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Preau S, Dewavrin F, Demaeght V, Chiche A, Voisin B, Minacori F, Poissy J, Boulle-Geronimi C, Blazejewski C, Onimus T, Durocher A, Saulnier F. The use of static and dynamic haemodynamic parameters before volume expansion: A prospective observational study in six French intensive care units. Anaesth Crit Care Pain Med 2015; 35:93-102. [PMID: 26603329 DOI: 10.1016/j.accpm.2015.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/31/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of the present study was to determine the use of static and dynamic haemodynamic parameters for predicting fluid responsiveness prior to volume expansion (VE) in intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS). METHODS We conducted a prospective, multicentre, observational study in 6 French ICUs in 2012. ICU physicians were audited concerning their use of static and dynamic haemodynamic parameters before each VE performed in patients with SIRS for 6 consecutive weeks. RESULTS The median volume of the 566 VEs administered to patients with SIRS was 1000mL [500-1000mL]. Although at least one static or dynamic haemodynamic parameter was measurable before 99% (95% CI, 99%-100%) of VEs, at least one them was used in only 38% (95% CI, 34%-42%) of cases: static parameters in 11% of cases (95% CI, 10%-12%) and dynamic parameters in 32% (95% CI, 30%-34%). Static parameters were never used when uninterpretable. For 15% of VEs (95% CI, 12%-18%), a dynamic parameter was measured in the presence of contraindications. Among dynamic parameters, respiratory variations in arterial pulse pressure (PPV) and passive leg raising (PLR) were measurable and interpretable before 17% and 90% of VEs, respectively. CONCLUSIONS Haemodynamic parameters are underused for predicting fluid responsiveness in current practice. In contrast to static parameters, dynamic parameters are often incorrectly used in the presence of contraindications. PLR is more frequently valid than PPV for predicting fluid responsiveness in ICU patients.
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Affiliation(s)
- Sébastien Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Florent Dewavrin
- Intensive Care Unit, General Hospital of Valenciennes, 59300 Valenciennes, France.
| | - Vincent Demaeght
- Intensive Care Unit, General Hospital of Valenciennes, 59300 Valenciennes, France.
| | - Arnaud Chiche
- Intensive Care Unit, General Hospital of Tourcoing, 59200 Tourcoing, France.
| | - Benoît Voisin
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Franck Minacori
- Intensive Care Unit, University Hospital of Lomme, 59160 Lomme, France.
| | - Julien Poissy
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | | | - Caroline Blazejewski
- Intensive Care Unit, Salengro Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Thierry Onimus
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Alain Durocher
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
| | - Fabienne Saulnier
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000 Lille, France.
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102
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Seo H, Kong YG, Jin SJ, Chin JH, Kim HY, Lee YK, Hwang JH, Kim YK. Dynamic Arterial Elastance in Predicting Arterial Pressure Increase After Fluid Challenge During Robot-Assisted Laparoscopic Prostatectomy: A Prospective Observational Study. Medicine (Baltimore) 2015; 94:e1794. [PMID: 26469925 PMCID: PMC4616778 DOI: 10.1097/md.0000000000001794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
During robot-assisted laparoscopic prostatectomy, specific physiological conditions such as carbon dioxide insufflation and the steep Trendelenburg position can alter the cardiac workload and cerebral hemodynamics. Inadequate arterial blood pressure is associated with hypoperfusion, organ damage, and poor outcomes. Dynamic arterial elastance (Ea) has been proposed to be a useful index of fluid management in hypotensive patients. We therefore evaluated whether dynamic Ea can predict a mean arterial pressure (MAP) increase ≥ 15% after fluid challenge during pneumoperitoneum and the steep Trendelenburg position.We enrolled 39 patients receiving robot-assisted laparoscopic prostatectomy. Fluid challenge was performed with 500 mL colloids in the presence of preload-dependent conditions and arterial hypotension. Patients were classified as arterial pressure responders or arterial pressure nonresponders according to whether they showed an MAP increase ≥15% after fluid challenge. Dynamic Ea was defined as the ratio between the pulse pressure variation and stroke volume variation. Receiver operating characteristic curve analysis was performed to assess the arterial pressure responsiveness after fluid challenge during robot-assisted laparoscopic prostatectomy.Of the 39 patients, 17 were arterial pressure responders and 22 were arterial pressure nonresponders. The mean dynamic Ea before fluid challenge was significantly higher in arterial pressure responders than in arterial pressure nonresponders (0.79 vs 0.61, P < 0.001). In receiver operating characteristic curve analysis, dynamic Ea showed an area under the curve of 0.810. The optimal cut-off value of dynamic Ea for predicting an MAP increase of ≥ 15% after fluid challenge was 0.74.Dynamic Ea can predict an MAP increase ≥ 15% after fluid challenge during robot-assisted laparoscopic prostatectomy. This result suggests that evaluation of arterial pressure responsiveness using dynamic Ea helps to maintain an adequate arterial blood pressure and to improve perioperative outcomes in preload-dependent patients receiving robot-assisted laparoscopic prostatectomy under pneumoperitoneum and in the steep Trendelenburg position.
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Affiliation(s)
- Hyungseok Seo
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea (HS); Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (Y-GK, S-JJ, J-HC, J-HH, Y-KK); and Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea (H-YK, Y-KL)
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Bocchi L, Romagnoli S. Resonance artefacts in modern pressure monitoring systems. J Clin Monit Comput 2015; 30:707-14. [PMID: 26310613 DOI: 10.1007/s10877-015-9760-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 08/20/2015] [Indexed: 12/21/2022]
Abstract
Resonance in pressure monitoring catheters is a well-known problem which was studied several years ago. Current piezoelectric devices have mechanical properties providing a resonance frequency and damping factor that theoretically assure resonance-free data. However, in particular cases, the coupling between the device, the catheter, and the vascular compliance of the patient could introduce artefacts in clinical settings leading to wrong pressure waveforms and values displayed in the monitor. In this research work we study a laboratory model of a clinical setting to evaluate in which cases the compound (catheter and device) could cause resonances in an unacceptable range. The classical pop-test is expanded for analysing the effect of the catheter. Results indicate that the presence of different catheters may alter significantly the acquired signal, up to an unacceptable level. Particular care should be used in the selection of the appropriate catheter. In particular, smaller diameters introduce higher damping coefficient that could help in avoiding undesired oscillations.
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Affiliation(s)
- L Bocchi
- Department of Information Engineering, University of Florence, Via S. Marta 3, 50139, Florence, Italy.
| | - S Romagnoli
- Department of Anesthesia and Intensive Care - Department of Health Science, Section of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi - University of Florence, Florence, Italy
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104
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Begot E, Dalmay F, Etchecopar C, Clavel M, Pichon N, Francois B, Lang R, Vignon P. Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe. Intensive Care Med 2015; 41:1886-94. [PMID: 26254013 DOI: 10.1007/s00134-015-3998-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/16/2015] [Indexed: 01/30/2023]
Abstract
PURPOSE To assess the feasibility, image quality, diagnostic accuracy, therapeutic impact and tolerance of diagnostic and hemodynamic assessment using a novel miniaturized multiplane transesophageal echocardiography (TEE) probe in ventilated ICU patients with cardiopulmonary compromise. STUDY DESIGN Prospective, descriptive, single-center study. METHODS Fifty-seven ventilated patients with acute circulatory or respiratory failure were assessed, using a miniaturized multiplane TEE probe and a standard TEE probe used as reference, randomly by two independent experienced operators. Measurements of hemodynamic parameters were independently performed off-line by a third expert. Diagnostic groups of acute circulatory failure (n = 5) and of acute respiratory failure (n = 3) were distinguished. Hemodynamic monitoring was performed in 9 patients using the miniaturized TEE probe. TEE tolerance and therapeutic impact were reported. RESULTS The miniaturized TEE probe was easier to insert than the standard TEE probe. Despite lower imaging quality of the miniaturized TEE probe, the two probes had excellent diagnostic agreement in patients with acute circulatory failure (Kappa: 0.95; 95% CI: 0.85-1) and with acute respiratory failure (Kappa: 1; 95% CI: 1.0-1.0). Accordingly, therapeutic strategies derived from both TEE examinations were concordant (Kappa: 0.82; 95% CI: 0.66-0.97). The concordance between quantitative hemodynamic parameters obtained with both TEE probes was also excellent. No relevant complication secondary to TEE probes insertion occurred. CONCLUSIONS Hemodynamic assessment of ventilated ICU patients with cardiopulmonary compromise using a miniaturized multiplane TEE probe appears feasible, well-tolerated, and relevant in terms of diagnostic information and potential therapeutic impact. Further larger-scale studies are needed to confirm these preliminary results.
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Affiliation(s)
- Emmanuelle Begot
- Medical-Surgical ICU, Réanimation Polyvalente, CHU Dupuytren, Dupuytren University Hospital, 2 avenue Martin Luther King, 87042, Limoges, France
- Faculty of Medicine, University of Limoges, Limoges, France
- Inserm CIC1435, Limoges, France
| | - François Dalmay
- Department of Biostatistics, INSERM UMR1094, Limoges, France
| | | | - Marc Clavel
- Medical-Surgical ICU, Réanimation Polyvalente, CHU Dupuytren, Dupuytren University Hospital, 2 avenue Martin Luther King, 87042, Limoges, France
- Inserm CIC1435, Limoges, France
| | - Nicolas Pichon
- Medical-Surgical ICU, Réanimation Polyvalente, CHU Dupuytren, Dupuytren University Hospital, 2 avenue Martin Luther King, 87042, Limoges, France
- Inserm CIC1435, Limoges, France
| | - Bruno Francois
- Medical-Surgical ICU, Réanimation Polyvalente, CHU Dupuytren, Dupuytren University Hospital, 2 avenue Martin Luther King, 87042, Limoges, France
- Inserm CIC1435, Limoges, France
| | - Roberto Lang
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL, USA
| | - Philippe Vignon
- Medical-Surgical ICU, Réanimation Polyvalente, CHU Dupuytren, Dupuytren University Hospital, 2 avenue Martin Luther King, 87042, Limoges, France.
- Faculty of Medicine, University of Limoges, Limoges, France.
- Inserm CIC1435, Limoges, France.
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105
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Biais M, Berthezène R, Petit L, Cottenceau V, Sztark F. Ability of esCCO to track changes in cardiac output. Br J Anaesth 2015. [PMID: 26209443 DOI: 10.1093/bja/aev219] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We investigated whether cardiac output measured with pulse wave transit time (esCCO, Nihon Kohden, Tokyo, Japan) is able to track changes in cardiac output induced by an increase in preload (volume expansion/passive leg-raising) or by changes in vasomotor tone (variation in norepinephrine dosage) in critically ill patients. METHODS Eighty patients for whom the decision to give fluid (500 mL of saline over 15 min) (n=20), to perform passive leg-raising (n=20), and to increase (n=20) or to decrease (n=20) norepinephrine were included by the physician. Cardiac output was measured with pulse wave transit time (CO-esCCO) and transthoracic echocardiography (CO-TTE) before and after therapeutic intervention. RESULTS Comparison between CO-TTE and CO-esCCO showed a bias of -0.7 l min(-1) and limits of agreement of -4.4 to 2.9 l min(-1), before therapeutic intervention and a bias of -0.5 l min(-1) and limits of agreement of -4.2 to 3.2 l min(-1) after therapeutic intervention. Bias was correlated with systemic vascular resistance (r(2)=0.60, P<0.0001). Percentage error was 61% before and 59% after therapeutic intervention. Considering the overall data (n=80), the concordance rate was 84%, polar plot analysis revealed an angular bias (sd) of -11°(35°) and radial limits of agreement of (sd 50°). With regard to passive leg-raising and volume expansion groups (n=40), the concordance rate was 83%, the angular bias (sd) was -20°(36°) and radial limits of agreement ( 50°). Considering variations in norepinephrine dosage groups (n=40), the concordance rate was 86%, the angular bias (sd) was -1.8°(33°) and radial limits of agreement (40°). CONCLUSIONS esCCO was not able to track changes in cardiac output, induced by an increase in preload or by variations in vasomotor tone. Therefore, esCCO cannot guide haemodynamic interventions in critically ill patients.
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Affiliation(s)
- M Biais
- Department of Anaesthesiology and Critical Care III, Bordeaux University Hospital, F-33000 Bordeaux, France INSERM, Adaptation Cardiovasculaire à L'ischémie, U1034, F-33600 Pessac, France Univ. Bordeaux, Adaptation Cardiovasculaire à L'ischémie, U1034, F-33600 Pessac, France
| | - R Berthezène
- Department of Anaesthesiology and Critical Care I, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - L Petit
- Department of Anaesthesiology and Critical Care I, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - V Cottenceau
- Department of Anaesthesiology and Critical Care I, Bordeaux University Hospital, F-33000 Bordeaux, France
| | - F Sztark
- INSERM, Adaptation Cardiovasculaire à L'ischémie, U1034, F-33600 Pessac, France Univ. Bordeaux, Adaptation Cardiovasculaire à L'ischémie, U1034, F-33600 Pessac, France Department of Anaesthesiology and Critical Care I, Bordeaux University Hospital, F-33000 Bordeaux, France
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106
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Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiol 2015; 15:82. [PMID: 26041437 PMCID: PMC4453106 DOI: 10.1186/s12871-015-0064-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 05/23/2015] [Indexed: 12/21/2022] Open
Abstract
Background Major abdominal surgery is associated with significant risk of morbidity and mortality in the perioperative period. Optimising intraoperative fluid administration may result in improved outcomes. Our aim was to compare the effects of central venous pressure (CVP), and central venous oxygen saturation (ScvO2)-assisted fluid therapy on postoperative complications in patients undergoing high risk surgery. Methods Patients undergoing elective major abdominal surgery were randomised into control and ScvO2 groups. The target level of mean arterial pressure (MAP) was ≥ 60 mmHg in both groups. In cases of MAP < 60 mmHg patients received either a fluid or vasopressor bolus according to the CVP < 8 mmHg in the control group. In the ScvO2 group, in addition to the MAP, an ScvO2 of <75 % or a >3 % decrease indicated need for intervention, regardless of the actual MAP. Data are presented as mean ± standard deviation or median (interquartile range). Results We observed a lower number of patients with complications in the ScvO2 group compared to the control group, however it did not reach statistical significance (ScvO2 group: 10 vs. control group: 19; p = 0.07). Patients in the ScvO2 group (n = 38) received more colloids compared to the control group (n = 41) [279(161) vs. 107(250) ml/h; p < 0.001]. Both groups received similar amounts of crystalloid (1126 ± 471 vs. 1049 ± 431 ml/h; p = 0.46) and norepinephrine [37(107) vs. 18(73) mcg/h; p = 0.84]. Despite similar blood loss in both groups, the ScvO2 group received more blood transfusions (63 % vs. 37 %; p = 0.018). More patients in the control group had a postoperative PaO2/FiO2 < 200 mmHg (23 vs. 10, p < 0.01). Twenty eight day survival was significantly higher in the ScvO2 group (37/38 vs. 33/41 p = 0.018). Conclusion ScvO2-assisted intraoperative haemodynamic support provided some benefits, including significantly better postoperative oxygenation and 28 day survival rate, compared to CVP-assisted therapy without a significant effect on postoperative complications during major abdominal surgery. Trial registration ClinicalTrials.gov NCT02337010.
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107
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Nee PA, Bailey DJ, Todd V, Lewington AJ, Wootten AE, Sim KJ. Critical care in the emergency department: acute kidney injury. Emerg Med J 2015; 33:361-5. [PMID: 25969433 DOI: 10.1136/emermed-2015-204722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/07/2015] [Indexed: 11/03/2022]
Abstract
Acute kidney injury (AKI) is common among emergency department patients admitted to hospital. There is evidence of inadequate management of the condition leading to adverse outcomes. We present an illustrative case of AKI complicating a gastrointestinal disorder in an older adult. We discuss the clinical presentation, assessment and management of AKI with reference to recent consensus guidelines on classification and treatment.
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Affiliation(s)
- Patrick A Nee
- Faculty of Education, Health and Community, Liverpool John Moores University, Liverpool, UK Department of Emergency and Critical Care Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, Merseyside, UK
| | - David J Bailey
- Department of Emergency Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
| | - Victoria Todd
- Department of Biochemistry, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
| | | | - Andrea E Wootten
- Department of Emergency Medicine, Wirral University Hospital, Merseyside, UK
| | - Kevin J Sim
- Intensive Care Unit, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside, UK
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108
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2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Am Coll Cardiol 2015; 65:e7-e26. [DOI: 10.1016/j.jacc.2015.03.036] [Citation(s) in RCA: 354] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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109
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Pavlovic G, Diaper J, Ellenberger C, Frei A, Bendjelid K, Bonhomme F, Licker M. Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial. J Clin Monit Comput 2015; 30:87-99. [PMID: 25851818 DOI: 10.1007/s10877-015-9691-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.
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Affiliation(s)
- Gordana Pavlovic
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Angela Frei
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Karim Bendjelid
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Faculty of medecine, University of Geneva, Geneva, Switzerland
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland. .,Faculty of medecine, University of Geneva, Geneva, Switzerland.
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Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American heart assocation, the cardiological society of India, and sociedad latino America. Catheter Cardiovasc Interv 2015; 85:E175-96. [DOI: 10.1002/ccd.25720] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/25/2014] [Indexed: 12/20/2022]
Affiliation(s)
| | - Srihari S. Naidu
- Division of Cardiology; Winthrop University Hospital; Mineola New York
| | | | - Wilson Y. Szeto
- Department of Surgery; University of Pennsylvania; Philadelphia Pennsylvania
| | - James A. Burke
- Division of Cardiology; Lehigh Valley Heart Specialists; Allentown, PA
| | | | - Morton Kern
- Division of Cardiology; UCI Medical Center; Orange CA
| | - Kirk N. Garratt
- Department of Cardiac and Vascular Services, Heart and Vascular Institute of New York; Lenox Hill Hospital; New York New York
| | - James A. Goldstein
- Division of Cardiology; Beaumont Heart Center Clinic; Royal Oak Michigan
| | - Vivian Dimas
- Pediatric Cardiology; UT Southwestern; Dallas Texas
| | - Thomas Tu
- Louisville Cardiology Group; Interventional Cardiology; Louisville Kentucky
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111
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Gjonbrataj J, Kim HJ, Jung HI, Choi WI. Does the Mean Arterial Pressure Influence Mortality Rate in Patients with Acute Hypoxemic Respiratory Failure under Mechanical Ventilation? Tuberc Respir Dis (Seoul) 2015; 78:85-91. [PMID: 25861341 PMCID: PMC4388905 DOI: 10.4046/trd.2015.78.2.85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/07/2014] [Accepted: 12/10/2014] [Indexed: 12/29/2022] Open
Abstract
Background In sepsis patients, target mean arterial pressures (MAPs) greater than 65 mm Hg are recommended. However, there is no such recommendation for patients receiving mechanical ventilation. We aimed to evaluate the influence of MAP over the first 24 hours after intensive care unit (ICU) admission on the mortality rate at 60 days post-admission in patients showing acute hypoxemic respiratory failure under mechanical ventilation. Methods This prospective, multicenter study included 22 ICUs and compared the mortality and clinical outcomes in patients showing acute hypoxemic respiratory failure with high (75-90 mm Hg) and low (65-74.9 mm Hg) MAPs over the first 24 hours of admission to the ICU. Results Of the 844 patients with acute hypoxemic respiratory failure, 338 had a sustained MAP of 65-90 mm Hg over the first 24 hours of admission to the ICU. At 60 days, the mortality rates in the low (26.2%) and high (24.5%) MAP groups were not significantly different. The ICU days, hospital days, and 60-day mortality rate did not differ between the groups. Conclusion In the first 24 hours of ICU admission, MAP range between 65 and 90 mm Hg in patients with acute hypoxemic respiratory failure under mechanical ventilation may not cause significantly differences in 60-day mortality.
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Affiliation(s)
- Juarda Gjonbrataj
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea. ; Department of Internal Medicine, Mother Thereza University Hospital, Tirana, Albania
| | - Hyun Jung Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hye In Jung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Timsit JF, Perner A, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Doig GS, Herridge M, Jaber S, Joannidis M, Papazian L, Peters MJ, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Citerio G, Azoulay E. Year in review in Intensive Care Medicine 2014: III. Severe infections, septic shock, healthcare-associated infections, highly resistant bacteria, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics. Intensive Care Med 2015; 41:575-88. [PMID: 25810214 PMCID: PMC4491096 DOI: 10.1007/s00134-015-3755-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Jean-François Timsit
- APHP-Hopital Bichat-Medical and Infectious Diseases ICU, UMR 1137-IAME Team 5-DeSCID: Decision Sciences in Infectious Diseases, Control and Care Inserm/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France,
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Silverstein DC, Santoro Beer KA. Controversies regarding choice of vasopressor therapy for management of septic shock in animals. J Vet Emerg Crit Care (San Antonio) 2015; 25:48-54. [DOI: 10.1111/vec.12282] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 10/26/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Deborah C. Silverstein
- From the Department of Clinical Studies; University of Pennsylvania; Philadelphia PA 19104-6010
| | - Kari A. Santoro Beer
- From the Department of Clinical Studies; University of Pennsylvania; Philadelphia PA 19104-6010
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Cecconi M, Monge García MI, Gracia Romero M, Mellinghoff J, Caliandro F, Grounds RM, Rhodes A. The Use of Pulse Pressure Variation and Stroke Volume Variation in Spontaneously Breathing Patients to Assess Dynamic Arterial Elastance and to Predict Arterial Pressure Response to Fluid Administration. Anesth Analg 2015; 120:76-84. [DOI: 10.1213/ane.0000000000000442] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shiga H, Hirasawa H, Nishida O, Oda S, Nakamura M, Mashiko K, Matsuda K, Kitamura N, Kikuchi Y, Fuke N. Continuous hemodiafiltration with a cytokine-adsorbing hemofilter in patients with septic shock: a preliminary report. Blood Purif 2014; 38:211-8. [PMID: 25531978 DOI: 10.1159/000369377] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM We investigated the clinical efficacy of continuous hemodiafiltration (CHDF) with AN69ST hemofilter (AN69ST-CHDF) in patients with septic shock. MATERIALS AND METHODS A prospective, multicenter, single-arm study was conducted. Patients with sepsis and shock defined by hyperlactemia were enrolled. The patients were treated with CHDF and in accordance with the Surviving Sepsis Campaign guidelines (SSCG). RESULTS Thirty-four patients were enrolled. On ICU admission, the mean blood IL-6 level was 44,800 ± 77,700 pg/ml, and the mean blood lactate level was 69.0 ± 49.4 mg/dl. Both the mean blood IL-6 and lactate levels had significantly decreased to normal ranges after 72 h of AN69ST-CHDF. Though the mean APACHE II score was 32.7 ± 9.8, 28-day survival was 73.5%. CONCLUSION The current study suggested that adding AN69ST-CHDF to the treatments outlined in the SSCG might lead to good outcomes for patients with septic shock, probably via the removal of cytokines from the bloodstream.
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Affiliation(s)
- Hidetoshi Shiga
- Emergency and Intensive Care Center, Teikyo University Chiba Medical Center, Chiba, Japan
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Abstract
Despite the multiple causes of the shock state, all causes possess the common abnormality of oxygen supply not meeting tissue metabolic demands. Compensatory mechanisms may mask the severity of hypoxemia and hypoperfusion, since catecholamines and extracellular fluid shifts initially compensate for the physiologic derangements associated with patients in shock. Despite the achievement of normal physiologic parameters after resuscitation, significant metabolic acidosis may continue to be present in the tissues, as evidenced by increased lactate levels and metabolic acidosis. This review discusses the major endpoints of resuscitation in clinical use.
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Affiliation(s)
- Ramon F Cestero
- Division of Trauma and Emergency Surgery, Department of Surgery, UT Health Science Center San Antonio, 7703 Floyd Curl Drive, Mail Code 7740, San Antonio, TX 78229-3900, USA.
| | - Daniel L Dent
- Division of Trauma and Emergency Surgery, Department of Surgery, UT Health Science Center San Antonio, 7703 Floyd Curl Drive, Mail Code 7740, San Antonio, TX 78229-3900, USA
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Boulain T, Boisrame-Helms J, Ehrmann S, Lascarrou JB, Bouglé A, Chiche A, Lakhal K, Gaudry S, Perbet S, Desachy A, Cabasson S, Geneau I, Courouble P, Clavieras N, Massanet PL, Bellec F, Falquet Y, Réminiac F, Vignon P, Dequin PF, Meziani F. Volume expansion in the first 4 days of shock: a prospective multicentre study in 19 French intensive care units. Intensive Care Med 2014; 41:248-56. [PMID: 25447804 DOI: 10.1007/s00134-014-3576-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/19/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE To describe the current practices of volume expansion in French intensive care units (ICU). METHODS In 19 ICUs, we prospectively observed the prescription and monitoring practices of volume expansion in consecutive adult patients with shock [sustained hypotension and/or need of vasopressor therapy, associated with at least tachycardia and/or sign (s) of hypoperfusion]. Patients were included at the time of prescription of the first fluid bolus (FB). Thereafter, all the FBs administered during the 96 h following shock onset were surveyed. An FB was defined as an intravenous bolus of at least 100 ml of a blood volume expander intended to rapidly improve the patient's circulatory condition. RESULTS We included 777 patients [age: 63 ± 15 years; female gender: 274 (35 %); simplified acute physiology score II: 55.9 ± 20.6; ICU length of stay: 6 days (interquartile range (IQR) 3-13); ICU mortality: 32.8 %] and surveyed 2,694 FBs. At enrolment mean arterial pressure was 63 mmHg (IQR 55-71). The most frequent triggers of FB were hypotension, low urine output, tachycardia, skin mottling and hyperlactataemia. Amount of fluid given at each FB was highly variable between centres. Crystalloids were used in 91 % (2,394/2,635) and synthetic colloids in 3.3 % (87/2,635) of FBs. Overall, clinicians used any kind of haemodynamic assessment (central venous pressure measurement, predictive indices of fluid responsiveness, echocardiography, cardiac output monitoring or a combination of these) in 23.6 % (635/2,694) of all FBs surveyed, with an important between-centre heterogeneity. CONCLUSIONS High between-centre variability characterised all the aspects of FB prescription and monitoring, but overall haemodynamic exploration to help guide and monitor FB was infrequent.
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Affiliation(s)
- Thierry Boulain
- Medical-Surgical Intensive Care Unit, Hôpital de La Source, Centre Hospitalier Régional d'Orléans, BP 6709, 45067, Orleans Cedex, France,
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Increasing mean arterial pressure in cardiogenic shock secondary to myocardial infarction: effects on hemodynamics and tissue oxygenation. Shock 2014; 41:269-74. [PMID: 24509521 DOI: 10.1097/shk.0000000000000099] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are very few data regarding the effects of norepinephrine uptitration on global and regional hemodynamics in cardiogenic shock. We studied 25 patients with shock secondary to myocardial infarction successfully treated with percutaneous coronary intervention. Before the inclusion, 16 of 25 patients presented a cardiac arrest in the presence of medical staff. Norepinephrine was titrated to increase mean arterial pressure (MAP) from 65 to 85 mmHg during 1 h. Swan-Ganz variables, arterial and mixed venous blood gases, lactate, and thenar near-infrared spectroscopy variables (muscle tissue oxygen saturation [StO2] and its changes during a vascular occlusion test) were measured before, 1 h after norepinephrine uptitration, and 1 h after norepinephrine downtitration. To obtain a MAP at 85 mmHg, norepinephrine was increased from 0.6 (0.28-1.2) to 1.53 µg · kg · min (0.76-2.6 µg · kg · min) (P < 0.00001) (median and interquartile range), with no change in heart rate. Norepinephrine uptitration significantly increased cardiac index (2.3 ± 0.5 to 2.8 ± 0.1 L · min · m), cardiac power index (0.40 ± 0.1 to 0.55 ± 0.1 W/m), mixed venous oxygen saturation (69% ± 9% to 73% ± 9%), and coronary perfusion pressure (32 ± 3 to 43 ± 4 mmHg). Lactate level decreased from 2.6 ± 1.7 to 1.6 ± 0.4 mmol/L (P < 0.05). Pulmonary artery occlusion pressure remained unchanged. Regarding near-infrared spectroscopy variables, all values except StO2 were significantly pathological when compared with healthy volunteers. The StO2 recovery slope and delta StO2, respectively, increased from 3.0% ± 1.3%/s to 3.6% ± 1.3%/s and 10% ± 3% to 14% ± 4%, whereas StO2 did not change (83% ± 6% to 83% ± 7%). After H1, norepinephrine was decreased to basal values, and all variables returned to baseline. In conclusion, a short-term increase in MAP with norepinephrine in resuscitated cardiogenic shock complicated by postreperfusion disease is associated with better cardiac performance and improved microcirculatory variables.
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Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795-815. [PMID: 25392034 PMCID: PMC4239778 DOI: 10.1007/s00134-014-3525-z] [Citation(s) in RCA: 947] [Impact Index Per Article: 94.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. METHODS The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. RESULTS Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. CONCLUSIONS This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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Affiliation(s)
- Maurizio Cecconi
- Anaesthesia and Intensive Care, St George's Hospital and Medical School, SW17 0QT, London, UK,
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Romagnoli S, Ricci Z, Quattrone D, Tofani L, Tujjar O, Villa G, Romano SM, De Gaudio AR. Accuracy of invasive arterial pressure monitoring in cardiovascular patients: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:644. [PMID: 25433536 PMCID: PMC4279904 DOI: 10.1186/s13054-014-0644-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 11/05/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Critically ill patients and patients undergoing high-risk and major surgery, are instrumented with intra-arterial catheters and invasive blood pressure is considered the "gold standard" for arterial pressure monitoring. Nonetheless, artifacts due to inappropriate dynamic response of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values. We sought to analyze the incidence and causes of resonance/underdamping phenomena in patients undergoing major vascular and cardiac surgery. METHODS Arterial pressures were measured invasively and, according to the fast-flush Gardner's test, each patient was attributed to one of two groups depending on the presence (R-group) or absence (NR-group) of resonance/underdamping. Invasive pressure values were then compared with the non-invasive ones. RESULTS A total of 11,610 pulses and 1,200 non-invasive blood pressure measurements were analyzed in 300 patients. Ninety-two out of 300 (30.7%) underdamping/resonance arterial signals were found. In these cases (R-group) systolic invasive blood pressure (IBP) average overestimation of non-invasive blood pressure (NIBP) was 28.5 (15.9) mmHg (P <0.0001) while in the NR-group the overestimation was 4.1(5.3) mmHg (P < 0.0001). The mean IBP-NIBP difference in diastolic pressure in the R-group was -2.2 (10.6) mmHg and, in the NR-group -1.1 (5.8) mmHg. The mean arterial pressure difference was 7.4 (11.2) mmHg in the R-group and 2.3 (6.4) mmHg in the NR-group. A multivariate logistic regression identified five parameters independently associated with underdamping/resonance: polydistrectual arteriopathy (P = 0.0023; OR = 2.82), history of arterial hypertension (P = 0.0214; OR = 2.09), chronic obstructive pulmonary disease (P = 0.198; OR = 2.61), arterial catheter diameter (20 vs. 18 gauge) (P < 0.0001; OR = 0.35) and sedation (P = 0.0131; OR = 0.5). The ROC curve for the maximal pressure-time ratio, showed an optimum selected cut-off point of 1.67 mmHg/msec with a specificity of 97% (95% CI: 95.13 to 99.47%) and a sensitivity of 77% (95% CI: 67.25 to 85.28%) and an area under the ROC curve by extended trapezoidal rule of 0.88. CONCLUSION Physicians should be aware of the possibility that IBP can be inaccurate in a consistent number of patients due to underdamping/resonance phenomena. NIBP measurement may help to confirm/exclude the presence of this artifact avoiding inappropriate treatments.
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Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Diego Quattrone
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Omar Tujjar
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Gianluca Villa
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Salvatore M Romano
- Department of Heart and Vessels, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - A Raffaele De Gaudio
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Yang X, Du B. Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:650. [PMID: 25427970 PMCID: PMC4258282 DOI: 10.1186/s13054-014-0650-6] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 11/06/2014] [Indexed: 02/08/2023]
Abstract
Introduction Fluid resuscitation is crucial in managing hemodynamically unstable patients. The last decade witnessed the use of pulse pressure variation (PPV) to predict fluid responsiveness. However, as far as we know, no systematic review and meta-analysis has been carried out to evaluate the value of PPV in predicting fluid responsiveness specifically upon patients admitted into intensive care units. Methods We searched MEDLINE and EMBASE and included clinical trials that evaluated the association between PPV and fluid responsiveness after fluid challenge in mechanically ventilated patients in intensive care units. Data were synthesized using an exact binomial rendition of the bivariate mixed-effects regression model modified for synthesis of diagnostic test data. Result Twenty-two studies with 807 mechanically ventilated patients with tidal volume more than 8 ml/kg and without spontaneous breathing and cardiac arrhythmia were included, and 465 were responders (58%). The pooled sensitivity was 0.88 (95% confidence interval (CI) 0.81 to 0.92) and pooled specificity was 0.89 (95% CI 0.84 to 0.92). A summary receiver operating characteristic curve yielded an area under the curve of 0.94 (95% CI 0.91 to 0.95). A significant threshold effect was identified. Conclusions PPV predicts fluid responsiveness accurately in mechanically ventilated patients with relative large tidal volume and without spontaneous breathing and cardiac arrhythmia. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0650-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaobo Yang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, PR China.
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, PR China.
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Bortolotti P, Saulnier F, Colling D, Redheuil A, Preau S. New tools for optimizing fluid resuscitation in acute pancreatitis. World J Gastroenterol 2014; 20:16113-22. [PMID: 25473163 PMCID: PMC4239497 DOI: 10.3748/wjg.v20.i43.16113] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/02/2014] [Accepted: 06/12/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a frequent disease with degrees of increasing severity responsible for high morbidity. Despite continuous improvement in care, mortality remains significant. Because hypovolemia, together with microcirculatory dysfunction lead to poor outcome, fluid therapy remains a cornerstone of the supportive treatment. However, poor clinical evidence actually support the aggressive fluid therapy recommended in recent guidelines since available data are controversial. Fluid management remains unclear and leads to current heterogeneous practice. Different strategies may help to improve fluid resuscitation in AP. On one hand, integration of fluid therapy in a global hemodynamic resuscitation has been demonstrated to improve outcome in surgical or septic patients. Tailored fluid administration after early identification of patients with high-risk of poor outcome presenting inadequate tissue oxygenation is a major part of this strategy. On the other hand, new decision parameters have been developed recently to improve safety and efficiency of fluid therapy in critically ill patients. In this review, we propose a personalized strategy integrating these new concepts in the early fluid management of AP. This new approach paves the way to a wide range of clinical studies in the field of AP.
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García MIM, Romero MG, Cano AG, Aya HD, Rhodes A, Grounds RM, Cecconi M. Dynamic arterial elastance as a predictor of arterial pressure response to fluid administration: a validation study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:626. [PMID: 25407570 PMCID: PMC4271484 DOI: 10.1186/s13054-014-0626-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 10/28/2014] [Indexed: 12/19/2022]
Abstract
Introduction Functional assessment of arterial load by dynamic arterial elastance (Eadyn), defined as the ratio between pulse pressure variation (PPV) and stroke volume variation (SVV), has recently been shown to predict the arterial pressure response to volume expansion (VE) in hypotensive, preload-dependent patients. However, because both SVV and PPV were obtained from pulse pressure analysis, a mathematical coupling factor could not be excluded. We therefore designed this study to confirm whether Eadyn, obtained from two independent signals, allows the prediction of arterial pressure response to VE in fluid-responsive patients. Methods We analyzed the response of arterial pressure to an intravenous infusion of 500 ml of normal saline in 53 mechanically ventilated patients with acute circulatory failure and preserved preload dependence. Eadyn was calculated as the simultaneous ratio between PPV (obtained from an arterial line) and SVV (obtained by esophageal Doppler imaging). A total of 80 fluid challenges were performed (median, 1.5 per patient; interquartile range, 1 to 2). Patients were classified according to the increase in mean arterial pressure (MAP) after fluid administration in pressure responders (≥10%) and non-responders. Results Thirty-three fluid challenges (41.2%) significantly increased MAP. At baseline, Eadyn was higher in pressure responders (1.04 ± 0.28 versus 0.60 ± 0.14; P <0.0001). Preinfusion Eadyn was related to changes in MAP after fluid administration (R2 = 0.60; P <0.0001). At baseline, Eadyn predicted the arterial pressure increase to volume expansion (area under the receiver operating characteristic curve, 0.94; 95% confidence interval (CI): 0.86 to 0.98; P <0.0001). A preinfusion Eadyn value ≥0.73 (gray zone: 0.72 to 0.88) discriminated pressure responder patients with a sensitivity of 90.9% (95% CI: 75.6 to 98.1%) and a specificity of 91.5% (95% CI: 79.6 to 97.6%). Conclusions Functional assessment of arterial load by Eadyn, obtained from two independent signals, enabled the prediction of arterial pressure response to fluid administration in mechanically ventilated, preload-dependent patients with acute circulatory failure. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0626-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manuel Ignacio Monge García
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain. .,Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Manuel Gracia Romero
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain.
| | - Anselmo Gil Cano
- Servicio de Cuidados Intensivos y Urgencias, Hospital SAS de Jerez, C/Circunvalación s/n, 11407, Jerez de la Frontera, Spain.
| | - Hollmann D Aya
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Robert Michael Grounds
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - Maurizio Cecconi
- Department of Intensive Care Medicine, St George's Healthcare NHS Trust and St George's University of London, Blackshaw Road, Tooting, London, SW17 0QT, UK.
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Boulain T, Garot D, Vignon P, Lascarrou JB, Desachy A, Botoc V, Follin A, Frat JP, Bellec F, Quenot JP, Mathonnet A, Dequin PF. Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:609. [PMID: 25529124 PMCID: PMC4265332 DOI: 10.1186/s13054-014-0609-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022]
Abstract
Introduction In septic shock patients, the prevalence of low (<70%) central venous oxygen saturation (ScvO2) on admission to the intensive care unit (ICU) and its relationship to outcome are unknown. The objectives of the present study were to estimate the prevalence of low ScvO2 in the first hours of ICU admission and to assess its potential association with mortality in patients with severe sepsis or septic shock. Methods This was a prospective, multicentre, observational study conducted over a one-year period in ten French ICUs. Clinicians were asked to include patients with severe sepsis or septic shock preferably within 6 hours of ICU admission and as soon as possible without changing routine practice. ScvO2 was measured at inclusion and 6 hours later (H6), by blood sampling. Results We included 363 patients. Initial ScvO2 below 70% was present in 111 patients and the pooled estimate for its prevalence was 27% (95% Confidence interval (95%CI): 18% to 37%). At time of inclusion, among 166 patients with normal lactate concentration (≤2 mmol/L), 55 (33%) had a low initial ScvO2 (<70%), and among 136 patients who had already reached the classic clinical endpoints for mean arterial pressure (≥65 mmHg), central venous pressure (≥8 mmHg), and urine output (≥0.5 mL/Kg of body weight), 43 (32%) had a low initial ScvO2 (<70%). Among them, 49% had lactate below 2 mmol/L. The day-28 mortality was higher in case of low initial ScvO2 (37.8% versus 27.4%; P = 0.049). When adjusted for confounders including the Simplified Acute Physiology Score and initial lactate concentration, a low initial ScvO2 (Odds ratio (OR) = 3.60, 95%CI: 1.76 to 7.36; P = 0.0004) and a low ScvO2 at H6 (OR = 2.18, 95%CI: 1.12 to 4.26; P = 0.022) were associated with day-28 mortality by logistic regression. Conclusions Low ScvO2 was common in the first hours of admission to the ICU for severe sepsis or septic shock even when clinical resuscitation endpoints were achieved and even when arterial lactate was normal. A ScvO2 below 70% in the first hours of ICU admission and six hours later was associated with day-28 mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0609-7) contains supplementary material, which is available to authorized users.
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Dynamic device properties of pulse contour cardiac output during transcatheter aortic valve implantation. J Clin Monit Comput 2014; 29:323-31. [DOI: 10.1007/s10877-014-9630-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 10/20/2014] [Indexed: 01/03/2023]
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Oda S, Aibiki M, Ikeda T, Imaizumi H, Endo S, Ochiai R, Kotani J, Shime N, Nishida O, Noguchi T, Matsuda N, Hirasawa H. The Japanese guidelines for the management of sepsis. J Intensive Care 2014; 2:55. [PMID: 25705413 PMCID: PMC4336273 DOI: 10.1186/s40560-014-0055-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/16/2014] [Indexed: 02/08/2023] Open
Abstract
This is a guideline for the management of sepsis, developed by the Sepsis Registry Committee of The Japanese Society of Intensive Care Medicine (JSICM) launched in March 2007. This guideline was developed on the basis of evidence-based medicine and focuses on unique treatments in Japan that have not been included in the Surviving Sepsis Campaign guidelines (SSCG), as well as treatments that are viewed differently in Japan and in Western countries. Although the methods in this guideline conform to the 2008 SSCG, the Japanese literature and the results of the Sepsis Registry Survey, which was performed twice by the Sepsis Registry Committee in intensive care units (ICUs) registered with JSICM, are also referred. This is the first and original guideline for sepsis in Japan and is expected to be properly used in daily clinical practice. This article is translated from Japanese, originally published as “The Japanese Guidelines for the Management of Sepsis” in the Journal of the Japanese Society of Intensive Care Medicine (J Jpn Soc Intensive Care Med), 2013; 20:124–73. The original work is at http://dx.doi.org/10.3918/jsicm.20.124.
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Affiliation(s)
- Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba 260-8677 Japan
| | - Mayuki Aibiki
- Department of Emergency Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Toshiaki Ikeda
- Division of Critical Care and Emergency Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Hitoshi Imaizumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556 Japan
| | - Shigeatsu Endo
- Department of Emergency Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate 020-0023 Japan
| | - Ryoichi Ochiai
- First Department of Anesthesia, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541 Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8131 Japan
| | - Nobuaki Shime
- Division of Intensive Care Unit, University Hospital, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566 Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Takayuki Noguchi
- Department of Anesthesiology and Intensive Care Medicine, Oita University School of Medicine, 1-1 Idaigaoka, Hazamacho, Yufu, Oita 879-5593 Japan
| | - Naoyuki Matsuda
- Emergency and Critical Care Medicine, Graduate School of Medicine Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550 Japan
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Suehiro K, Tanaka K, Matsuura T, Funao T, Yamada T, Mori T, Nishikawa K. The Vigileo-FloTracTM System: Arterial Waveform Analysis for Measuring Cardiac Output and Predicting Fluid Responsiveness: A Clinical Review. J Cardiothorac Vasc Anesth 2014; 28:1361-74. [DOI: 10.1053/j.jvca.2014.02.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Indexed: 02/03/2023]
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Dong ZZ, Fang Q, Zheng X, Shi H. Passive leg raising as an indicator of fluid responsiveness in patients with severe sepsis. World J Emerg Med 2014; 3:191-6. [PMID: 25215062 DOI: 10.5847/wjem.j.issn.1920-8642.2012.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 07/20/2012] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND In the management of critically ill patients, the assessment of volume responsiveness and the decision to administer a fluid bolus constitute a common dilemma for physicians. Static indices of cardiac preload are poor predictors of volume responsiveness. Passive leg raising (PLR) mimics an endogenous volume expansion (VE) that can be used to predict fluid responsiveness. This study was to assess the changes in stroke volume index (SVI) induced by PLR as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis. METHODS This was a prospective study. Thirty-two mechanically ventilated patients with severe sepsis were admitted for VE in ICU of the First Affiliated Hospital, Zhejiang University School of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to December 2011. Patients with non-sinus rhythm or arrhythmia, parturients, and amputation of the lower limbs were excluded. Measurements of SVI were obtained in a semi-recumbent position (baseline) and during PLR by the technique of pulse indicator continuous cardiac output (PiCCO) system prior to VE. Measurements were repeated after VE (500 mL 6% hydroxyethyl starch infusion within 30 minutes) to classify patients as either volume responders or non-responders based on their changes in stroke volume index (ΔSVI) over 15%. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between the two groups. The changes of ABPs, ABPm, CVPm, and SVI after PLR and VE were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and the change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS 17.0 software was used for statistical analysis. RESULTS Among the 32 patients, 22 were responders and 10 were non-responders. After PLR among the responders, some hemodynamic variables (including ABPs, ABPd, ABPm and CVPm) were significantly elevated (101.2±17.6 vs.118.6±23.7, P=0.03; 52.8±10.7 vs. 64.8±10.7, P=0.006; 68.3±11.7 vs. 81.9±14.4, P=0.008; 6.8±3.2 vs. 11.9±4.0, P=0.001). After PLR, the area under curve (AUC) and the ROC curve of ΔSVI and ΔCVPm for predicting the responsiveness after VE were 0.882±0.061 (95%CI 0.759-1.000) and 0.805±0.079 (95%CI 0.650-0.959) when the cut-off levels of ΔSVI and ΔCVPm were 8.8% and 12.7%, the sensitivities were 72.7% and 72.7%, and the specificities were 80% and 80%. CONCLUSION Changes in ΔSVI and ΔCVPm induced by PLR are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.
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Affiliation(s)
- Zhou-Zhou Dong
- Intensive Care Unit, Ningbo Medical Center Lihuili Hospital, Ningbo 315040, China
| | - Qiang Fang
- Intensive Care Unit, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xia Zheng
- Intensive Care Unit, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Heng Shi
- Intensive Care Unit, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
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Inohara T, Kohsaka S, Sato N, Kajimoto K, Keida T, Mizuno M, Takano T. Prognostic impact of renal dysfunction does not differ according to the clinical profiles of patients: insight from the acute decompensated heart failure syndromes (ATTEND) registry. PLoS One 2014; 9:e105596. [PMID: 25197833 PMCID: PMC4157767 DOI: 10.1371/journal.pone.0105596] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/22/2014] [Indexed: 11/19/2022] Open
Abstract
Background Renal dysfunction associated with acute decompensated heart failure (ADHF) is associated with impaired outcomes. Its mechanism is attributed to renal arterial hypoperfusion or venous congestion, but its prognostic impact based on each of these clinical profiles requires elucidation. Methods and Results ADHF syndromes registry subjects were evaluated (N = 4,321). Logistic regression modeling calculated adjusted odds ratios (OR) for in-hospital mortality for patients with and without renal dysfunction. Renal dysfunction risk was calculated for subgroups with hypoperfusion-dominant (eg. cold extremities, a low mean blood pressure or a low proportional pulse pressure) or congestion-dominant clinical profiles (eg. peripheral edema, jugular venous distension, or elevated brain natriuretic peptide) to evaluate renal dysfunction's prognostic impact in the context of the two underlying mechanisms. On admission, 2,150 (49.8%) patients aged 73.3±13.6 years had renal dysfunction. Compared with patients without renal dysfunction, those with renal dysfunction were older and had dominant ischemic etiology jugular venous distension, more frequent cold extremities, and higher brain natriuretic peptide levels. Renal dysfunction was associated with in-hospital mortality (OR 2.36; 95% confidence interval 1.75–3.18, p<0.001), and the prognostic impact of renal dysfunction was similar in subgroup of patients with hypoperfusion- or congestion-dominant clinical profiles (p-value for the interaction ranged from 0.104–0.924, and was always >0.05). Conclusions Baseline renal dysfunction was significantly associated with in-hospital mortality in ADHF patients. The prognostic impact of renal dysfunction was the same, regardless of its underlying etiologic mechanism.
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Affiliation(s)
- Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Naoki Sato
- Internal Medicine, Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | | | - Takehiko Keida
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Masayuki Mizuno
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teruo Takano
- Department of Internal Medicine, Nippon Medical University, Tokyo, Japan
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Jiménez-Herrera MF, Azeli Y, Valero-Mora E, Lucas-Guarque I, López-Gomariz A, Castro-Naval E, Axelsson C. Passive leg raise (PLR) during cardiopulmonary (CPR) - a method article on a randomised study of survival in out-of-hospital cardiac arrest (OHCA). BMC Emerg Med 2014; 14:15. [PMID: 24993861 PMCID: PMC4096750 DOI: 10.1186/1471-227x-14-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 06/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is estimated that about 275,000 inhabitants experience an out-of-hospital cardiac arrest (OHCA) every year in Europe. Survival in out-of-hospital cardiac arrest is relatively low, generally between five per cent and 10%. Being able to explore new methods to improve the relatively low survival rate is vital for people with these conditions. Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) has been found to improve cardiac preload and blood flow during chest compressions. The aim of our study is to evaluate whether early PLR during CPR also has an impact on one-month survival in sudden and unexpected out-of-hospital cardiac arrest (OHCA). METHOD/DESIGN A prospective, randomized, controlled trial in which all patients (≥18 years) receiving out-of hospital CPR are randomized by envelope to be treated with either PLR or in the flat position. The ambulance crew use a special folding stool which allows the legs to be elevated about 20 degrees. Primary end-point: survival to one month. Secondary end-point: survival to hospital admission to one month and to one year with acceptable cerebral performance classification (CPC) 1-2. DISCUSSION PLR is a simple and fast maneuver. We believe that the greatest benefit with PLR is when performed early in the process, during the first minutes of CPR and before the first defibrillation. To reach power this study need 3000 patients, we hope that this method article will encourage other sites to contact us and take part in our study. TRIAL REGISTRATION ClinicalTrials.gov NCT01952197.
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Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology 2014; 120:1168-81. [PMID: 24755786 DOI: 10.1097/aln.0000000000000216] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) remains a serious postoperative complication. Although ARDS prevention is a priority, the inability to identify patients at risk for ARDS remains a barrier to progress. The authors tested and refined the previously reported surgical lung injury prediction (SLIP) model in a multicenter cohort of at-risk surgical patients. METHODS This is a secondary analysis of a multicenter, prospective cohort investigation evaluating high-risk patients undergoing surgery. Preoperative ARDS risk factors and risk modifiers were evaluated for inclusion in a parsimonious risk-prediction model. Multiple imputation and domain analysis were used to facilitate development of a refined model, designated SLIP-2. Area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model performance. RESULTS Among 1,562 at-risk patients, ARDS developed in 117 (7.5%). Nine independent predictors of ARDS were identified: sepsis, high-risk aortic vascular surgery, high-risk cardiac surgery, emergency surgery, cirrhosis, admission location other than home, increased respiratory rate (20 to 29 and ≥30 breaths/min), FIO2 greater than 35%, and SpO2 less than 95%. The original SLIP score performed poorly in this heterogeneous cohort with baseline risk factors for ARDS (area under the receiver operating characteristic curve [95% CI], 0.56 [0.50 to 0.62]). In contrast, SLIP-2 score performed well (area under the receiver operating characteristic curve [95% CI], 0.84 [0.81 to 0.88]). Internal validation indicated similar discrimination, with an area under the receiver operating characteristic curve of 0.84. CONCLUSIONS In this multicenter cohort of patients at risk for ARDS, the SLIP-2 score outperformed the original SLIP score. If validated in an independent sample, this tool may help identify surgical patients at high risk for ARDS.
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Evaluation of cardiac function index as measured by transpulmonary thermodilution as an indicator of left ventricular ejection fraction in cardiogenic shock. BIOMED RESEARCH INTERNATIONAL 2014; 2014:598029. [PMID: 25013790 PMCID: PMC4071812 DOI: 10.1155/2014/598029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/07/2014] [Accepted: 05/19/2014] [Indexed: 01/28/2023]
Abstract
Introduction. The PiCCO transpulmonary thermodilution technique provides two indices of cardiac systolic function, the cardiac function index (CFI) and the global ejection fraction (GEF). Both appear to be correlated with left ventricular ejection fraction (LVEF) measured by echocardiography in patients with circulatory failure, especially in septic shock. The aim of the present study was to test the reliability of CFI as an indicator of LVEF in patients with cardiogenic shock. Methods. In thirty-five patients with cardiogenic shock, we performed (i) simultaneous measurements of echocardiography LVEF and cardiac function index assessed by transpulmonary thermodilution (n = 72) and (ii) transpulmonary thermodilution before/after increasing inotropic agents (n = 18). Results. Mean LVEF was 31% (+/−11.7), CFI 3/min (+/−1), and GEF 14.2% (+/−6). CFI and GEF were both positively correlated with LVEF (P < 0.0001, r2 = 0.27). CFI and GEF were significantly increased with inotropic infusion (resp., P = 0.005, P = 0.007). A cardiac function index <3.47/min predicted a left ventricular ejection fraction ≤35% (sensitivity 81.1% and specificity 63%). In patients with right ventricular dysfunction, CFI was not correlated with LVEF. Conclusion. CFI is correlated with LVEF provided that patient does not present severe right ventricular dysfunction. Thus, the PiCCO transpulmonary thermodilution technique is useful for the monitoring of inotropic therapy during cardiogenic shock.
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Cherpanath TG, Aarts LP, Groeneveld JA, Geerts BF. Defining Fluid Responsiveness: A Guide to Patient-Tailored Volume Titration. J Cardiothorac Vasc Anesth 2014; 28:745-54. [DOI: 10.1053/j.jvca.2013.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Indexed: 11/11/2022]
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Gradwohl-Matis I, Brunauer A, Dankl D, Dünser M. Stellenwert von Vasopressin im septischen Schock. Anaesthesist 2014; 63:503-10. [DOI: 10.1007/s00101-014-2335-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jozwiak M, Monnet X, Cinotti R, Bontemps F, Reignier J, Belliard G. Prospective assessment of a score for assessing basic critical-care transthoracic echocardiography skills in ventilated critically ill patients. Ann Intensive Care 2014; 4:12. [PMID: 25097797 PMCID: PMC4113285 DOI: 10.1186/2110-5820-4-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/07/2014] [Indexed: 11/20/2022] Open
Abstract
Background We studied a score for assessing basic transthoracic echocardiography (TTE) skills exhibited by residents who examined critically ill patients receiving mechanical ventilation. Methods We conducted a prospective study in the 16 residents who worked in our medical-surgical ICU between 1 May 2008 and 1 November 2009. The residents received theoretical teaching (two hours) then performed supervised TTEs during their six-month rotation. Their basic TTE skills in mechanically ventilated patients were evaluated after one (M1), three (M3), and six (M6) months by two experts, who used a scoring system devised for the study. After scoring, residents gave their hemodynamic diagnosis and suggested a treatment. Results The 4 residents with previous TTE skills obtained a significantly higher total score than did the 12 novices at M1 (18 (16 to 19) versus 13 (10 to 15), respectively, P = 0.03). In the novices, the total score increased significantly during training (M1, 13 (10 to 14); M3, 15 (12 to 16); and M6, 17 (15 to 18); P < 0.001) and correlated significantly with the number of supervised TTEs (r = 0.68, P < 0.0001). In the overall population, agreement with experts regarding the diagnosis and treatment was associated with a significantly higher total score (17 (16 to 18) versus 13 (12 to 16), P = 0.002). A total score ≥ 19/20 points had 100% specificity (95% confidence interval, 79 to 100%) for full agreement with the experts regarding the diagnosis and treatment. Conclusions Our results validate the scoring system developed for our study of the assessment of basic critical-care TTE skills in residents.
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Affiliation(s)
- Mathieu Jozwiak
- Centre Hospitalier Départemental de la Vendée, service de réanimation, La Roche-sur-Yon F-85000, France
| | - Xavier Monnet
- AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre F-94270, France ; Faculté de Médecine Paris-Sud, Université Paris-Sud, EA4533, Le Kremlin-Bicêtre F-94270, France
| | - Raphaël Cinotti
- Centre Hospitalo-Universitaire Guillaume et René Laennec, service de réanimation chirurgicale, Nantes F-44000, France
| | - Fréderic Bontemps
- Centre Hospitalier Côte de Lumière, service de médecine polyvalente, Les Sables d'Olonne F-85100, France
| | - Jean Reignier
- Centre Hospitalier Départemental de la Vendée, service de réanimation, La Roche-sur-Yon F-85000, France
| | - Guillaume Belliard
- Centre Hospitalier Bretagne Sud Lorient, service de réanimation médicale, Lorient F-56100, France
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Gabbay U, Bobrovsky BZ. A novel hypothesis comprehensively explains shock, heart failure and aerobic exhaustion through an assumed central physiological control of the momentary cardiovascular performance reserve. Med Hypotheses 2014; 82:694-9. [PMID: 24679381 DOI: 10.1016/j.mehy.2014.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 03/05/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Heart failure (HF) and shock are incomprehensively understood, inconclusively defined and lack a single conclusive test. The proceedings that preceded and triggered clinical manifestations are occult. The relationships in between different shock and HF types and between each HF type and its matched shock are poorly understood. THE ASSUMED HYPOTHESIS We suggest that HF and shock are attributed to a momentary cardiovascular performance reserve - "the reserve". The reserve is controlled through an assumed central physiological mechanism that continuously detects and responds accordingly--"the reserve control". The assumed reserve is maximal at rest, and decreases with aerobic activity. When it decreases to a given threshold the reserve control alerts by induces manifestations of dyspnea and fatigue enforcing activity decrease, follow which the manifestations dissolve. HF is a condition of low reserve at baseline; hence, fatigue and dyspnea are frequently experienced following mild activity. Shock is assumed to occur when the cardiovascular reserve deteriorates below a sustainable limit where the reserve control induces a salvage-sacrifice response, preserving vital organ perfusion while impairing microcirculation effective perfusion in non-vital organ in which it causes cellular hypoxia followed by the familiar devastating cascade of events seen in shock. DISCUSSION AND CONCLUSIONS The hereby hypothesis may comprehensively explain the heart failure - shock puzzle as no alternative theory had ever succeeded. It provides the missing link between the different types of HF as of shock and in between. The hypothesis poses a great prove challenge but opens new research and clinical possibilities.
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Affiliation(s)
- Uri Gabbay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; School of Electrical Engineering, Tel Aviv University, Tel Aviv, Israel.
| | - Ben Zion Bobrovsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; School of Electrical Engineering, Tel Aviv University, Tel Aviv, Israel
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Coen D, Cortellaro F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, Cazzaniga M, Boghi D. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014; 32:563-8. [PMID: 24666743 DOI: 10.1016/j.ajem.2014.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/30/2014] [Accepted: 02/10/2014] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Early goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion. METHODS We enrolled 51 patients with septic shock. As a marker of preload optimization, we measured IVC collapse in place of CVP and serum lactate clearance in place of central venous oxygen saturation as a marker of tissue perfusion. As outcomes, we considered the accomplishment of the noninvasive EGDT goals, the number of patients treated without the need of a CVC, the amount of fluids administered in the first 6 hours, the development of pulmonary edema, and the overall mortality rate. RESULTS Inferior vena cava US evaluation resulted feasible in 92% of patients. Lung US was performed in 100% of cases. In the first 6 hours, only 61.7% of patients received a CVC, an average of 5.5 L of crystalloids were administered, and only 4 patients developed clinical overt pulmonary edema. Mortality was 34% at 28 days and 38.3% at 60 days. CONCLUSIONS Our approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.
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Affiliation(s)
- Daniele Coen
- Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy.
| | | | - Simone Pasini
- Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy
| | - Valeria Tombini
- Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy
| | - Angelica Vaccaro
- Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy
| | | | | | - Daniele Boghi
- Ospedale Niguarda Ca' Granda, Emergency Department, Milan, Italy
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Repessé X, Bodson L, Vieillard-Baron A. Doppler echocardiography in shocked patients. Curr Opin Crit Care 2014; 19:221-7. [PMID: 23481099 DOI: 10.1097/mcc.0b013e3283602344] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To reiterate the necessity of integrating echocardiography in the management of shocked patients and to propose a step-by-step functional evaluation of hemodynamics proven to optimize hemodynamic monitoring and to adapt the treatment. RECENT FINDINGS Echocardiography has become the cornerstone to hemodynamic monitoring. By providing real-time images, echocardiography has the advantage over 'blind' technologies of an excellent diagnostic performance and of quick provision of information about the pathophysiology of circulatory failure. Critical care echocardiography (CCE) has been defined as echocardiography performed and interpreted by intensivists themselves, 7/7 and 24/24, at the bedside. Basic CCE is mainly a diagnostic approach, allowing quick and focused examination of cardiac function. Advanced CCE is the core of functional hemodynamic monitoring. It is based not only on transthoracic echocardiography but also strongly on transesophageal echocardiography, a very useful approach in ventilated patients. However, this monitoring is discontinuous. A single-use 72-h indwelling transesophageal probe was recently tested, allowing functional hemodynamic monitoring more continuously. SUMMARY Echocardiography has become a hemodynamic monitoring technique used worldwide. It allows to make a quick and simple diagnosis of typical hemodynamic situations, by means of basic CCE, and also to achieve real functional hemodynamic monitoring, through advanced CCE.
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Affiliation(s)
- Xavier Repessé
- Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Boulogne-Billancourt, France
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Kotanen CN, Guiseppi-Elie A. Monitoring systems and quantitative measurement of biomolecules for the management of trauma. Biomed Microdevices 2014; 15:561-77. [PMID: 23494594 DOI: 10.1007/s10544-013-9756-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Continued high morbidity and complications due to trauma related hemorrhage underscores the fact that our understanding of the detailed molecular events of trauma are inadequate to bring life-saving changes to practice. The current state of efficacy and advances in biomedical microdevice technology for trauma diagnostics concerning hemorrhage and hemorrhagic shock was considered with respect to vital signs and metabolic biomarkers. Tachycardia and hypotension are markers of hemorrhagic shock in decompensated trauma patients. Base deficit has been predicative of injury severity at hospital admission. Tissue oxygen saturation has been predicative of onset of multiple organ dysfunction syndrome. Blood potassium levels increase with onset of hemorrhagic shock. Lactate is a surrogate for tissue hypoxia and its clearance predicts mortality. Triage glucose measurements have been shown to be specific in predicting major injuries. No vital sign has yet to be proven effective as an independent predictor of trauma severity. Point of care (POC) devices allow for rapid results, easy sample preparation and processing, small sample volumes, small footprint, multifunctional analysis, and low cost. Advances in the field of in-vivo biosensors has provided a much needed platform by which trauma related metabolites can be monitored easily, rapidly and continuously. Multi-analyte monitoring biosensors have the potential to explore areas still undiscovered in the realm of trauma physiology.
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Affiliation(s)
- Christian N Kotanen
- Center for Bioelectronics, Biosensors and Biochips, Clemson University Advanced Materials Center, 100 Technology Drive, Anderson, SC 29625, USA.
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Lichtenstein D. Fluid administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (the FALLS-protocol). Expert Rev Respir Med 2014; 6:155-62. [DOI: 10.1586/ers.12.13] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Pulmonary Arterial Hypertension in Intensive Care Unit. UNCOMMON DISEASES IN THE ICU 2014. [PMCID: PMC7120311 DOI: 10.1007/978-3-319-04576-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
For the intensive care unit (ICU) physician, the diagnosis of pulmonary arterial hypertension (PAH) is difficult as it can easily be confounded with other forms of pulmonary hypertension (PH). The key issue is that PAH is a form of PH. On the opposite, PH does not automatically imply PAH. Pulmonary arterial hypertension must be differentiated from other causes of PH that are frequently seen in ICU. It was recently emphasized that pulmonary veno-occlusive disease (PVOD) must be differentiated from PH and PAH. The prognosis of PAH was consistently improved in the ten past years by introduction of selective pulmonary vasodilators and management by highly specialized medical teams. In ICU patients, PAH remains a severe disease with a high mortality rate. When PAH is suspected, a systematic diagnosis approach is of particular importance in order to rapidly eliminate left cardiac, thromboembolic and pulmonary causes of PH. Left cardiac disease is the most common cause of PH. Early recognition of PAH allows a rapid introduction of selective pulmonary vasodilators that can improve outcome. Idiopathic PAH is the most frequent cause but it can also be associated with scleroderma, HIV infection, anorexigen toxicity, thyroid disease, cirrhosis. Pulmonary vasodilators should be only a part of a general management including treatment of triggering factors, optimization of fluid balance, decrease of RV afterload by using pulmonary vasodilators while maintaining cardiac output and mean arterial pressure. The early contact of PH referral center or specialized physician is of particular importance.
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Ochagavía A, Baigorri F, Mesquida J, Ayuela JM, Ferrándiz A, García X, Monge MI, Mateu L, Sabatier C, Clau-Terré F, Vicho R, Zapata L, Maynar J, Gil A. [Hemodynamic monitoring in the critically patient. Recomendations of the Cardiological Intensive Care and CPR Working Group of the Spanish Society of Intensive Care and Coronary Units]. Med Intensiva 2013; 38:154-69. [PMID: 24296336 DOI: 10.1016/j.medin.2013.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/20/2013] [Indexed: 12/14/2022]
Abstract
Hemodynamic monitoring offers valuable information on cardiovascular performance in the critically ill, and has become a fundamental tool in the diagnostic approach and in the therapy guidance of those patients presenting with tissue hypoperfusion. From introduction of the pulmonary artery catheter to the latest less invasive technologies, hemodynamic monitoring has been surrounded by many questions regarding its usefulness and its ultimate impact on patient prognosis. The Cardiological Intensive Care and CPR Working Group (GTCIC-RCP) of the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) has recently impulsed the development of an updating series in hemodynamic monitoring. Now, a final series of recommendations are presented in order to analyze essential issues in hemodynamics, with the purpose of becoming a useful tool for residents and critical care practitioners involved in the daily management of critically ill patients.
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Affiliation(s)
- A Ochagavía
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Corporació, Sanitària Parc Taulí, Institut Universitari Parc Tauli, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España.
| | - F Baigorri
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Corporació, Sanitària Parc Taulí, Institut Universitari Parc Tauli, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | - J Mesquida
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Corporació, Sanitària Parc Taulí, Institut Universitari Parc Tauli, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | - J M Ayuela
- Servicio de Medicina Intensiva, Hospital de Burgos, Burgos, España
| | - A Ferrándiz
- Servicio de Medicina Intensiva, Hospital Universitario General de Castellón, Castellón, España
| | - X García
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Corporació, Sanitària Parc Taulí, Institut Universitari Parc Tauli, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | - M I Monge
- Servicio de Cuidados Críticos y Urgencias, Hospital del SAS Jerez, Jerez de la Frontera, Cádiz, España
| | - L Mateu
- Servicio de Medicina Intensiva, Hospital Universitario General de Castellón, Castellón, España
| | - C Sabatier
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Corporació, Sanitària Parc Taulí, Institut Universitari Parc Tauli, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | - F Clau-Terré
- Institut Reçerca, Hospital de Vall d'Hebron y Consorci Sanitàri Terrasa, Barcelona, España
| | - R Vicho
- Servicio de Medicina Intensiva, Clínica USP-Palmaplanas, Palma de Mallorca, España
| | - L Zapata
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Maynar
- Servicio de Medicina Intensiva, Hospital Universitario Araba, Vitoria, Álava, España
| | - A Gil
- Servicio de Cuidados Críticos y Urgencias, Hospital del SAS Jerez, Jerez de la Frontera, Cádiz, España
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145
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De Backer D. Year in review 2012: Critical Care--Cardiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:247. [PMID: 24267398 PMCID: PMC4059378 DOI: 10.1186/cc13127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this review I discuss key research papers in cardiology and intensive care published in Critical Care during 2012 with related studies published in other journals quoted whenever appropriate. These studies are grouped into the following categories: cardiovascular therapies, mechanical therapies, pathophysiologic mechanisms, hemodynamic monitoring, ultrasound in respiratory failure, microcirculation, and miscellaneous.
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146
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Kelm DJ, Valerio-Rojas JC, Cabello-Garza J, Gajic O, Cartin-Ceba R. Predictors of Disseminated Intravascular Coagulation in Patients with Septic Shock. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/219048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose. The goal of this study was to identify potential clinical predictors for the development of disseminated intravascular coagulation (DIC) in patients with septic shock. Material and Methods. We performed a retrospective analysis of a cohort of adult (>18 years of age) patients with septic shock admitted to a medical ICU in a tertiary care hospital from July 2005 until September 2007. A multivariate logistic regression model was used to determine the association of risk factors with overt DIC. Results. In this study, a total of 390 patients with septic shock were analyzed, of whom 66 (17%) developed overt DIC. Hospital mortality was significantly greater in patients who developed overt DIC (68% versus 38%, P<0.001). A delay in the timing of antibiotics was associated with an increased risk of the development of overt DIC (P<0.001). Patients on antiplatelet therapy prior to hospital admission and who that received adequate early goal-directed therapy (EGDT) were associated with a decreased risk of overt DIC (P<0.001). Conclusions. In our cohort of patients with septic shock, there was a risk reduction for overt DIC in patients on antiplatelet therapy and adequate EGDT, while there was an increased risk of DIC with antibiotic delay.
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Affiliation(s)
- Diana J. Kelm
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Juan Carlos Valerio-Rojas
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Rochester, MN 55905, USA
| | - Javier Cabello-Garza
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Rochester, MN 55905, USA
| | - Ognjen Gajic
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Rodrigo Cartin-Ceba
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
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147
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Abstract
Hemodynamic assessment is a key component of the evaluation of the critically ill patients and has both diagnostic and prognostic utility. This review outlines a general approach to assessment of hemodynamics and perfusion, and then discusses various hemodynamic parameters: heart rate, BP, intravascular (central venous and pulmonary artery) pressures, cardiac output, and myocardial performance, within the context not only of how they are best measured but also how they should be used in a clinical context. Hemodynamics are best assessed using a combination of not only different hemodynamic parameters but also those with the inclusion of clinical indices of perfusion. The benefits of these techniques, as with all medical testing and interventions, must be weighed against any potential risks. Although what to measure and how to measure it is important, what is most important is how to use the information. Evaluating the response to therapeutic interventions is frequently the most useful way to employ hemodynamic monitoring techniques. For the practitioner, learning how to select from a robust set of hemodynamic tools and how to tailor their use to individual clinical settings will allow for optimal patient care.
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Affiliation(s)
- Steven M Hollenberg
- Cooper Medical School of Rowan University; and Coronary Care Unit, Cooper University Hospital, Camden, NJ.
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148
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Study of agreement of aortic, radial and femoral blood pressures during aortic endografting. ACTA ACUST UNITED AC 2013; 32:e97-e101. [PMID: 23953836 DOI: 10.1016/j.annfar.2013.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 06/11/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE To estimate the agreement between radial or femoral, and ascending aortic invasive blood pressure values. PATIENTS AND METHODS Prospective study on 32 patients who underwent an aortic endografting under general anesthesia. After deploying the prosthesis under controlled hypotension, a catheter was introduced in the aorta to measure the staged systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, in particular at the level of ascending aorta and femoral artery. RESULTS No differences were observed between SAP, DAP or MAP measured in the aorta versus femoral or radial arteries. A better agreement was observed between the aortic and femoral MAP (bias of 1mmHg, limits of agreement between: -8.8mmHg and +10.8mmHg) than between the aortic and the radial MAP (bias of 1.7mmHg, limits of agreement between: -14.1mmHg and +17.5mmHg). The comparison between radial and femoral MAP was not satisfying (bias of -4.7mmHg and limits of agreement between -19.1mmHg and +9.7mmHg). CONCLUSION The femoral MAP is more accurate to predict value of the aortic MAP than the radial MAP in a hypotensive setting. The clinician should be aware of these discrepancies in conditions of hemodynamic impairment to optimize the treatment.
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149
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Kirton OC, Calabrese RC, Staff I. Increasing use of less-invasive hemodynamic monitoring in 3 specialty surgical intensive care units: a 5-year experience at a tertiary medical center. J Intensive Care Med 2013; 30:30-6. [PMID: 23940109 DOI: 10.1177/0885066613498055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). HYPOTHESIS The decrease in use of PACs is not associated with increased mortality. METHODS Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (β-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. RESULTS There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from β-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). CONCLUSIONS In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.
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Affiliation(s)
| | | | - Ilene Staff
- Research Administration, Hartford Hospital, Hartford, CT, USA
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150
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Bar-Or D, Salottolo KM, Orlando A, Mains CW, Bourg P, Offner PJ. Association between a geriatric trauma resuscitation protocol using venous lactate measurements and early trauma surgeon involvement and mortality risk. J Am Geriatr Soc 2013; 61:1358-64. [PMID: 23889501 DOI: 10.1111/jgs.12365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate whether implementing a geriatric resuscitation protocol that uses lactate-guided therapy with early trauma surgeon involvement is associated with lower mortality through the early recognition of occult hypoperfusion (OH). DESIGN Prospective cohort study. SETTING Level I trauma center. PARTICIPANTS All hemodynamically stable individuals with blunt trauma aged 65 and older admitted to the Level I trauma center from October 1, 2008, through December 31, 2011 (n = 1,998). MEASUREMENTS Mortality over time (according to quarter) was analyzed using an adjusted logarithmic regression model stratified according to the presence of OH. OH was defined as lactate of 2.5 mM or greater. RESULTS Overall mortality was 3.9% (n = 78). Admission venous lactate was collected in 73.5% of participants, of whom 20.5% had OH (n = 301). In participants with OH, a significant decrease in mortality was observed over time (adjusted coefficient of determination (R(2) ) = 0.66, P = .002). A smaller yet significant decrease in mortality rates in participants with normal perfusion status was also observed (adjusted R(2) = 0.55, P = .01). CONCLUSION Early identification and treatment of OH in elderly adults with trauma using venous lactate-guided therapy coupled with early trauma surgeon involvement was associated with significantly lower mortality. A protocol that uses lactate-guided therapy with early trauma surgeon involvement should be followed to improve the care of elderly adults with trauma.
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Affiliation(s)
- David Bar-Or
- Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado 80228, USA.
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