A web-based Italian survey of current trends, habits and beliefs in hemodynamic monitoring and management

Indwelling catheters increase altered mental status and urinary tract infection risk: A retrospective Cohort Study

Background

Although indwelling urinary catheters (IUCs) are used intraoperatively and may cause complications (e.g., delirium), only few robust studies have investigated the association between intraoperative IUC use and complications. We hypothesized that IUC use might increase the postoperative incidence of altered mental status and/or urinary catheter infection.

Materials and methods

In this retrospective single-center cohort study, we analyzed the data of adult patients undergoing surgery at our facility between January 2013 and December 2018. The primary endpoint was altered mental status and/or incidence of urinary catheter infections. The patients were divided into IUC and control groups. A multivariable logistic regression model was used to identify the predictors of postoperative complications, and a multivariable Cox proportional hazards regression model was used to analyze hospital discharge in unmatched and inverse propensity-weighted patients.

Results

Of the 14,284 patients that were reviewed, we analyzed 5112 patients (control group, 44.0%; IUC group, 56.0%). Almost all procedures comprised less invasive surgeries. The prevalence of postoperative altered mental status and postoperative urinary catheter infection were 3.56% and 0.04%, respectively. After inverse propensity weighting, all baseline characteristics were similar between the two groups. However, patients with IUCs had a higher risk of postoperative complications (adjusted odds ratio, 1.97; 95% confidence interval [CI], 1.50-2.59) and prolonged hospital stays (hazard ratio, 0.84; 95% CI, 0.80-0.89).

Conclusion

In patients undergoing less invasive surgery, IUCs may be associated with a relatively high risk of altered mental status or urinary catheter infection. These data may facilitate preoperative discussions regarding the perioperative use of IUCs.

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.

Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

Advanced hemodynamic monitoring in intensive care medicine : A German web-based survey study

BACKGROUND

Advanced hemodynamic monitoring is recommended in patients with complex circulatory shock.

OBJECTIVES

To evaluate the current attitudes and beliefs among German intensivists, regarding advanced hemodynamic monitoring, the actual hemodynamic management in clinical practice, and the barriers to using it.

MATERIALS AND METHODS

Web-based survey among members of the German Society of Medical Intensive Care and Emergency Medicine.

RESULTS

Of 284 respondents, 249 (87%) agreed that further hemodynamic assessment is needed to determine the type of circulatory shock if no clear clinical diagnosis can be made. In all, 281 (99%) agreed that echocardiography is helpful for this purpose (transpulmonary thermodilution: 225 [79%]; pulmonary artery catheterization: 126 [45%]). More than 70% of respondents agreed that blood flow variables (cardiac output, stroke volume) should be measured in patients with hemodynamic instability. The parameters most respondents agreed should be assessed in a patient with hemodynamic instability were mean arterial pressure, cardiac output, and serum lactate. Echocardiography is available in 99% of ICUs (transpulmonary thermodilution: 91%; pulmonary artery catheter: 63%). The respondents stated that, in clinical practice, invasive arterial pressure measurements and serum lactate measurements are performed in more than 90% of patients with hemodynamic instability (cardiac output monitoring in about 50%; transpulmonary thermodilution in about 40%). The respondents did not feel strong barriers to the use of advanced hemodynamic monitoring in clinical practice.

CONCLUSIONS

This survey study shows that German intensivists deem advanced hemodynamic assessment necessary for the differential diagnosis of circulatory shock and to guide therapy with fluids, vasopressors, and inotropes in ICU patients.

Effect of patent ductus arteriosus and patent foramen ovale on left ventricular stroke volume measurement by electrical velocimetry in comparison to transthoracic echocardiography in neonates

This prospective single-center observational study compared impedance cardiography [electrical velocimetry (EV)] with transthoracic echocardiography (TTE, based on trans-aortic flow) and analyzed the influence of physiological shunts, such as patent ductus arteriosus (PDA) or patent foramen ovale (PFO), on measurement accuracy. Two hundred and ninety-one triplicate simultaneous paired left ventricular stroke volume (LVSV) measurements by EV (LVSV_EV) and TTE (LVSV_TTE) in 99 spontaneously breathing neonates (mean weight 3270 g; range 1227-4600 g) were included. For the whole cohort, the mean absolute LVSV_EV was 5.5 mL, mean LVSV_TTE was 4.9 mL, resulting in an absolute Bland-Altman bias of -0.7 mL (limits of agreement LOA -3.0 to 1.7 mL), relative bias -12.8 %; mean percentage error MPE 44.9 %; true precision TP_EV 33.4 % (n = 99 aggregated data points). In neonates without shunts (n = 32): mean LVSV_EV 5.0 mL, mean LVSV_TTE 4.6 mL, Bland-Altman bias -0.4 mL (LOA -2.8 to 2.0 mL), relative bias -8.2 %; MPE 50.7 %; TP_EV 40.9 %. In neonates with shunts (PDA and/or PFO; n = 67): mean LVSV_EV 5.8 mL, mean LVSV_TTE 5.0 mL, bias -0.8 mL (LOA -3.1 to 1.5 mL), relative bias -14.8 %, MPE 41.9 %, TP_EV 29.3 %. Accuracy was affected by PDA and/or PFO, with a significant increase in the relative difference in LVSV_EV versus LVSV_TTE: Subjects without shunts -2.9 % (n = 91), PFO alone -9.6 % (n = 125), PDA alone -14.0 % (n = 12), and PDA and PFO -18.5 % (n = 63). Physiological shunts (PDA and/or PFO) in neonates affect measurement accuracy and cause overestimation of LVSV_EV compared with LVSV_TTE.