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Jerman CF, Baker KH, Fitzsimons MG. Invasive Pressure Monitors: Leveling the Playing Field. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00331-2. [PMID: 37286401 DOI: 10.1053/j.jvca.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
Invasive pressure monitors are ubiquitous in cardiothoracic and vascular anesthesia. This technology allows beat-to-beat assessment of central venous, pulmonary, and arterial blood pressures during surgery, procedural interventions, and critical care. Education is commonly focused on the procedural aspects and the complications associated with the initial placement of these monitors without instruction on the technical concepts required for obtaining accurate data. Anesthesiologists must understand the fundamental concepts on which measurements are made to effectively use invasive pressure monitors, including pulmonary artery catheters, central venous catheters, intra-arterial catheters, external ventricular drains, and spinal or lumbar drains. This review will address important gaps in knowledge surrounding leveling and zeroing of invasive pressure monitors, emphasizing the impact of varied practice patterns on patient care.
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Affiliation(s)
- Catherine Foley Jerman
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith H Baker
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.
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Oh C, Lee S, Jeon S, Park H, Chung W, Shim MS, Yoon SH, Kim YH, Lee SY, Hong B. Errors in pressure measurements due to changes in pressure transducer levels during adult cardiac surgery: a prospective observational study. BMC Anesthesiol 2023; 23:8. [PMID: 36609229 PMCID: PMC9824971 DOI: 10.1186/s12871-023-01968-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Blood pressure measurement is an essential element during intraoperative patient management. However, errors caused by changes in transducer levels can occur during surgery. METHODS This single center, prospective, observational study enrolled 25 consecutive patients scheduled for elective cardiac surgery with invasive arterial and central venous pressure (CVP) monitoring. Hydrostatic pressures caused by level differences (leveling pressure) between a reference point (on the center of the left biceps brachii muscle) and the transducers (fixed on the right side of the operating table) for arterial and central lines were continuously measured using a leveling transducer. Adjusted pressures were calculated as measured pressure - leveling pressure. Hypotension (mean arterial pressure < 80, <70, and < 60 mmHg), and CVP (< 6, ≥6 and < 15, or ≥ 15 mmHg) and pulmonary artery pressure (PAP, mean > 20 mmHg) levels were determined using unadjusted and adjusted pressures. RESULTS Twenty-two patients were included in the analysis. Leveling pressure ≥ 3 mmHg and ≥ 5 mmHg observed at 46.0 and 18.7% of pooled data points, respectively. Determinations of hypotension using unadjusted and adjusted pressures showed disagreements ranging from 3.3 to 9.4% depending on the cutoffs. Disagreements in defined levels of CVP and PAP were observed at 23.0 and 17.2% of the data points, respectively. CONCLUSIONS The errors in pressure measurement due to changes in transducer level were not trivial and caused variable disagreements in the determination of MAP, CVP, and PAP levels. To prevent distortions in intraoperative hemodynamic management, strategies should be sought to minimize or adjust for these errors in clinical practice. TRIAL REGISTRATION cris.nih.go.kr (KCT0006510).
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Affiliation(s)
- Chahyun Oh
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Soomin Lee
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Seungbin Jeon
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Hanmi Park
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Woosuk Chung
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Man-Shik Shim
- grid.411665.10000 0004 0647 2279Department of Thoracic & Cardiovascular Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Seok-Hwa Yoon
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Yoon-Hee Kim
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Sun Yeul Lee
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Boohwi Hong
- grid.411665.10000 0004 0647 2279Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea ,grid.254230.20000 0001 0722 6377Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea ,grid.411665.10000 0004 0647 2279Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
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Werner-Moller P, Heinisch PP, Hana A, Bachmann KF, Sondergaard S, Jakob SM, Takala J, Berger D. Experimental validation of a mean systemic pressure analog against zero-flow measurements in porcine VA-ECMO. J Appl Physiol (1985) 2022; 132:726-736. [PMID: 35085032 DOI: 10.1152/japplphysiol.00804.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
The mean systemic pressure analog (Pmsa), calculated from running hemodynamic data, estimates mean systemic filling pressure (MSFP). This post hoc study used data from a porcine veno-arterial extracorporeal membrane oxygenation (ECMO) model [n = 9; Sus scrofa domesticus; ES breed (Schweizer Edelschwein)] with eight experimental conditions; Euvolemia [a volume state where ECMO flow produced normal mixed venous saturation (SVO2) without vascular collapse]; three levels of increasing norepinephrine infusion (Vasoconstriction 1-3); status after stopping norepinephrine (Post Vasoconstriction); and three steps of volume expansion (10 mL/kg crystalloid bolus) (Volume Expansion 1-3). In each condition, Pmsa and a "reduced-pump-speed-Pmsa" (Pmsared) were calculated from baseline and briefly reduced pump speeds, respectively. We calculated agreement for absolute values (per condition) and changes (between consecutive conditions) of Pmsa and Pmsared, against MSFP at zero ECMO flow. Euvolemia venous return driving pressure was 5.1 ± 2.0 mmHg. Bland-Altman analysis for Pmsa vs. MSFP (all conditions; 72 data pairs) showed bias (confidence interval) 0.5 (0.1-0.9) mmHg; limits of agreement (LoA) -2.7 to 3.8 mmHg. Bias for ΔPmsa vs. ΔMSFP (63 data pairs): 0.2 (-0.2 to 0.6) mmHg, LoA -3.2 to 3.6 mmHg. Bias for Pmsared vs. MSFP (72 data pairs): 0.0 (-0.3 to -0.3) mmHg; LoA -2.3 to 2.4 mmHg. Bias for ΔPmsared vs. ΔMSFP (63 data pairs) was 0.2 (-0.1 to 0.4) mmHg; LoA -1.8 to 2.1 mmHg. In conclusion, during veno-arterial ECMO, under clinically relevant levels of vasoconstriction and volume expansion, Pmsa accurately estimated absolute and changing values of MSFP, with low between-method precision. The within-method precision of Pmsa was excellent, with a least significant change of 0.15 mmHg.NEW & NOTEWORTHY This is the first study ever to validate the mean systemic pressure analog (Pmsa) against the reference mean systemic filling pressure (MSFP) determined at full arterio-venous pressure equilibrium. Using a porcine ECMO model with clinically relevant levels of vasoconstriction and volume expansion, we showed that Pmsa accurately estimated absolute and changing values of MSFP, with a poor between-method precision. The within-method precision of Pmsa was excellent.
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Affiliation(s)
- Per Werner-Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesia, Surgery and Intensive Care, SV Hospital Group, Alingsas, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Anisa Hana
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Laurentius Hospital, Roermond, The Netherlands
| | - Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Intensive Care Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Soren Sondergaard
- Department of Intensive Care and Neurointensive Stepdown Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Two-stage goal-directed therapy protocol for non-donor open hepatectomy: an interventional before–after study. J Anesth 2019; 33:656-664. [DOI: 10.1007/s00540-019-02688-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022]
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Sjödin C, Sondergaard S, Johansson L. Variability in alignment of central venous pressure transducer to physiologic reference point in the intensive care unit-A descriptive and correlational study. Aust Crit Care 2018; 32:213-217. [PMID: 29866610 DOI: 10.1016/j.aucc.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/20/2018] [Accepted: 05/02/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The phlebostatic axis is the most commonly used anatomical external reference point for central venous pressure measurements. Deviation in the central venous pressure transducer alignment from the phlebostatic axis causes inadequate pressure readings, which may affect treatment decisions for critically ill patients in intensive care units. AIM The primary aim of the study was to assess the variability in central venous pressure transducer levelling in the intensive care unit. We also assessed whether patient characteristics impacted on central venous pressure transducer alignment deviation. METHODS A sample of 61 critical care nurses was recruited and asked to place a transducer at the appropriate level for central venous pressure measurement. The measurements were performed in the intensive care unit on critically ill patients in supine and Fowler's positions. The variability among the participants using eyeball levelling and a laser levelling device was calculated in both sessions and adjusted for patient characteristics. RESULTS A significant variation was found among critical care nurses in the horizontal levelling of the pressure transducer placement when measuring central venous pressure in the intensive care unit. Using a laser levelling device did not reduce the deviation from the phlebostatic axis. Patient characteristics had little impact on the deviation in the measurements. CONCLUSION The anatomical external landmark for the phlebostatic axis varied between critical care nurses, as the variation in the central venous pressure transducer placement was not reduced with a laser levelling device. Standardisation of a zero-level for vascular pressures should be considered to reduce the variability in vascular pressure readings in the intensive care unit to improve patient treatment decisions. Further studies are needed to evaluate critical care nurses' knowledge and use of central venous pressure monitoring and whether assistive tools and/or routines can improve the accuracy in vascular pressure measurements in intensive care units.
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Affiliation(s)
- Carl Sjödin
- Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Soren Sondergaard
- Centre of Elective Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Lotta Johansson
- Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Caring Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden
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Saugel B, Bendjelid K, Critchley LAH, Scheeren TWL. Journal of Clinical Monitoring and Computing 2017 end of year summary: cardiovascular and hemodynamic monitoring. J Clin Monit Comput 2018; 32:189-196. [PMID: 29484529 DOI: 10.1007/s10877-018-0119-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 12/23/2022]
Abstract
Hemodynamic monitoring provides the basis for the optimization of cardiovascular dynamics in intensive care medicine and anesthesiology. The Journal of Clinical Monitoring and Computing (JCMC) is an ideal platform to publish research related to hemodynamic monitoring technologies, cardiovascular (patho)physiology, and hemodynamic treatment strategies. In this review, we discuss selected papers published on cardiovascular and hemodynamic monitoring in the JCMC in 2017.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Karim Bendjelid
- Department of Anesthesiology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Lester A H Critchley
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,The Belford Hospital, Fort William, The Highlands, Scotland, UK
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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