output (CO) measurements obtained by PhysioFlow impedance cardiography or HDI CR-2000 pulse wave analysis (Pulse) are interchangeable with measurements obtained by echocardiography in patients with coronary artery disease (CAD) or heart failure (HF). The study involved 48 men with heart disease (CAD or HF). We compared SV and CO measurements with the three devices at rest, as well as relative changes in SV and CO derived from a rehabilitation program. SV and CO measurements were carried out first by echocardiography and immediately after using tonometry and impedancemetry techniques simultaneously. The Bland-Altman analysis showed a significant bias in the measurement of absolute SV and CO values with Pulse and PhysioFlow. Four quadrant plot and polar plot analysis of relative change SV between Pulse and echocardiography show a rate of concordance of 77% (95% CI 60-88%) and 79% (95% CI 63-89%) respectively. The polar plot analysis showed a mean polar angle of 34° ± 22°, and a 30° radial sector containing 52% of the data points. Both Pulse and PhysioFlow devices overestimate absolute SV and CO values compared to values recorded using echocardiography. Similarly, neither Pulse nor PhysioFlow reliably track SV or CO changes after a rehabilitation program compared with echocardiography.
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70
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Cardiac Output Monitoring in Children, Adolescents and Adults Based on Pulse Contour Analysis: Comparison with Echocardiography-Derived Data and Identification of Factors Associated with Their Differences. Cardiovasc Eng Technol 2019; 11:67-83. [DOI: 10.1007/s13239-019-00439-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/18/2019] [Indexed: 01/24/2023]
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Corl KA, Azab N, Nayeemuddin M, Schick A, Lopardo T, Zeba F, Phillips G, Baird G, Merchant RC, Levy MM, Blaivas M, Abbasi A. Performance of a 25% Inferior Vena Cava Collapsibility in Detecting Fluid Responsiveness When Assessed by Novice Versus Expert Physician Sonologists. J Intensive Care Med 2019; 35:1520-1528. [PMID: 31610729 DOI: 10.1177/0885066619881123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Inferior vena cava collapsibility (cIVC) measured by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means of assessing fluid responsiveness. We aimed to prospectively evaluate the performance of a 25% cIVC cutoff value to detect fluid responsiveness among spontaneously breathing intensive care unit (ICU) patients when assessed with POCUS by novice versus expert physician sonologists. METHODS Prospective observational study of spontaneously breathing ICU patients. Fluid responsiveness was defined as a >10% increase in cardiac index following a 500 mL fluid bolus, measured by bioreactance. Novice sonologist measured cIVC with POCUS. Their measurements were later compared to an expert physician sonologist who independently reviewed the POCUS images and assessed cIVCs. RESULTS Of the 85 participants, 44 (52%) were fluid responders. A 25% cIVC cutoff value performed better when assessed by expert sonologists than novice physician sonologists (receiver-operator characteristic curve, ROC = 0.82 [0.74-0.88] vs ROC = 0.69 [0.60-0.77]). CONCLUSIONS A 25% cIVC cutoff value measured by POCUS detects fluid responsiveness. However, the experience of the physician sonologist affects test performance and should be considered when interpreting and clinically using cIVC to direct intravenous fluid resuscitation.
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Affiliation(s)
- Keith A Corl
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Nader Azab
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Mohammed Nayeemuddin
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Alexandra Schick
- Department of Emergency Medicine, 12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas Lopardo
- 12321Alpert Medical School of Brown University, the Brown University School of Public Health, Providence, RI, USA
| | - Fatima Zeba
- Department of Medicine, Kent Hospital, 12321Alpert Medical School of Brown University, Warwick, RI, USA
| | - Gary Phillips
- Center for Biostatistics, Department of Biomedical Informatics, Ohio State University, Columbus, Ohio, USA
| | - Grayson Baird
- Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA
| | - Roland C Merchant
- 6752Brown University School of Public Health, Providence, RI, USA.,Department of Emergency Medicine, 1861Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchell M Levy
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Michael Blaivas
- Department of Emergency Medicine, St Francis Hospital, 2629University of South Carolina School of Medicine, Columbus, SC, USA
| | - Adeel Abbasi
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA.,6752Brown University School of Public Health, Providence, RI, USA
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Automated systems for perioperative goal-directed hemodynamic therapy. J Anesth 2019; 34:104-114. [DOI: 10.1007/s00540-019-02683-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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73
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Kim GE, Kim SY, Kim SJ, Yun SY, Jung HH, Kang YS, Koo BN. Accuracy and Efficacy of Impedance Cardiography as a Non-Invasive Cardiac Function Monitor. Yonsei Med J 2019; 60:735-741. [PMID: 31347328 PMCID: PMC6660442 DOI: 10.3349/ymj.2019.60.8.735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/09/2019] [Accepted: 06/16/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The most common method of monitoring cardiac output (CO) is thermodilution using pulmonary artery catheter (PAC), but this method is associated with complications. Impedance cardiography (ICG) is a non-invasive CO monitoring technique. This study compared the accuracy and efficacy of ICG as a non-invasive cardiac function monitoring technique to those of thermodilution and arterial pressure contour. MATERIALS AND METHODS Sixteen patients undergoing liver transplantation were included. Cardiac index (CI) was measured by thermodilution using PAC, arterial waveform analysis, and ICG simultaneously in each patient. Statistical analysis was performed using intraclass correlation coefficient (ICC) and Bland-Altman analysis to assess the degree of agreement. RESULTS The difference by thermodilution and ICG was 1.13 L/min/m², and the limits of agreement were -0.93 and 3.20 L/min/m². The difference by thermodilution and arterial pressure contour was 0.62 L/min/m², and the limits of agreement were -1.43 and 2.67 L/min/m². The difference by arterial pressure contour and ICG was 0.50 L/min/m², and the limits of agreement were -1.32 and 2.32 L/min/m². All three percentage errors exceeded the 30% limit of acceptance. Substantial agreement was observed between CI of thermodilution with PAC and ICG at preanhepatic and anhepatic phases, as well as between CI of thermodilution and arterial waveform analysis at preanhepatic phase. Others showed moderate agreement. CONCLUSION Although neither method was clinically equivalent to thermodilution, ICG showed more substantial correlation with thermodilution method than with arterial waveform analysis. As a non-invasive cardiac function monitor, ICG would likely require further studies in other settings.
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Affiliation(s)
- Go Eun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seon Ju Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Young Yun
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Ho Jung
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yhen Seung Kang
- Department of Anesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Bon Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-153. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
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Effect of octopus tissue stabilizer on cardiac output during off-pump coronary artery bypass graft surgery. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 16:69-73. [PMID: 31410093 PMCID: PMC6690156 DOI: 10.5114/kitp.2019.86358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/28/2019] [Indexed: 12/04/2022]
Abstract
Introduction Significant hemodynamic derangements can occur during off-pump coronary artery bypass graft (OPCAB) surgery resulting from the displacement of the beating heart, which may necessitate conversion to on-pump surgery. Aim We proposed to evaluate the alterations in hemodynamic parameters in patients during the course of anastomosis in OPCAB surgery using the Octopus tissue stabilizer. Material and methods In 100 consecutive patients undergoing OPCAB surgery, hemodynamic variables including cardiac output (CO), heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were recorded at baseline, during each coronary artery anastomosis at 2 min, 10 min and after release of the Octopus tissue stabilizer. Results CO decreased significantly after target stabilization and during all coronary anastomoses (5.42 ±1.1 l/min at baseline, 4.26 ±1.02 l/min at 2 min and 3.92 ±0.98 l/min at 10 min; p < 0.001), with the greatest decrease noted during obtuse marginal (OM) branch of left circumflex artery anastomosis (3.67 ±0.86 l/min at 2 min and 3.38 ±0.78 l/min at 10 min). Inotropic drugs were required to maintain mean arterial pressure (MAP) > 60 mm Hg in 43 patients, which was most frequently noted during OM anastomosis (p < 0.001). The incidence of bradycardia requiring inotropes was noted to be the highest during left anterior descending (LAD) artery anastomosis (p = 0.002). Conclusions During OPCAB surgery using the Octopus for coronary target stabilization, CO decreased the most during OM anastomosis requiring inotropes, while bradycardia was most frequent during LAD anastomosis. Careful monitoring and management of hemodynamic variables are therefore of utmost importance to avoid conversion to on-pump surgery.
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Hino H, Matsuura T, Kihara Y, Tsujikawa S, Mori T, Nishikawa K. Comparison between hemodynamic effects of propofol and thiopental during general anesthesia induction with remifentanil infusion: a double-blind, age-stratified, randomized study. J Anesth 2019; 33:509-515. [DOI: 10.1007/s00540-019-02657-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/14/2019] [Indexed: 12/11/2022]
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Sanders M, Servaas S, Slagt C. Accuracy and precision of non-invasive cardiac output monitoring by electrical cardiometry: a systematic review and meta-analysis. J Clin Monit Comput 2019; 34:433-460. [PMID: 31175501 PMCID: PMC7205855 DOI: 10.1007/s10877-019-00330-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
Cardiac output monitoring is used in critically ill and high-risk surgical patients. Intermittent pulmonary artery thermodilution and transpulmonary thermodilution, considered the gold standard, are invasive and linked to complications. Therefore, many non-invasive cardiac output devices have been developed and studied. One of those is electrical cardiometry. The results of validation studies are conflicting, which emphasize the need for definitive validation of accuracy and precision. We performed a database search of PubMed, Embase, Web of Science and the Cochrane Library of Clinical Trials to identify studies comparing cardiac output measurement by electrical cardiometry and a reference method. Pooled bias, limits of agreement (LoA) and mean percentage error (MPE) were calculated using a random-effects model. A pooled MPE of less than 30% was considered clinically acceptable. A total of 13 studies in adults (620 patients) and 11 studies in pediatrics (603 patients) were included. For adults, pooled bias was 0.03 L min-1 [95% CI - 0.23; 0.29], LoA - 2.78 to 2.84 L min-1 and MPE 48.0%. For pediatrics, pooled bias was - 0.02 L min-1 [95% CI - 0.09; 0.05], LoA - 1.22 to 1.18 L min-1 and MPE 42.0%. Inter-study heterogeneity was high for both adults (I2 = 93%, p < 0.0001) and pediatrics (I2 = 86%, p < 0.0001). Despite the low bias for both adults and pediatrics, the MPE was not clinically acceptable. Electrical cardiometry cannot replace thermodilution and transthoracic echocardiography for the measurement of absolute cardiac output values. Future research should explore it's clinical use and indications.
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Affiliation(s)
- M Sanders
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, The Netherlands
| | - S Servaas
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, The Netherlands
| | - C Slagt
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, The Netherlands.
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Saugel B, Cecconi M, Hajjar LA. Noninvasive Cardiac Output Monitoring in Cardiothoracic Surgery Patients: Available Methods and Future Directions. J Cardiothorac Vasc Anesth 2019; 33:1742-1752. [DOI: 10.1053/j.jvca.2018.06.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 12/28/2022]
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Joosten A, Boudart C, Vincent JL, Vanden Eynden F, Barvais L, Van Obbergh L, Rinehart J, Desebbe O. Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery. Anesth Analg 2019; 128:1145-1151. [PMID: 31094781 DOI: 10.1213/ane.0000000000003652] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32-36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60-0.84] vs 0.68 [0.54-0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54-0.92) and a specificity of 74% (95% CI, 0.55-0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42-0.88) and a specificity of 74% (95% CI, 0.48-0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP = 0.818 [P = .0001]; PPVPC = 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP = 0.645 [P = .19]; PPVPC = 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: -2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66-77). CONCLUSIONS In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness.
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Affiliation(s)
| | | | | | | | | | | | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, Irvine, California
| | - Olivier Desebbe
- Departments of Anesthesiology and Intensive Care, Clinique de la Sauvegarde, Lyon, France
- Université Lyon 1, EA4169, SFR Lyon-Est Santé - INSERM US 7- CNRS UMS 3453, Lyon, France
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Cowie BS, Buckley AB, Kluger R, Phan TD. The cardiovascular effects of crystalloid administration in endoscopy patients. Anaesth Intensive Care 2019; 47:45-51. [PMID: 30864482 DOI: 10.1177/0310057x18811761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intravenous fluids are commonly administered for patients having colonoscopy despite relatively little data to support this practice. It is unclear what, if any, effect crystalloid administration has on stroke volume and cardiac output in patients who are fasting and have had bowel preparation agents. We aimed to assess the physiological effect of 10 ml/kg of crystalloid administration in colonoscopy patients on haemodynamic parameters including stroke volume, stroke volume variation and cardiac output, as measured with transthoracic echocardiography. Our secondary aims were to determine whether stroke volume variation predicted fluid responsiveness in gastrointestinal endoscopy patients and whether these haemodynamic measures are different in fasting patients with bowel preparation (colonoscopy patients) compared to fasting patients alone (gastroscopy patients). We recruited 54 patients having elective gastrointestinal endoscopy (25 colonoscopy, 29 gastroscopy). All patients had stroke volume, cardiac output and stroke volume variation measured with transthoracic echocardiography at baseline. In colonoscopy patients, stroke volume, cardiac output and stroke volume variation were remeasured after 10 ml/kg of intravenous crystalloid. Administration of 10 ml/kg of crystalloid increases stroke volume by 19.6 ml ( p < 0.00005) and cardiac output by 0.81 l/min ( p < 0.001). Stroke volume variation reduced from 23% to 14% after fluid administration ( p < 0.0011). The optimum threshold of stroke volume variation to predict fluid responsiveness was 21% with a sensitivity of 77.8% and specificity of 62.5%. Administration of 10 ml/kg of crystalloid increases stroke volume and cardiac output, and reduces stroke volume variation in fasting elective colonoscopy patients.
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Affiliation(s)
- Brian S Cowie
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - Aisling B Buckley
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - Roman Kluger
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
| | - Tuong D Phan
- Department of Anaesthesia, St Vincent's Hospital, Melbourne, Australia
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Tronstad C, Høgetveit JO, Elvebakk O, Kalvøy H. Age-related Differences in the Morphology of the Impedance Cardiography Signal. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2019; 10:139-145. [PMID: 33584895 PMCID: PMC7851975 DOI: 10.2478/joeb-2019-0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Indexed: 06/12/2023]
Abstract
Impedance cardiography (ICG) is a non-invasive method of hemodynamic measurement, mostly known for estimation of stroke volume and cardiac output based on characteristic features of the signal. Compared with electrocardiography, the knowledge on the morphology of the ICG signal is scarce, especially with respect to age-dependent changes in ICG waveforms. Based on recordings from ten younger (20-29 years) and ten older (60-79) healthy human subjects after three different levels of physical activity, the typical interbeat ICG waveforms were derived based on ensemble averages. Comparison of these waveforms between the age groups indicates the following differences: a later initial upward deflection for the younger group, an additional hump in the waveform from many older subjects not presented in the younger group, and a more pronounced second wave in the younger group. The explanation for these differences is not clear, but may be related to arterial stiffness. Further studies are suggested to determine whether these morphological differences have clinical value.
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Affiliation(s)
- Christian Tronstad
- Department of Clinical and Biomedical Engineering, Oslo University Hospital, Oslo, Norway
| | - Jan Olav Høgetveit
- Department of Clinical and Biomedical Engineering, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo. Norway
| | - Ole Elvebakk
- Department of Clinical and Biomedical Engineering, Oslo University Hospital, Oslo, Norway
| | - Håvard Kalvøy
- Department of Clinical and Biomedical Engineering, Oslo University Hospital, Oslo, Norway
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83
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Maeda T, Hamaguchi E, Kubo N, Shimokawa A, Kanazawa H, Ohnishi Y. The accuracy and trending ability of cardiac index measured by the fourth-generation FloTrac/Vigileo system™ and the Fick method in cardiac surgery patients. J Clin Monit Comput 2018; 33:767-776. [DOI: 10.1007/s10877-018-0217-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/01/2018] [Indexed: 12/25/2022]
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84
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Su CH, Liu SH, Tan TH, Lo CH. Using the Pulse Contour Method to Measure the Changes in Stroke Volume during a Passive Leg Raising Test. SENSORS 2018; 18:s18103420. [PMID: 30322018 PMCID: PMC6210240 DOI: 10.3390/s18103420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 11/16/2022]
Abstract
The pulse contour method is often used with the Windkessel model to measure stroke volume. We used a digital pressure and flow sensors to detect the parameters of the Windkessel model from the pulse waveform. The objective of this study was to assess the stability and accuracy of this method by making use of the passive leg raising test. We studied 24 healthy subjects (40 ± 9.3 years), and used the Medis® CS 1000, an impedance cardiography, as the comparing reference. The pulse contour method measured the waveform of the brachial artery by using a cuff. The compliance and resistance of the peripheral artery was detected from the cuff characteristics and the blood pressure waveform. Then, according to the method proposed by Romano et al., the stroke volume could be measured. This method was implemented in our designed blood pressure monitor. A passive leg raising test, which could immediately change the preloading of the heart, was done to certify the performance of our method. The pulse contour method and impedance cardiography simultaneously measured the stroke volume. The measurement of the changes in stroke volume using the pulse contour method had a very high correlation with the Medis® CS 1000 measurement, the correlation coefficient of the changed ratio and changed differences in stroke volume were r² = 0.712 and r² = 0.709, respectively. It was shown that the stroke volume measured by using the pulse contour method was not accurate enough. But, the changes in the stroke volume could be accurately measured with this pulse contour method. Changes in stroke volume are often used to understand the conditions of cardiac preloading in the clinical field. Moreover, the operation of the pulse contour method is easier than using impedance cardiography and echocardiography. Thus, this method is suitable to use in different healthcare fields.
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Affiliation(s)
- Chun-Hung Su
- Institute of Medicine, School of Medicine, Chung-Shan Medical University; Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung 402, Taiwan.
| | - Shing-Hong Liu
- Department of Computer Science and Information Engineering, Chaoyang University of Technology, Taichung 413, Taiwan.
| | - Tan-Hsu Tan
- Department of Electrical Engineering, National Taipei University of Technology, Taipei 10608, Taiwan.
| | - Chien-Hsien Lo
- Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung 402, Taiwan.
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85
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Ontiveros N, Eapen-John D, Osorio N, Song J, Li L, Sheshadri A, Tiang X, Ghosh N, Vaporciyan A, Correa A, Walsh G, Grosu HB, Ost DE. Predicting Lung Function Following Lobectomy: A New Method to Adjust for Inherent Selection Bias. Respiration 2018; 96:434-445. [PMID: 30257257 DOI: 10.1159/000490258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/21/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Predictions that overestimate post-lobectomy lung function are more likely than underestimates to lead to lobectomy. Studies of post-lobectomy lung function have included only surgical patients, so overestimates are overrepresented. This selection bias has led to incorrect estimates of prediction bias, which has led to inaccurate threshold values for determining lobectomy eligibility. OBJECTIVE The objective of this study was to demonstrate and adjust for this selection bias in order to arrive at correct estimates of prediction bias, the 95% limits of agreement, and adjusted threshold values for determining when exercise testing is warranted. METHODS We conducted a retrospective study of patients evaluated for lobectomy. We used multiple imputations to determine postoperative results for patients who did not have surgery because their predicted postoperative values were low. We combined these results with surgical patients to adjust for selection bias. We used the Bland-Altman method and the bivariate normal distribution to determine threshold values for surgical eligibility. RESULTS Lobectomy evaluation was performed in 114 patients; 79 had lobectomy while 35 were ineligible based on predicted values. Prediction bias using the Bland-Altman method changed significantly after controlling for selection bias. To achieve a postoperative FEV1 > 30% and DLCO ≥30%, a predicted FEV1 > 46% and DLCO ≥53% were required. Compared to current guidelines, using these thresholds would change management in 17% of cases. CONCLUSION The impact of selection bias on estimates of prediction accuracy was significant but can be corrected. Threshold values for determining surgical eligibility should be reassessed.
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Affiliation(s)
- Narda Ontiveros
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - David Eapen-John
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Natasha Osorio
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Juhee Song
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Xin Tiang
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Natasha Ghosh
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ara Vaporciyan
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Arlene Correa
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Garrett Walsh
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Horiana B Grosu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - David E Ost
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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86
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Gillies MA, Edwards MR. Performance of cardiac output monitoring in the peri-operative setting. Anaesthesia 2018; 73:1457-1459. [PMID: 30074240 DOI: 10.1111/anae.14374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M R Edwards
- Department of Anaesthesia and Peri-operative Medicine, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
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87
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Truijen J, Westerhof BE, Kim YS, Stok WJ, de Mol BA, Preckel B, Hollmann MW, van Lieshout JJ. The effect of haemodynamic and peripheral vascular variability on cardiac output monitoring: thermodilution and non-invasive pulse contour cardiac output during cardiothoracic surgery. Anaesthesia 2018; 73:1489-1499. [DOI: 10.1111/anae.14380] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- J. Truijen
- Laboratory for Clinical Cardiovascular Physiology; Department of Medical Biology, section Systems Physiology; Academic Medical Center; University of Amsterdam; The Netherlands
| | - B. E. Westerhof
- Department of Pulmonary Diseases; VU University Medical Center; Amsterdam The Netherlands
| | - Y.-S. Kim
- Department of Nephrology; VU University Medical Center; Amsterdam The Netherlands
| | - W. J. Stok
- Laboratory for Clinical Cardiovascular Physiology; Department of Medical Biology, section Systems Physiology; Academic Medical Center; University of Amsterdam; The Netherlands
| | - B. A. de Mol
- Department of Cardiothoracic Surgery; Academic Medical Center; University of Amsterdam; The Netherlands
| | - B. Preckel
- Department of Anaesthesiology; Academic Medical Center; University of Amsterdam; The Netherlands
| | - M. W. Hollmann
- Department of Anaesthesiology; Academic Medical Center; University of Amsterdam; The Netherlands
| | - J. J. van Lieshout
- MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research; School of Life Sciences; University of Nottingham Medical School; Queen's Medical Centre; Nottingham UK
- Department of Internal Medicine; Academic Medical Center; University of Amsterdam; The Netherlands
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88
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Minimally invasive cardiac output technologies in the ICU: putting it all together. Curr Opin Crit Care 2018; 23:302-309. [PMID: 28538248 DOI: 10.1097/mcc.0000000000000417] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Haemodynamic monitoring is a cornerstone in the diagnosis and evaluation of treatment in critically ill patients in circulatory distress. The interest in using minimally invasive cardiac output monitors is growing. The purpose of this review is to discuss the currently available devices to provide an overview of their validation studies in order to answer the question whether these devices are ready for implementation in clinical practice. RECENT FINDINGS Current evidence shows that minimally invasive cardiac output monitoring devices are not yet interchangeable with (trans)pulmonary thermodilution in measuring cardiac output. However, validation studies are generally single centre, are based on small sample sizes in heterogeneous groups, and differ in the statistical methods used. SUMMARY Minimally and noninvasive monitoring devices may not be sufficiently accurate to replace (trans)pulmonary thermodilution in estimating cardiac output. The current paradigm shift to explore trending ability rather than investigating agreement of absolute values alone is to be applauded. Future research should focus on the effectiveness of these devices in the context of (functional) haemodynamic monitoring before adoption into clinical practice can be recommended.
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89
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90
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Altamirano-Diaz L, Welisch E, Dempsey AA, Park TS, Grattan M, Norozi K. Non-invasive measurement of cardiac output in children with repaired coarctation of the aorta using electrical cardiometry compared to transthoracic Doppler echocardiography. Physiol Meas 2018; 39:055003. [PMID: 29695645 DOI: 10.1088/1361-6579/aac02b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the equivalence of the ICON® electrical cardiometry (EC) haemodynamic monitor to measure cardiac output (CO) relative to transthoracic Doppler echocardiography (TTE) in paediatric patients with repaired coarctation of the aorta (CoA). APPROACH A group of n = 28 CoA patients and n = 27 matched controls were enrolled. EC and TTE were performed synchronously on each participant and CO measurements compared using linear regression and Bland-Altman analysis. The CoA group was further subdivided into two groups, with n = 10 and without n = 18 increased left ventricular outflow tract velocity (iLVOTv) for comparison. MAIN RESULTS CO measurements from EC and TTE in controls showed a strong correlation (R = 0.80, p < 0.001) and an acceptable percentage error (PE) of 28.1%. However, combining CoA and control groups revealed a moderate correlation (R = 0.57, p < 0.001) and a poor PE (44.2%). We suspected that the CO in a subset of CoA participants with iLVOTv was overestimated by TTE. Excluding the iLVOTv CoA participants improved the correlation (R = 0.77, p < 0.001) and resulted in an acceptable PE of 31.2%. SIGNIFICANCE CO measurements in paediatric CoA patients in the absence of iLVOTv are clinically equivalent between EC and TTE. The presence of iLVOTv may impact the accuracy of CO measurement by TTE, but not EC.
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Affiliation(s)
- Luis Altamirano-Diaz
- Department of Paediatrics, Western University, London, Ontario, Canada. Children's Health Research Institute, London, Ontario, Canada. Paediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, Ontario, Canada
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91
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Alternatives to the Swan–Ganz catheter. Intensive Care Med 2018; 44:730-741. [DOI: 10.1007/s00134-018-5187-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
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92
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Teefy P, Bagur R, Phillips C, Karimi-Shahri K, Teefy J, Sule R, Dempsey AA, Norozi K. Impact of Obesity on Noninvasive Cardiac Hemodynamic Measurement by Electrical Cardiometry in Adults With Aortic Stenosis. J Cardiothorac Vasc Anesth 2018; 32:2505-2511. [PMID: 29903682 DOI: 10.1053/j.jvca.2018.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES There are substantial potential benefits to noninvasive cardiac monitoring methods, such as electrical cardiometry (EC), over more invasive methods, including significantly reduced risk of complications, lower up-front and operational costs, ease of use, and continuous monitoring. To take advantage of these technologies, clinical equivalence to currently established methods must be determined. The authors sought to determine if the noninvasive measurement of cardiac index (CI) by EC was clinically equivalent to thermodilution (TD) in adult patients with aortic stenosis (AS). DESIGN This is a cross-sectional study comparing measurement devices in a single patient group. SETTING Single-center, university teaching hospital. PARTICIPANTS The study included 52 adult patients with aortic stenosis undergoing right heart catheterization. INTERVENTIONS Cardiac output (CO) was measured concurrently using EC with an ICON device and TD in 52 participants with AS. CI values were to determine the accuracy and precision of EC in reference to TD. Percentage error (PE) was used to assess their clinical equivalence. The participants were divided further into groups (normal and overweight/obese) based on body mass index and the analysis was repeated. MEASUREMENTS AND MAIN RESULTS CO measurement made by EC in adult patients with obesity or overweight was reduced significantly relative to TD. This was not observed in normal-weight adult AS patients. EC provided clinically equivalent measurements to TD for measuring CI in normal-weight adult AS patients (PE = 25.0%), but not for those adult AS patients with overweight or obesity (PE = 42.3%). CONCLUSION Overall, the ICON device produced lower CO and index measurements relative to TD in adult patients with AS. Overweight and obesity also significantly affected the relative precision and accuracy of the ICON electrical cardiometric device to measure CI in these patients.
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Affiliation(s)
- Patrick Teefy
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - Rodrigo Bagur
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - Chantal Phillips
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - Kourosh Karimi-Shahri
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - John Teefy
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - Raksha Sule
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada
| | - Adam A Dempsey
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada; Children's Health Research Institute, London, Canada; Paediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, Canada
| | - Kambiz Norozi
- Department of Paediatrics, Division of Paediatric Cardiology, Western University, London, Canada; Children's Health Research Institute, London, Canada; Paediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, Canada; Department of Paediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany; Department of Paediatric Cardiology and Intensive Care Medicine, University of Goettingen, Goettingen, Germany.
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93
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Galarza L, Mercado P, Teboul JL, Girotto V, Beurton A, Richard C, Monnet X. Estimating the rapid haemodynamic effects of passive leg raising in critically ill patients using bioreactance. Br J Anaesth 2018; 121:567-573. [PMID: 30115254 DOI: 10.1016/j.bja.2018.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/15/2018] [Accepted: 03/24/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Rapid detection of changes in cardiac index (CI) in real time using minimally invasive monitors may be of clinical benefit. We tested whether the Starling-SV bioreactance device, which averages CI over a short 8 s period, could assess the effects of passive leg raising (PLR), a clinical test that is recommended to assess fluid responsiveness during septic shock. METHODS In 32 critically ill patients, we measured CI by transpulmonary thermodilution (PiCCO2, CItd), pulse contour analysis (PiCCO2, CIPulse), and the Starling-SV device (CIStarling) at baseline. CIPulse and CIStarling were measured again at the end of a PLR test. In the 13 patients with a positive PLR test, CItd, CIPulse, and CIStarling were measured before and after a 500 ml saline infusion. The primary outcome was relative changes from baseline measurements in CItd, CIPulse, and CIStarling. Secondary outcomes compared absolute values measured by each method. RESULTS Relative changes in CIPulse and CItd were significantly correlated (r=0.82; n=45; P<0.001), with an 89% concordance rate (n=45 paired measurements). Relative changes in CIStarling and CItd were also significantly correlated (r=0.59; n=45; P<0.001) with a 78% concordance rate. For absolute measures of CI (n=77 paired measurements), the bias between CIPulse and CItd was 0.01 L min-1 m-2 (limits of agreement, -0.49 and 0.51 L min-1 m-2; 15% percentage error). Bias between CIStarling and CItd was 0.03 L min-1 m-2 (limits of agreement, -1.61 and 1.67 L min-1 m-2; 48% percentage error). CONCLUSIONS In critically ill patients, a non-invasive bioreactance device with a shorter averaging period assessed a passive leg raising test with reasonable accuracy.
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Affiliation(s)
- L Galarza
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - P Mercado
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - J-L Teboul
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - V Girotto
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - A Beurton
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - C Richard
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - X Monnet
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Assistance Publique - Hôpitaux de Paris, Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France.
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94
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Abstract
Role of hemodynamic monitoring in critically ill patients is still controversial. While invasive monitoring is accurate, it may be counter-productive in view of its essentially invasive nature. Non-invasive monitoring is less intrusive but has not yet been well validated for accuracy compared with gold standard of invasive monitoring.
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95
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Benes J, Cerny V. Fluid therapy and endothelial glycocalyx layer. On the track of the water-phobic Bigfoot. Minerva Anestesiol 2018; 84:1007-1009. [PMID: 29624031 DOI: 10.23736/s0375-9393.18.12811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic - .,Biomedical Center, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic -
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J. E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic.,Centrum for Research and Development, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic.,Department of Anesthesiology and Intensive Care, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.,Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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96
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Impact of continuous non-invasive blood pressure monitoring on hemodynamic fluctuation during general anesthesia: a randomized controlled study. J Clin Monit Comput 2018; 32:1005-1013. [DOI: 10.1007/s10877-018-0125-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
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97
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Lorne E, Diouf M, de Wilde RB, Fischer MO. Assessment of interchangeability rate between 2 methods of measurements: An example with a cardiac output comparison study. Medicine (Baltimore) 2018; 97:e9905. [PMID: 29443764 PMCID: PMC5839816 DOI: 10.1097/md.0000000000009905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The Bland-Altman (BA) and percentage error (PE) methods have been previously described to assess the agreement between 2 methods of medical or laboratory measurements. This type of approach raises several problems: the BA methodology constitutes a subjective approach to interchangeability, whereas the PE approach does not take into account the distribution of values over a range. We describe a new methodology that defines an interchangeability rate between 2 methods of measurement and cutoff values that determine the range of interchangeable values. We used a simulated data and a previously published data set to demonstrate the concept of the method. The interchangeability rate of 5 different cardiac output (CO) pulse contour techniques (Wesseling method, LiDCO, PiCCO, Hemac method, and Modelflow) was calculated, in comparison with the reference pulmonary artery thermodilution CO using our new method. In our example, Modelflow with a good interchangeability rate of 93% and a cutoff value of 4.8 L min, was found to be interchangeable with the thermodilution method for >95% of measurements. Modelflow had a higher interchangeability rate compared to Hemac (93% vs 86%; P = .022) or other monitors (Wesseling cZ = 76%, LiDCO = 73%, and PiCCO = 62%; P < .0001). Simulated data and reanalysis of a data set comparing 5 CO monitors against thermodilution CO showed that, depending on the repeatability of the reference method, the interchangeability rate combined with a cutoff value could be used to define the range of values over which interchangeability remains acceptable.
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Affiliation(s)
- Emmanuel Lorne
- Anesthesiology and Critical Care Department, Amiens University Hospital
- INSERM U 1088, Jules Vernes University of Picardy, Centre Universitaire de Recherche en Santé
| | - Momar Diouf
- Department of Biostatistics and Clinical Research, Amiens University Hospital, Amiens, France
| | - Robert B.P. de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc-Olivier Fischer
- Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre, Caen, France
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98
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Braun F, Proença M, Lemay M, Bertschi M, Adler A, Thiran JP, Solà J. Limitations and challenges of EIT-based monitoring of stroke volume and pulmonary artery pressure. Physiol Meas 2018; 39:014003. [DOI: 10.1088/1361-6579/aa9828] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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99
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Braun F, Proença M, Adler A, Riedel T, Thiran JP, Solà J. Accuracy and reliability of noninvasive stroke volume monitoring via ECG-gated 3D electrical impedance tomography in healthy volunteers. PLoS One 2018; 13:e0191870. [PMID: 29373611 PMCID: PMC5786320 DOI: 10.1371/journal.pone.0191870] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/12/2018] [Indexed: 01/31/2023] Open
Abstract
Cardiac output (CO) and stroke volume (SV) are parameters of key clinical interest. Many techniques exist to measure CO and SV, but are either invasive or insufficiently accurate in clinical settings. Electrical impedance tomography (EIT) has been suggested as a noninvasive measure of SV, but inconsistent results have been reported. Our goal is to determine the accuracy and reliability of EIT-based SV measurements, and whether advanced image reconstruction approaches can help to improve the estimates. Data were collected on ten healthy volunteers undergoing postural changes and exercise. To overcome the sensitivity to heart displacement and thorax morphology reported in previous work, we used a 3D EIT configuration with 2 planes of 16 electrodes and subject-specific reconstruction models. Various EIT-derived SV estimates were compared to reference measurements derived from the oxygen uptake. Results revealed a dramatic impact of posture on the EIT images. Therefore, the analysis was restricted to measurements in supine position under controlled conditions (low noise and stable heart and lung regions). In these measurements, amplitudes of impedance changes in the heart and lung regions could successfully be derived from EIT using ECG gating. However, despite a subject-specific calibration the heart-related estimates showed an error of 0.0 ± 15.2 mL for absolute SV estimation. For trending of relative SV changes, a concordance rate of 80.9% and an angular error of -1.0 ± 23.0° were obtained. These performances are insufficient for most clinical uses. Similar conclusions were derived from lung-related estimates. Our findings indicate that the key difficulty in EIT-based SV monitoring is that purely amplitude-based features are strongly influenced by other factors (such as posture, electrode contact impedance and lung or heart conductivity). All the data of the present study are made publicly available for further investigations.
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Affiliation(s)
- Fabian Braun
- Systems Division, Centre Suisse d’Electronique et de Microtechnique (CSEM), CH-2002 Neuchâtel, Switzerland
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
- * E-mail:
| | - Martin Proença
- Systems Division, Centre Suisse d’Electronique et de Microtechnique (CSEM), CH-2002 Neuchâtel, Switzerland
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, ON K1S 5B6, Canada
| | - Thomas Riedel
- Cantonal Hospital Graubuenden, CH-7000 Chur, Switzerland
- University Children’s Hospital and University of Bern, CH-3010 Bern, Switzerland
| | - Jean-Philippe Thiran
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
- Department of Radiology, University Hospital Center (CHUV) and University of Lausanne (UNIL), CH-1011 Lausanne, Switzerland
| | - Josep Solà
- Systems Division, Centre Suisse d’Electronique et de Microtechnique (CSEM), CH-2002 Neuchâtel, Switzerland
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Calixto Fernandes MH, Schricker T, Magder S, Hatzakorzian R. Perioperative fluid management in kidney transplantation: a black box. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:14. [PMID: 29368625 PMCID: PMC5784708 DOI: 10.1186/s13054-017-1928-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/21/2017] [Indexed: 01/14/2023]
Abstract
The incidence of delayed graft function in patients undergoing kidney transplantation remains significant. Optimal fluid therapy has been shown to decrease delayed graft function after renal transplantation. Traditionally, the perioperative volume infusion regimen in this patient population has been guided by central venous pressure as an estimation of the patient’s volume status and mean arterial pressure, but this is based on sparse evidence from mostly retrospective observational studies. Excessive volume infusion to the point of no further fluid responsiveness can damage the endothelial glycocalyx and is no longer considered to be the best approach. However, achievement of adequate flow to maintain sufficient tissue perfusion without maximization of cardiac filling remains a challenge. Novel minimally invasive technologies seem to reliably assess volume responsiveness, heart function and perfusion adequacy. Prospective comparative clinical studies are required to better understand the use of dynamic analyses of flow parameters for adequate fluid management in kidney transplant recipients. We review perioperative fluid assessment techniques and discuss conventional and novel monitoring strategies in the kidney transplant recipient.
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Affiliation(s)
| | - Thomas Schricker
- Department of Anesthesia, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Sheldon Magder
- Department of Critical Care Medicine, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Roupen Hatzakorzian
- Department of Anesthesia, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.,Department of Critical Care Medicine, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
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