[Minimally invasive hemodynamic monitoring with esophageal echoDoppler]

[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]

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.

[Respiratory and hemodynamic changes during lung recruitment maneuvering through progressive increases and decreases in PEEP level]

OBJECTIVE

To evaluate the respiratory and hemodynamic changes during lung recruitment maneuvering (LRM) through stepwise increases and decreases in PEEP level.

DESIGN AND SETTING

A retrospective study in a 17-bed ICU was carried out.

PATIENTS

Twenty-one patients with acute respiratory failure and bilateral pulmonary infiltration.

INTERVENTION

LRM was carried out, consisting of stepwise increases in PEEP (4 cmH(2)O every 3 minutes), with fixed ventilation pressure, until reaching a maximal value of 36 cmH(2)O PEEP (ascending branch), followed by progressive decreases in PEEP (2 cmH(2)O every 3 minutes) until establishing the open-lung PEEP at the value associated to maximum respiratory compliance (Crs) (descending branch). Continuous hemodynamic monitoring was performed using an esophageal echodoppler probe.

RESULTS

Crs gradually decreased in the ascending branch of the LRM, and progressively increased surpassing the initial value after establish the open-lung PEEP in the descending branch, reducing the ventilation pressure and increasing the SpO(2)/FiO(2) ratio. Hemodynamic changes primarily consisted of a fall in cardiac output and left ventricular preload, together with an increased heart rate and cardiac contractility. At comparable levels of PEEP and mean airway pressure, these changes were more pronounced during the descending branch of the LRM.

CONCLUSIONS

1) LRM increased Crs, improving oxygenation and decreasing ventilation pressure; 2) the main hemodynamic consequence was the drop in cardiac output and left ventricular preload; and 3) the unequal hemodynamic derangement in both branches, at the same level of PEEP and mean airway pressure, showed that, along with intrathoracic pressure, other factor such as Crs and hypercapnia may have influenced the hemodynamic consequences of this type of LRM.

Esophageal Doppler monitoring during colorectal resection offers cost-effective improvement of hemodynamic control

OBJECTIVES

Hemodynamic control can improve the outcome of surgery. Esophageal Doppler monitoring measures blood flow by ultrasound waves. This work investigates the cost-effectiveness of this procedure during colorectal resection.

METHODS

Meta-analyses of randomized controlled trials of esophageal Doppler monitoring used in colorectal resection were conducted to help determine its cost-effectiveness. An analytical decision model was used to compare the cost-effectiveness of strategies involving conventional clinical assessment with or without the measurement of central venous pressure, with or without esophageal Doppler monitoring. Avoided mortality and avoided major complications were used as measures of clinical effectiveness.

RESULTS

In the meta-analyses comparing conventional clinical assessment plus central venous pressure monitoring with or without esophageal Doppler monitoring, statistically significant differences in total and major complications favoring the use of Doppler were found. No differences were seen in mortality. The use of esophageal Doppler monitoring was associated with lower costs, mainly due to fewer complications, shorter hospital stays and shorter surgery times.

CONCLUSIONS

Although the information regarding the clinical effectiveness of esophageal Doppler monitoring in colorectal resection is limited, strategies including this form of blood flow monitoring may be cost-effective. Further comparisons of Doppler monitoring against other hemodynamic monitoring systems should be undertaken.