[S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]

How Would I Treat My Own Thoracoabdominal Aortic Aneurysm: Perioperative Considerations From the Anesthesiologist Perspective

A thoracoabdominal aortic aneurysm (TAAA) can be potentially life-threatening due to its associated risk of rupture. Thoracoabdominal aortic aneurysm repair, performed as endovascular repair and/or open surgery, is the recommended therapy of choice. Hemodynamic instability, severe blood loss, and spinal cord or cerebral ischemia are some potential hazards the perioperative team has to face during these procedures. Therefore, preoperative risk assessment and intraoperative anesthesia management addressing these potential hazards are essential to improving patients' outcomes. Based on a presented index case, an overview focusing on anesthetic measures to identify perioperatively and manage these risks in TAAA repair is provided.

Practical training concept for perfusionists at the heart and diabetes center Nordrhein-Westfalen

BACKGROUND

Increasing regulations and requirements of advisory bodies, in particular the Joint Federal Committee and the Medical Service of the health insurance funds, make it necessary to employ only demonstrably well-trained perfusionists. The minimum requirement for this staff is EBCP certification. Currently there is limited availability of such specialists on the German market. Therefore, the qualification of young people in this area is of central importance. The aim of this paper is to strengthen the training of perfusionists at our centre, to standardise the process and to provide the respective student with a "roadmap" to their internship.

MATERIAL & METHODS

The structure is based on a rough division of the 24 weeks of internship. This is described in detail in the following and is backed up with the learning objectives for the respective time periods.

RESULTS

At our centre, practical training has been standardized and clear responsibilities have been defined. Furthermore, as a centre of maximum care in the field of cardiac surgery, we can offer students the necessary number of perfusions in just six months to meet the requirements of the ECBP for practical training. According to this concept, 20 perfusionists have been successfully trained in the last 8 years. All of them have passed the exams and have been certified according to EBCP.

CONCLUSION

The aim of the practical semester is for the student to be in a position at the end of the semester to independently supervise simple cardiac surgery procedures with the aid of the Extra- Corporal Circulation (ECC) and to carry this out in accordance with the currently valid guidelines and directives (1-8) and the departmental procedural instructions based on them. Great emphasis is placed to the students becoming aware of their competence to act, knowing their limits and being able to assess when these limits have been reached and the involvement of experienced colleagues is necessary to ensure patient safety.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis

INTRODUCTION

Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes.

METHODS

Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch.

RESULTS

Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ.

CONCLUSION

GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.

A classification system for pulmonary artery catheters

Flow-directed, balloon-tipped pulmonary artery catheters allow measuring cardiac output and other haemodynamic variables including intracardiac pressures. We propose classifying pulmonary artery catheters by generations and specifying additional measurement modalities. Based on the method used to measure cardiac output, pulmonary artery catheters can be classified into three generations: first-generation using intermittent pulmonary artery thermodilution; second-generation using a thermal filament for automated pulmonary artery thermodilution; and third-generation combining thermal filament-based automated pulmonary artery thermodilution and pulmonary artery pulse wave analysis. Each of these pulmonary artery catheter generations can include additional measurements, such as continuous mixed venous oxygen saturation, right ventricular ejection fraction and end-diastolic volume, and right ventricular pressure. This classification should help define indications for pulmonary artery catheters in clinical practice and research.

Influence of timing of Levosimendan administration on outcomes in cardiac surgery

Purpose

Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality.

Methods

All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups.

Results

After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy.

Conclusions

Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.

[Intensive Care in Heart Surgery - is All Now Different?]

With approximately 100000 operations performed in Germany per year, cardiac surgery is among the surgical specialties that require intensive care tratment most frequently. Although all therapeutic aspects of ICU treatment are of high importance among cardiac surgery patients, there is a focus on hemodynamics with the overarching goal of sufficient oxygen delivery. Patients undergoing cardiac surgery are particularily prone to hemodynamic instability and low cardiac output syndrome, potentially culminating into cardiogenic shock. This article presents an overview of essential elements of intensive care medicine in cardiac surgery, paying special attention to hemodynamic monitoring, low cardiac output syndrome, inotropy, cardiac arrhyhmia, perioperative myocardial infarction, and patient blood management.

Cardiac output monitoring with pulmonary versus trans-cardiopulmonary thermodilution in left ventricular assist devices: Interchangeable methods?

Cardiac output (CO) measurement is mandatory in patients with left ventricular assist devices (LVADs). Thermodilution with pulmonary artery catheter (PAC) remains the clinical gold standard to measure CO in these patients, however it is associated with several complications. Therefore, the agreement between PAC and new, minimally invasive monitoring methods in LVAD needs to be further investigated. The aim of this study was to assess the accuracy and reliability of transpulmonary thermodilution with a PiCCO2 monitor compared with pulmonary artery thermodilution with PAC in a LVAD. Continuous-flow LVADs were implanted in six mini-pigs to assist the left ventricle. We studied two methods of measuring CO—intermittent transpulmonary thermodilution (CO_TPTD) by PiCCO2 and intermittent pulmonary artery thermodilution by CAP, standard technique (CO_PTD)—obtained in four consecutive moments of the study: before starting the LVAD (basal moment), and with the LVAD started in normovolemia, hypervolemia (fluid overloading) and hypovolemia (shock hemorrhage). A total of 72 paired measurements were analysed. At the basal moment, CO_TPTD and CO_PTD were closely correlated (r² = 0.89), with a mean bias of −0.085 ± 0.245 L/min and percentage error of 16%. After 15 min of partial support LVAD, CO_TPTD and CO_PTD were closely correlated (r² = 0.79), with a mean bias of −0.040 ± 0.417 L/min and percentage error of 26%. After inducing hypervolemia, CO_TPTD and CO_PTD were closely correlated (r² = 0.78), with a mean bias of −0.093 ± 0.339 L/min and percentage error of 13%. After inducing hypovolemia, CO_TPTD and CO_PTD were closely correlated (r² = 0.76), with a mean bias of −0.045 ± 0.281 L/min and percentage error of 28%. This study demonstrates a good agreement between transpulmonary thermodilution by PiCCO monitor and pulmonary thermodilution by PAC in the intermittent measurement of CO in a porcine model with a continuous-flow LVAD.

[Hemodynamic Monitoring in the ICU: the More Invasive, the Better?]

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

[Targeted hemodynamic monitoring in the operating theatre: what for and by what means?]

Goal directed hemodynamic monitoring and the balance in goal directed therapy between adequate fluid/volume therapy and the application of vasoactive or inotropic drugs are the basic elements of modern perioperative therapy.Surgical procedures should be accompanied by as few side effects and complications as possible. Nevertheless, the number of postoperative complications remains surprisingly high, despite of the modern surgical procedures. Anticipation of potential complications in the perioperative period and their rapid treatment build a core competence of anesthesiological action. Thus, it is clear that anesthesia plays a central role in this balancing act.This article aims to provide an overview of the application of the currently available perioperative goal directed hemodynamic monitoring. The current possibilities are discussed by using a case example and an outlook on the future of hemodynamic monitoring is given.

High Central Venous Pressure after Cardiac Surgery Might Depict Hemodynamic Deterioration Associated with Increased Morbidity and Mortality

Background: Cardiac surgery patients represent a high-risk cohort in intensive care units (ICUs). Central venous pressure (CVP) measurement seems to remain an integral part in hemodynamic monitoring, especially in cardio-surgical ICUs. However, its value as a prognostic marker for organ failure is still unclear. Therefore, we analyzed postoperative CVP values after adult cardiac surgery in a large cohort with regard to its prognostic value for morbidity and mortality. Methods: All adult patients admitted to our ICUs between 2006 and 2019 after cardiac surgery were eligible for inclusion in the study (n = 11,198). We calculated the median initial CVP (miCVP) after admission to the ICU, which returned valid values for 9802 patients. An ROC curve analysis for optimal cut-off miCVP to predict ICU mortality was conducted with consecutive patient allocation into a (a) low miCVP (LCVP) group (≤11 mmHg) and (b) high miCVP (HCVP) group (>11 mmHg). We analyzed the impact of high miCVP on morbidity and mortality by propensity score matching (PSM) and logistic regression. Results: ICU mortality was increased in HCVP patients. In addition, patients in the HCVP group required longer mechanical ventilation, had a higher incidence of acute kidney injury, were more frequently treated with renal replacement therapy, and showed a higher risk for postoperative liver dysfunction, parametrized by a postoperative rise of ≥ 10 in MELD Score. Multiple regression analysis confirmed HCVP has an effect on postoperative ICU-mortality and intrahospital mortality, which seems to be independent. Conclusions: A high initial CVP in the early postoperative ICU course after cardiac surgery is associated with worse patient outcome. Whether or not CVP, as a readily and constantly available hemodynamic parameter, should promote clinical efforts regarding diagnostics and/or treatment, warrants further investigations.

Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap

Levosimendan is a distinctive inodilator combing calcium sensitization, phosphodiesterase inhibition and vasodilating properties through the opening of adenosine triphosphate-dependent potassium channels. It was first approved in Sweden in 2000 for the short-term treatment of acutely decompensated severe chronic heart failure when conventional therapy is not sufficient, and in cases where inotropic support is considered appropriate. After more than 20 years, clinical applications have considerably expanded across critical care and emergency medicine, and levosimendan is now under investigation in different cardiac settings (eg, septic shock, pulmonary hypertension) and for non-cardiac applications (eg, amyotrophic lateral sclerosis). This narrative review outlines key milestones in levosimendan history, by addressing regulatory issues, pharmacological peculiarities and clinical aspects (efficacy and safety) of a drug that did not receive great attention in the heart failure guidelines. A brief outlook to the ongoing clinical trials is also offered.

Role of Echocardiography for the Perioperative Assessment of the Right Ventricle

Purpose of Review

This review aims to highlight the perioperative echocardiographic evaluation of right ventricular (RV) function with strengths and limitations of commonly used and evolving techniques. It explains the value of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and describes the perioperative changes of RV function echocardiographers should be aware of.

Recent Findings

RV dysfunction is an entity with strong influence on outcome. However, its definition and assessment in the perioperative interval are not well-defined. Moreover, values assessed by TTE and TEE are not interchangeable; while some parameters seem to correlate well, others do not. Myocardial strain analysis and three-dimensional echocardiography may overcome the limitations of conventional echocardiographic measures and provide further insight into perioperative cardiac mechanics.

Summary

Echocardiography has become an essential part of modern anesthesiology in patients with RV dysfunction. It offers the opportunity to evaluate not only global but also regional RV function and distinguish alterations of RV contraction.

Infectious Complications after Etomidate vs. Propofol for Induction of General Anesthesia in Cardiac Surgery-Results of a Retrospective, before-after Study

Background: Etomidate is typically used as an induction agent in cardiac surgery because it has little impact on hemodynamics. It is a known suppressor of adrenocortical function and may increase the risk for post-operative infections, sepsis, and mortality. The aim of this study was to evaluate whether etomidate increases the risk of postoperative sepsis (primary outcome) and infections (secondary outcome) compared to propofol. Methods: This was a retrospective before–after trial (IRB EA1/143/20) performed at a tertiary medical center in Berlin, Germany, between 10/2012 and 01/2015. Patients undergoing cardiac surgery were investigated within two observation intervals, during which etomidate and propofol were the sole induction agents. Results: One-thousand, four-hundred, and sixty-two patients, and 622 matched pairs, after caliper propensity-score matching, were included in the final analysis. Sepsis rates did not differ in the matched cohort (etomidate: 11.5% vs. propofol: 8.2%, p = 0.052). Patients in the etomidate interval were more likely to develop hospital-acquired pneumonia (etomidate: 18.6% vs. propofol: 14.0%, p = 0.031). Conclusion: Our study showed that a single-dose of etomidate is not statistically associated with higher postoperative sepsis rates after cardiac surgery, but is associated with a higher incidence of hospital-acquired pneumonia. However, there is a notable trend towards a higher sepsis rate.

Perioperative echocardiography-guided hemodynamic therapy in high-risk patients: a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

New Advances in Monitoring Cardiac Output in Circulatory Mechanical Assistance Devices. A Validation Study in a Porcine Model

Cardiac output (CO) measurement by continuous pulmonary artery thermodilution (CO_CTD) has been studied in patients with pulsatile-flow LVADs (left ventricular assist devices), confirming the clinical utility. However, it has not been validated in patients with continuous-flow LVADs. Therefore, the aim of this study was to assess the validity of CO_CTD in continuous-flow LVADs. Continuous-flow LVADs were implanted in six miniature pigs for partial assistance of the left ventricle. Both methods of measuring CO—measurement by CO_CTD and intermittent pulmonary artery thermodilution, standard technique (CO_ITD)—were used in four consecutive moments of the study: before starting the LVAD (basal moment), and with the LVAD started in normovolemia, hypervolemia (fluid overloading), and hypovolemia (shock hemorrhage). At the basal moment, CO_CTD and CO_ITD were closely correlated (r² = 0.97), with a mean bias of −0.13 ± 0.16 L/min and percentage error of 11%. After 15 min of partial support LVAD, CO_CTD and CO_ITD were closely correlated (r² = 0.91), with a mean bias of 0.31 ± 0.35 L/min and percentage error of 20%. After inducing hypervolemia, CO_CTD and CO_ITD were closely correlated (r² = 0.99), with a mean bias of 0.04 ± 0.07 L/min and percentage error of 5%. After inducing hypovolemia, CO_CTD and CO_ITD were closely correlated (r² = 0.74), with a mean bias of 0.08 ± 0.22 L/min and percentage error of 19%. This study shows that continuous pulmonary thermodilution could be an alternative method of monitoring CO in a porcine model with a continuous-flow LVAD.

An email-based survey of practice regarding hemodynamic monitoring and management in children with septic shock in China

BACKGROUND

Understanding current hemodynamic monitoring (HM) practice patterns is essential to determine education and training strategies in China. The survey was to describe the practice of HM and management in children with septic shock in China.

METHODS

We conducted an Email-based survey of members of sub-association of pediatric intensive care physicians. The questionnaire consisted of 22 questions and gathered the following information: (I) general information on the hospitals, respective ICUs and participants, (II) the availability of technical equipment and parameters of HM and (III) management simulation of septic shock in three clinical case vignettes.

RESULTS

Surveys were received from 68 institutions (87.2%) and 368 questionnaires (response-rate 45.1%) were included. Basic HM (93-100%) were reported as the most utilized parameters, followed by advanced HM which included central venous pressure (CVP) (56.0%), cardiac output (53.5%), and central venous oxygen saturation (36.7%), 61.1% (225/368) of respondents stated the utilization of non-invasive HM equipment. The factors such as ICU specialist training center (P=0.003) and more than 30 cases of septic shock per year (P=0.002) were related to the utilization of non-invasive monitoring equipment. In the simulated case vignette, 49.7% (183/368) of respondents reported performing fluid responsiveness and volume status (FR-VS) assessment. Despite differences in training centers (P=0.005) and educational backgrounds (P=0.030), FR-VS assessment was not related to the volume expansion decision.

CONCLUSIONS

There is a large variability in use advanced HM parameters, an increasing awareness and acceptance of non-invasive HM devices and a potential need for hemodynamic education and training in pediatric intensive care medicine in China.

[Individualized use of levosimendan in cardiac surgery]

BACKGROUND

Levosimendan is a cardiac inotrope that augments myocardial contractility without increasing myocyte oxygen consumption. Additionally, levosimendan has been shown to exhibit anti-inflammatory, antioxidative, and other cardioprotective properties and is approved for treatment of heart failure. Recent studies indicated that these beneficial effects can be achieved with doses lower than the standard dose of 12.5 mg. Patients with preoperatively diagnosed left ventricular ejection fraction (LVEF) ≤40% received 1.25 mg levosimendan after induction of anesthesia. After surgery, administration of low-dose levosimendan was repeated until cardiovascular stability was achieved.

OBJECTIVE

This study aimed to evaluate if pharmacological preconditioning with 1.25 mg levosimendan in patients with LVEF ≤40% altered the postoperative need for inotropic agents, the incidence of newly occurring atrial fibrillation, renal replacement therapy, mechanical circulatory support and 30-day mortality. The cumulative dosage of levosimendan was recorded to assess the required dosage in the context of individualized treatment.

MATERIAL AND METHODS

This retrospective study included patients with preoperatively diagnosed LVEF ≤40% who underwent cardiac surgery at this institution between January 2015 and December 2018 and who received 1.25 mg levosimendan after induction of anesthesia to prevent postoperative low cardiac output syndrome. Based on echocardiography results, invasive hemodynamic monitoring, and central venous or mixed venous oxygen saturation and lactate clearance, repetitive doses of levosimendan in 1.25 mg increments could be postoperatively administered until cardiovascular stability was achieved. The results were compared to the current literature.

RESULTS

We identified 183 patients with LVEF <40% who received pharmacological preconditioning with 1.25 mg levosimendan. Maximum doses of epinephrine, incidence of atrial fibrillation, need for renal replacement therapy and 30-day mortality were found to be below the published rates of comparable patient collectives. In 73.2% of patients, a cumulative dosage of 5 mg levosimendan or less was considered sufficient.

CONCLUSION

The presented concept of pharmacological preconditioning with 1.25 mg levosimendan followed by individualized additional dosing in cardiac surgery patients with preoperative LVEF ≤40% suggests that this concept is safe, with possible advantages regarding the need of inotropic agents, renal replacement therapy, and 30-day mortality, compared to the current literature. Individualized treatment with levosimendan to support hemodynamics and a timely reduction of inotropic agents needs further confirmation in randomized trials.

[Perioperative pharmacological circulatory support in daily clinical routine]

Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.

[Sonography in intensive care and emergency medicine : A new training concept]

Structured sonography training in internal medicine intensive care and emergency medicine (SIN) comprises two levels and was proposed by three national societies in Germany (DGIIN, DGK and DEGUM). The curriculum consists of a basic level (SIN-I) and an expert level (SIN-II) which are consecutive levels teaching both theoretical and hands-on skills using a symptom-based approach. Competency is assessed using written, oral and practical structured assessments at the end of each level. The goal is to implement national and international recommendations regarding the use of point-of-care ultrasound into clinical practice.

[Hemodynamic target variables in the intensive care unit]

Despite broad availability, extended hemodynamic monitoring is used in practice only in the minority of critical care patients. Pathophysiological reasoning suggests that systemic perfusion pressure (and thereby arterial as well as central venous pressure), cardiac stroke volume, and the systemic oxygen balance are key variables in maintaining adequate organ perfusion. In line with these assumptions, several studies support that a goal-directed optimization of these hemodynamic variables leads to a reduction in morbidity and mortality. The appropriate monitoring modality should be selected following echocardiographic evaluation of biventricular function. Ideally, high-risk patients with limited right ventricular function should be monitored with a pulmonary artery catheter. In patients with preserved right ventricular function, transpulmonary thermodilution with special consideration of extravascular lung water seems to be sufficient to guide hemodynamic therapy.

Perioperative hemodynamic monitoring: Still a place for cardiac filling pressures?

The clinical usefulness of the so-called "static" cardiac filling pressures - central (CVP) and pulmonary-artery-occlusion-pressure (PAOP) - has come into question for guiding hemodynamic therapy due to their poor ability to predict fluid responsiveness in comparison with other monitoring modalities such as transpulmonary thermodilution-derived volumetric measurements, dynamic variables for assessing fluid responsiveness, and the potential risks associated with pulmonary artery catheterization. This contrasts with observations in multiple patient populations showing a clear association between increased CVP and PAOP levels and poor outcomes, probably due to a reduction in effective perfusion pressure (mean arterial pressure minus CVP) and their role as effectiveness parameters of the cardiovascular system. Furthermore, clinical studies have revealed beneficial effects when interpreting CVP and PAOP dynamically and combining them with flow-related hemodynamic variables. Taking into account the additional information derived from bedside CVP and PAOP pulse curve interpretation, cardiac filling pressures remain an important hemodynamic monitoring tool.

Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.

Postoperative management of patients undergoing cardiac surgery in Austria : A national survey on current clinical practice in hemodynamic monitoring and postoperative management

Background

No data are currently available regarding the current clinical practice in postoperative care of cardiac surgical patients in Austria.

Objective

The study investigated the current intensive care management concerning hemodynamic monitoring and strategies to treat common perioperative disorders of patients after cardiac surgery in Austria.

Methods

A survey consisting of 31 questions was sent to intensivists at all 9 hospitals offering cardiac surgery in Austria.

Results

The response rate was 100%. The mean number of procedures on cardiopulmonary bypass per centre was 722 ± 223. In the majority of cases postoperative critical care is performed by anesthesiologists. Blood gas analysis, pulse oximetry, electrocardiogram, temperature, central venous pressure, arterial pressure and hourly urine output are de facto standard monitoring in all centers. Transesophageal echocardiography is available in all centers and is frequently used. Crystalloids are the first choice for volume replacement, whereas levosimendan and adrenaline are employed for the treatment of low cardiac output syndrome.

Conclusions

This study provides insights into the current state of postoperative management of cardiac surgical patients in Austria. Standard monitoring as proposed by international guidelines is well established in Austrian intensive care units. Echocardiography is widely seen as a very important tool in the postoperative care of cardiac surgical patients. Knowledge about the status quo of postoperative intensive care management of cardiac surgical patients enables further development of patient care.

Electronic supplementary material

The online version of this article (10.1007/s00508-018-1403-3) contains supplementary material, which is available to authorized users.

[Focused echocardiography in acute medicine]

Focused echocardiography has become increasingly important for bedside diagnostics in acute medicine. Focused echocardiography can detect various cardiac pathologies, such as pericardial effusion, left ventricular dysfunction, right heart strain, relevant heart valve defects and dissection of the ascending aorta. Echocardiographic findings should be interpreted in the clinical context.