A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients

EFFECT OF PULMONARY ARTERY CATHETERIZATION IN PATIENTS WITH NONISCHEMIC CARDIOGENIC SHOCK: A NATIONWIDE ANALYSIS

ABSTRACT

Background: Pulmonary artery catheterization (PAC) has been widely used in critically ill patients, yielding mixed results. Prior studies on cardiogenic shock (CS) predominantly included patients with acute myocardial infarction. This study aims to examine the effect of PAC use in patients with nonischemic CS. Methods: This retrospective cohort study employed data from the National Inpatient Sample database, including weighted hospitalizations of adult patients with nonischemic CS during 2017 to 2019. In-hospital outcomes were compared between groups using inverse probability of treatment weighting. Results: A total of 303,970 patients with nonischemic CS were included, of whom 17.5% received a PAC during their hospitalization. The median age was 67 years (interquartile range: 57-77) and 61% were male. After inverse probability of treatment weighting, patients in the PAC group had significantly lower in-hospital mortality (24.8% vs. 35.3%, P < 0.001), renal replacement therapy (10.7% vs. 12.4%, P = 0.002), in-hospital cardiac arrest (7.1% vs. 9.6%, P < 0.001), and mechanical ventilation (44.6% vs. 50.4%, P < 0.001) compared to non-PAC group. In contrast, the PAC group had higher use of intra-aortic balloon pump (15.4% vs. 3.4%, P < 0.001), percutaneous ventricular assist devices (12.6% vs. 2.6%, P < 0.001), extracorporeal membrane oxygenation (3.9% vs. 2.5%, P < 0.001), and heart transplantation (2.1% vs. 0.4%, P < 0.001). Conclusion: In the real-world setting, invasive hemodynamic monitoring with PAC in patients with nonischemic CS is associated with survival benefits and a reduction in adverse events, including reduced need for renal replacement therapy, mechanical ventilation and risk of in-hospital cardiac arrest.

Pulmonary artery catheter use and in-hospital outcomes in cardiac surgery: a systematic review and meta-analysis

OBJECTIVES

To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients.

METHODS

MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections.

RESULTS

Seven studies (25 853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12-2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54-4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16-0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25-0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12-0.76).

CONCLUSIONS

PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed.

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE

BACKGROUND

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking.

METHODS

This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed.

RESULTS

Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources.

CONCLUSIONS

The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

A comparison of hemodynamic measurement methods during orthotopic liver transplantation: evaluating agreement and trending ability of PiCCO versus pulmonary artery catheter techniques

BACKGROUND

Significant hemodynamic changes occur during liver transplantation, emphasizing the importance of precious and continuous monitoring of cardiac output, cardiac index, and other parameters. Although the monitoring of cardiac output by pulse indicator continuous cardiac output (PiCCO) was statistically homogeneous compared to the clinical gold standard pulmonary artery catheterization (PAC) in previous studies of liver transplantation, there are fewer statistical methods for the assessment of its conclusions, and a lack of comparisons of other hemodynamic parameters (e.g., SVRI, systemic vascular resistance index). Some studies have also concluded that the agreement between PiCCO and PAC is not good enough. Overall, there are no uniform conclusions regarding the agreement between PiCCO and PAC in previous studies. This study evaluates the agreement and trending ability of relevant hemodynamic parameters obtained with PiCCO compared to the clinical gold standard PAC from multiple perspectives, employing various statistical methods.

METHODS

Fifty-two liver transplantation patients were included. Cardiac output (CO), cardiac index (CI), SVRI and stroke volume index (SVI) values were monitored at eight time points using both PiCCO and PAC. The results were analyzed by Bland-Altman analysis, Passing-bablok regression, intra-class correlation coefficient (ICC), 4-quadrant plot, polar plot, and trend interchangeability method (TIM).

RESULTS

The Bland-Altman analysis revealed high percentage errors for PiCCO: 54.06% for CO, 52.70% for CI, 62.18% for SVRI, and 51.97% for SVI, indicating poor accuracy. While Passing-Bablok plots showed favorable agreement for SVRI overall and during various phases, the agreement for other parameters was less satisfactory. The ICC results confirmed good overall agreement between the two devices across most parameters, except for SVRI during the new liver phase, which showed poor agreement. Additionally, four-quadrant and polar plot analyses indicated that all agreement rate values fell below the clinically acceptable threshold of over 90%, and all angular deviation values exceeded ± 5°, demonstrating that PiCCO is unable to meet the acceptable trends. Using the TIM, the interchangeability rates were found to be quite low: 20% for CO and CI, 16% for SVRI, and 13% for SVI.

CONCLUSIONS

Our study revealed notable disparities in absolute values of CO, CI, SVRI and SVI between PiCCO and PAC in intraoperative liver transplant settings, notably during the neohepatic phase where errors were particularly pronounced. Consequently, these findings highlight the need for careful consideration of PiCCO's advantages and disadvantages in liver transplantation scenarios, including its multiple parameters (such as the encompassing extravascular lung water index), against its limited correlation with PAC.

Influence of different intraoperative fluid management on postoperative outcome after abdominal tumours resection

BACKGROUND

Intraoperative fluid management is a crucial aspect of cancer surgery, including colorectal surgery and pancreatoduodenectomy. The study tests if intraoperative multimodal monitoring reduces postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery treated by the same anaesthetic protocols with epidural analgesia.

PATIENTS AND METHODS

A prospective study was conducted in 2 parallel groups. High-risk surgical patients undergoing major abdominal surgery were randomly selected in the control group (CG), where standard monitoring was applied (44 patients), and the protocol group (PG), where cerebral oxygenation and extended hemodynamic monitoring were used with the protocol for intraoperative interventions (44 patients).

RESULTS

There were no differences in the median length of hospital stay, CG 9 days (interquartile range [IQR] 8 days), PG 9 (5.5), p = 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in the first 3 days) in CG, 0.75 mcg/L (IQR 3.19 mcg/L), than in PG, 0.3 mcg/L (0.88 mcg/L), p = 0.001. PG patients received a larger volume of intraoperative fluid; median intraoperative fluid balance +1300 ml (IQR 1063 ml) than CG; +375 ml (IQR 438 ml), p < 0.001.

CONCLUSIONS

There were significant differences in intraoperative fluid management and vasopressor use. The median postoperative value of procalcitonin was significantly higher in CG, suggesting differences in immune response to tissue trauma in different intraoperative fluid status, but there was no difference in postoperative morbidity or hospital stay.

The Use of Pulmonary Artery Catheters and Echocardiography in the Cardiac Surgery Setting: A Nationwide Italian Survey

OBJECTIVE

Wide variations exist in the use of pulmonary artery catheters (PACs) and echocardiography in the field of cardiac surgery.

DESIGN

A national survey promoted by the Italian Association of Cardio-Thoracic Anesthesiologists and Intensive Care was conducted.

SETTING

The study occurred in Italian cardiac surgery centers (n = 71).

PARTICIPANTS

Anesthesiologists-intensivists were enrolled.

INTERVENTIONS

Anonymous questionnaires were used to investigate the use of PACs and echocardiography in the operating room (OR) and intensive care unit (ICU).

MEASUREMENTS AND MAIN RESULTS

A total of 257 respondents (32.2% response rate) from 59 centers (83.1% response rate) participated. Use of PACs seems less common in ORs (median insertion in 20% [5-70] of patients), with slightly higher use in ICUs; in about half of cases, it was the continuous cardiac output monitoring system of choice. Almost two-thirds of respondents recently inserted at least one PAC within a few hours of ICU admission, despite its need being largely preoperatively predictable. Protocols regulating PAC insertion were reported by 25.3% and 28% of respondents (OR and ICU, respectively). Transesophageal echocardiography (TEE) was performed intraoperatively in >75% of patients by 86.4% of respondents; only 23.7% stated that intraoperative TEE relied on anesthesiologists. Tissue Doppler and/or 3D imaging were widely available (87.4% and 82%, respectively), but only 37.8% and 24.3% of respondents self-declared skills in these modalities, respectively; 77.1% of respondents had no echocardiography certification, nor were pursuing certification (various reasons); 40.9% had not attended recent echocardiography courses. Lower PAC use was associated with university hospitals (OR: p = 0.014, ICU: p = 0.032) and with lower interventions/year (OR: p = 0.023). Higher independence in performing TEE was reported in university hospitals (OR: p < 0.001; ICU: p = 0.006), centers with higher interventions/year (OR: p = 0.019), and by respondents with less experience in cardiology (ICU: p = 0.046).

CONCLUSION

Variability in the use of PACs and echocardiography was found. Protocols regulating the use of PACs seem infrequent. University centers use PACs less and have greater skills in TEE. Training and certifications in echocardiography should be encouraged.

Pulmonary Artery Catheter Usage and Impact on Mortality in Patients With Cardiogenic Shock: Results From a Canadian Single-Centre Registry

BACKGROUND

Hemodynamic assessment for cardiogenic shock (CS) phenotyping in patients has led to renewed interest in the use of pulmonary artery catheters (PACs).

METHODS

We included patients admitted with CS from January 2014 to December 2020 and compared clinical outcomes among patients who received PACs and those who did not. The primary outcome was the rate of in-hospital mortality. Secondary outcomes included use of advanced heart failure therapies and coronary intensive care unit (CICU) and hospital lengths of stay.

RESULTS

A total of 1043 patients were analysed and 47% received PACs. Patients selected for PAC-guided management were younger and had lower left ventricular function. They also had higher use of vasopressor and inotropes, and 15.2% of them were already supported with temporary mechanical circulatory support (MCS). In-hospital mortality was lower in patients who received PACs (29.3% vs 36.2%; P = 0.02), mainly driven by a reduction in mortality among those in Society for Cardiovascular Angiography and Interventions (SCAI) stages D and E CS. Patients who received PACs were more likely to receive temporary MCS with Impella, durable ventricular assist devices (VADs), or orthotopic heart transplantation (OHT) (P < 0.001 for all analyses). CICU and hospital lengths of stay were longer in patients who used PACs.

CONCLUSIONS

Among patients with CS, the use of PACs was associated with lower in-hospital mortality, especially among those in SCAI stages D and E. Patients who received PACs were also more frequently rescued with temporary MCS or received advanced heart failure therapies, such as durable VADs or OHT.

Cardiac Output and Stroke Volume Assessments by Transthoracic Echocardiography and Pulse index Continuous Cardiac Output Monitor in Critically ill Adult Patients: A Comparative Study

PURPOSE

Bedside transthoracic echocardiography (TTEcho) is a noninvasive cardiac output (CO) monitoring method that has grown recently. However, there are questions regarding its accuracy compared to invasive methods. We aimed to evaluate the agreement and correlation of TTEcho and pulse index continuous CO (PiCCO) monitor measurements for CO and systolic volume (SV) in critically ill patients.

METHODS

This prospective experimental study included consecutive adult patients who required invasive hemodynamic monitoring admitted at an intensive care unit in the Federal District, Brazil, from January/2019 to January/2021. Correlation and agreement between SV and CO measurements by PiCCO and TTEcho were performed using the Spearman correlation and the Bland-Altman analysis.

RESULTS

The study enrolled 29 patients, with adequate TTEcho evaluations in all patients. There were very strong correlations between CO-TTEcho and CO-PiCCO (r = 0.845, P < .001) and SV-TTEcho and SV-PiCCO (r = 0.800, P < .001). TTEcho estimations for CO and SV were feasible within the limits of agreement in 96.6% (28/29) compared to PiCCO. The mean difference between CO-PiCCO and CO-TTEcho was 0.250 L/min (limits of agreement: -1.083 to 1.583 L/min, percentage error: 21.0%), and between SV-PiCCO and SV-TTEcho was 2.000 mL (limits of agreement: -16.960 to 20.960, percentage error: 24.3%). The reduced cardiac index (CI) measurements by TTEcho showed an accuracy of 89.7% (95% IC: 72.6%-97.8%) and an F1 score of 92.7% (95% IC: 75.0%-98.0%), considering the CI-PiCCO as the gold standard.

CONCLUSION

Echocardiographic measurements of CO and SV are comparable to measurements by PiCCO. These results reinforce echocardiography as a reliable tool to evaluate hemodynamics in critically ill patients.

Pulmonary artery catheter receipt among cardiac surgery patients from the national inpatient sample (1999-2019): Prevalence, predictors and hospitalization charges

Despite limited evidence to support its efficacy, use of pulmonary artery catheter (PAC), a relatively expensive medical device, for monitoring clinical status and guiding therapeutic interventions, has become standard of care in many settings, and especially during and after cardiac surgery. We examined the prevalence and predictors of PAC use and its association with hospitalization charges among cardiac surgery patients generally and for each selected subgroup of high-risk or complex surgical procedures. We conducted an analysis on 1,442,528 records from the National Inpatient Sample (1999-2019) that included cardiac surgery patients ≥18 years of age. Subgroups were categorized based on the presence of specific disorders like tricuspid or mitral valve disease, pulmonary hypertension, heart failure, or cardiac surgery combinations. Multivariable regression models were constructed to assess predictors of PAC use as well as PAC use as a predictor of loge hospitalization charges controlling for patient and hospital characteristics. Based on International Classification of Diseases procedure codes, PAC use was prevalent among 7.15 % of cardiac surgery hospitalizations, and hospitalization charges were estimated at $191,345, with no differences according to PAC use. Overall, being female, having Charlson comorbidity index (CCI) > 0, and non-payer (versus Medicare) status were independently associated with PAC use. Among the subgroup with the selected conditions, being female, having CCI>0, and being a Medicaid (versus Medicare) recipient were independently associated with PAC use, whereas elective admission was inversely related to PAC use. Among the subgroup without the selected conditions, having a CCI >0, elective admission, and non-payer (vs. Medicare) status were independently associated with PAC use. PAC use was not independently related to hospitalization charges overall or among subgroups. In conclusion, approximately 7 % of cardiac surgery hospitalizations received a PAC, with no differences in charges according to PAC use and disparities in PAC use driven by sex, elective admission, CCI and health insurance status. Large randomized trials are required to characterize the safety, efficacy, and cost-effectiveness of PAC use among distinct groups of patients undergoing cardiac surgery.

Cardiac output estimation using ballistocardiography: a feasibility study in healthy subjects

There is no reliable automated non-invasive solution for monitoring circulation and guiding treatment in prehospital emergency medicine. Cardiac output (CO) monitoring might provide a solution, but CO monitors are not feasible/practical in the prehospital setting. Non-invasive ballistocardiography (BCG) measures heart contractility and tracks CO changes. This study analyzed the feasibility of estimating CO using morphological features extracted from BCG signals. In 20 healthy subjects ECG, carotid/abdominal BCG, and invasive arterial blood pressure based CO were recorded. BCG signals were adaptively processed to isolate the circulatory component from carotid (CCc) and abdominal (CCa) BCG. Then, 66 features were computed on a beat-to-beat basis to characterize amplitude/duration/area/length of the fluctuation in CCc and CCa. Subjects' data were split into development set (75%) to select the best feature subset with which to build a machine learning model to estimate CO and validation set (25%) to evaluate model's performance. The model showed a mean absolute error, percentage error and 95% limits of agreement of 0.83 L/min, 30.2% and - 2.18-1.89 L/min respectively in the validation set. BCG showed potential to reliably estimate/track CO. This method is a promising first step towards an automated, non-invasive and reliable CO estimator that may be tested in prehospital emergencies.

Comparative evaluation of stroke volume variation measured by pulse wave transit time and arterial pressure wave

BACKGROUND

Several monitors have been developed that measure stroke volume (SV) in a beat-to-beat manner. Accordingly, Stroke volume variation (SVV) induced by positive pressure ventilation is widely used to predict fluid responsiveness.

OBJECTIVE

The purpose of this study was to compare the ability of two different methods to predict fluid responsiveness using SVV, stroke volume variation by esCCO (esSVV) and stroke volume variation by FloTrac/VigileoTM (flSVV).

METHODS

esSVV, flSVV, and stroke volume index (SVI) by both monitoring devices of 37 adult patients who underwent laparotomy surgery, were measured. Receiver operating characteristic (ROC) analysis was performed.

RESULTS

The area under the ROC curve (AUC) of esSVV was significantly higher than that of flSVV (p= 0.030). esSVV and flSVV showed cutoff values of 6.1% and 10% respectively, to predict an increase of more than 10% in SVI after fluid challenge. The Youden index for esSVV was higher than flSVV, even with a cutoff value between 6% and 8%.

CONCLUSION

Since esSVV and flSVV showed significant differences in AUC and cutoff values, the two systems were not comparable in predicting fluid responsiveness. Furthermore, it seems that SVV needs to be personalized to accurately predict fluid responsiveness for each patient.

Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment

Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.

Pulmonary artery catheter monitoring versus arterial waveform-based monitoring during liver transplantation: a retrospective cohort study

Although pulmonary artery catheter (PAC) has been used during liver transplantation surgery, the usefulness of PAC has rarely been investigated. We evaluated whether the use of PAC is associated with better clinical outcomes compared to arterial waveform-based monitoring after liver transplantation. A total of 1565 cases undergoing liver transplantation were reviewed. We determined whether patients received PAC or not and divided our cohort into the PAC with hemodynamic monitoring using PAC and the non-PAC with arterial waveform-based monitoring using FloTrac-Vigileo. Propensity score matching was performed. Acute kidney injury (AKI), early allograft dysfunction (EAD) and 1-year all-cause mortality or graft failure were compared in the matched cohorts. Logistic regression analysis was performed in the inverse probability of treatment-weighted (IPTW) cohort for postoperative EAD and AKI, respectively. Five-year overall survival was compared between the two groups. In the matched cohort, there was no significant difference in the incidence of AKI, EAD, length of hospital or ICU stay, and 1-year all-cause mortality between the groups. In the IPTW cohort, the use of PAC was not a significant predictor for AKI or EAD (AKI: odds ratio (95% confidence interval) of 1.20 (0.47-1.56), p = 0.229; EAD: 0.99 (0.38-1.14), p = 0.323). There was no significant difference in the survival between groups after propensity score matching (Log-rank test p = 0.578). In conclusion, posttransplant clinical outcomes were not significantly different between the groups with and without PAC. Anesthetic management without the use of PAC may be possible in low-risk patients during liver transplantation. The risk should be carefully assessed by considering MELD scores, ischemic time, surgical history, previous treatment of underlying liver disease, and degree of portal and pulmonary hypertension.Registration: https://clinicaltrials.gov/ct2/show/NCT05457114 (registration date: July 15, 2022).

Characteristics of pulmonary artery catheter use in multicenter ICUs in Japan and the association with mortality: a multicenter cohort study using the Japanese Intensive care PAtient Database

BACKGROUND

It has been 50 years since the pulmonary artery catheter was introduced, but the actual use of pulmonary artery catheters in recent years is unknown. Some randomized controlled trials have reported no causality with mortality, but some observational studies have been published showing an association with mortality for patients with cardiogenic shock, and the association with a pulmonary artery catheter and mortality is unknown. The aim of this study was to investigate the utilization of pulmonary artery catheters (PACs) in the intensive care unit (ICU) and to examine their association with mortality, taking into account differences between hospitals.

METHODS

This is a retrospective analysis using the Japanese Intensive care PAtient Database, a multicenter, prospective, observational registry in Japanese ICUs. We included patients aged 16 years or older who were admitted to the ICU for reasons other than procedures. We excluded patients who were discharged within 24 h or had missing values. We compared the prognosis of patients with and without PAC. The primary outcome was hospital mortality. We performed propensity score analysis to adjust for baseline characteristics and hospital characteristics.

RESULTS

Among 184,705 patients in this registry from April 2015 to December 2020, 59,922 patients were included in the analysis. Most patients (94.0%) with a PAC in place had cardiovascular disease. There was a wide variation in the frequency of PAC use between hospitals, from 0 to 60.3% (median 14.4%, interquartile range 2.2-28.6%). Hospital mortality was not significantly different between the PAC use group and the non-PAC use group in patients after adjustment for propensity score analysis (3.9% vs 4.3%; difference, - 0.4%; 95% CI - 1.1 to 0.3; p = 0.32). Among patients with cardiac disease, those with post-open-heart surgery and those in shock, hospital mortality was also not significantly different between the two groups (3.4% vs 3.7%, p = 0.45, 1.7% vs 1.7%, p = 0.93, 4.8% vs 4.9%, p = 0.87).

CONCLUSIONS

The frequency of PAC use varied among hospitals. PAC use for ICU patients was not associated with lower hospital mortality after adjusting for differences between hospitals.

No association between pulmonary artery catheter use and postoperative complications in off-pump coronary artery bypass grafting: a single-center pilot study

BACKGROUND

A pulmonary artery catheter is often used in cardiac surgery despite its uncertain effectiveness. The aim of this pilot study was to investigate the associations between the use of a pulmonary artery catheter and clinical outcomes in off-pump coronary artery bypass grafting.

METHODS

Patients over 20 years of age who had undergone off-pump coronary artery bypass grafting between December 2018 and November 2021 were enrolled in this single-center retrospective pilot study. The propensity score of pulmonary artery catheterization was calculated. Multivariate analysis including the propensity score as a covariate was performed to assess clinical outcomes. The primary outcome was the composite outcome of in-hospital death, unplanned intraoperative conversion to cardiopulmonary bypass, resuscitated cardiac arrest, mechanical circulatory support, myocardial infarction, stroke, new initiation of renal replacement therapy, inhaled nitric oxide, re-intubation and tracheostomy.

RESULTS

Among the 315 patients who were enrolled, 298 were included in the final analysis. A pulmonary artery catheter was inserted in 131 patients. There were 50 patients with the composite outcome including two in-hospital deaths. Multivariate logistic regression analysis showed that pulmonary artery catheterization was not significantly related to the composite outcome. Clinical outcomes worsened significantly as the number of anastomoses increased (odds ratio: 1.450, 95% confidence interval: 1.040-2.040, P=0.029).

CONCLUSIONS

Pulmonary artery catheterization did not improve the clinical outcomes in off-pump coronary artery bypass grafting in this pilot study.

Clinical impact of pulmonary artery catheter in patients with cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

The clinical utility of the pulmonary artery catheter (PAC) for the management of cardiogenic shock (CS) remains controversial. We performed a systematic review and meta-analysis exploring the association between PAC use and mortality among patients with CS.

METHODS

Published studies of patients with CS treated with or without PAC hemodynamic guidance were retrieved from MEDLINE and PubMed databases from January 1, 2000, to December 31, 2021. The primary outcome was mortality, which was defined as a combination of in-hospital mortality and 30-day mortality. Secondary outcomes assessed 30-day and in-hospital mortality separately. To assess the quality of nonrandomized studies, the Newcastle-Ottawa Scale (NOS), a well-established scoring system was used. We analyzed outcomes for each study using NOS with a threshold value of >6, indicating high quality. We also performed analyses based on the countries of the studies conducted.

RESULTS

Six studies with a total of 930,530 patients with CS were analyzed. Of these, 85,769 patients were in the PAC-treated group, and 844,761 patients did not receive a PAC. PAC use was associated with a significantly lower risk of mortality (PAC: 4.6 % to 41.5 % vs control: 18.8 % to 51.0 %) (OR 0.63, 95 % CI: 0.41-0.97, I2 = 0.96). Subgroup analyses demonstrated no difference in the risk of mortality between NOS ≥ 6 studies and NOS < 6 studies (p-interaction = 0.57), 30-day and in-hospital mortality (p-interaction = 0.83), or the country of origin of studies (p-interaction = 0.08).

CONCLUSIONS

The use of PAC in patients with CS may be associated with decreased mortality. These data support the need for a randomized controlled trial testing the utility of PAC use in CS.

Goal-directed therapy in cardiovascular surgery: A case series study

Hemodynamic and intravascular volume monitoring has been utilized and significantly improved thanks to the technology revolution. Goal-Directed Therapy (GDT) derived from this advanced monitoring is beneficial for complex surgeries, and it shifted the medical approaches from static therapy to more personalized functional treatments. Conventional monitoring methods such as blood pressure, heart rate, urinary output, and central venous pressure are commonly used. However, studies have shown these routine parameters often cannot precisely estimate the quality of tissue perfusion. Tissue hypoperfusion and hypoxia play a crucial role in initiating a systemic inflammatory response after prolonged surgeries, resulting in unstable hemodynamic condition of the patients. Several studies reported the importance of GDT in non-cardiac surgeries and there are few reports on cardiac surgeries. However, tissue perfusion and fluid management are more critical in complex and prolonged cardiovascular surgeries to avoid complications such as low cardiac output syndrome and renal or pulmonary dysfunction. Different advanced hemodynamic monitorings have been utilized perioperatively in cardiac surgery to help decision-making on inotrope and fluid management. In this article we present 5 cases of usefulness hemodynamic monitoring in patients who underwent cardiovascular surgeries.

Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States)

The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p = 0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.

Association of pulmonary artery catheter with in-hospital outcomes after cardiac surgery in the United States: National Inpatient Sample 1999-2019

To examine associations of pulmonary artery catheter (PAC) use with in-hospital death and hospital length of stay (days) overall and within subgroups of hospitalized cardiac surgery patients. Secondary analyses of 1999-2019 National Inpatient Sample data were performed using 969,034 records (68% male, mean age: 65 years) representing adult cardiac surgery patients in the United States. A subgroup of 323,929 records corresponded to patients with congestive heart failure, pulmonary hypertension, mitral/tricuspid valve disease and/or combined surgeries. We evaluated PAC in relation to clinical outcomes using regression and targeted maximum likelihood estimation (TMLE). Hospitalized cardiac surgery patients experienced more in-hospital deaths and longer stays if they had ≥ 1 subgroup characteristics. For risk-adjusted models, in-hospital deaths were similar among recipients and non-recipients of PAC (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.96, 1.12), although PAC was associated with more in-hospital deaths among the subgroup with congestive heart failure (OR 1.14, 95% CI 1.03, 1.26). PAC recipients experienced shorter stays than non-recipients (β =  - 0.40, 95% CI - 0.64, - 0.15), with variations by subgroup. We obtained comparable results using TMLE. In this retrospective cohort study, PAC was associated with shorter stays and similar in-hospital death rates among cardiac surgery patients. Worse clinical outcomes associated with PAC were observed only among patients with congestive heart failure. Prospective cohort studies and randomized controlled trials are needed to confirm and extend these preliminary findings.

Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review

Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.

A new assessment method for right ventricular diastolic function using right heart catheterization by pressure-volume loop

Diastolic stiffness coefficient (β) and end-diastolic elastance (Eed) are ventricular-specific diastolic parameters. However, the diastolic function of right ventricle had not been investigated sufficiently due to the lack of established evaluation method. We evaluated the validity of these parameters calculated using only data of right heart catheterization (RHC) and assessed it in patients with restrictive cardiomyopathy (RCM) and cardiac amyloidosis. We retrospectively analyzed 46 patients with heart failure who underwent RHC within 10 days of cardiac magnetic resonance (CMR). Right ventricular end-diastolic volume and end-systolic volume were calculated using only RHC data, which were found to be finely correlated with those obtained from CMR. β and Eed calculated by this method were also significantly correlated with those derived from conventional method using CMR. By this method, β and Eed were significantly higher in RCM with amyloidosis group than dilated cardiomyopathy group. In addition, the β and Eed calculated by our method were finely correlated with E/A ratio on echocardiography. We established an easy method to estimate β and Eed of right ventricle from only RHC. The method finely demonstrated right ventricular diastolic dysfunction in patients with RCM and amyloidosis.

Malposition of a pulmonary artery catheter in the left ventricle: a case report

BACKGROUND

Placement of pulmonary artery catheters may be associated with a variety of complications. We present a case where a pulmonary artery catheter was accidentally advanced into the left ventricle by perforating the intraventricular septum.

CASE PRESENTATION

A 73-year-old woman underwent mitral valve dysfunction. A pulmonary artery catheter could not pass the tricuspid valve under general anesthesia, which was manually advanced via the right ventricle during surgery. After valve replacement, systolic pulmonary artery pressure was higher than radial arterial blood pressure. Transesophageal echocardiography (TEE) revealed the tip of the catheter in the left ventricle. The catheter was withdrawn and then advanced to the pulmonary artery under monitoring of TEE. Transseptal shunt flow gradually decreased and finally disappeared. The surgery was completed without additional procedures.

CONCLUSIONS

Although ventricular septal perforation is rare, it should be recognized as a potential complication of pulmonary artery catheter insertion.

Intraoperative pleth variability index-based fluid management therapy and gastrointestinal surgical outcomes in elderly patients: a randomised controlled trial

BACKGROUND

Intraoperative goal-directed fluid therapy (GDFT) has been reported to reduce postoperative complications of patients undergoing major abdominal surgery. The clinical benefits of pleth variability index (PVI)-directed fluid management for gastrointestinal (GI) surgical patients remain unclear. Therefore, this study aimed to evaluate the impact of PVI-directed GDFT on GI surgical outcomes in elderly patients.

METHODS

This randomised controlled trial was conducted in two university teaching hospitals from November 2017 to December 2020. In total, 220 older adults undergoing GI surgery were randomised to the GDFT or conventional fluid therapy (CFT) group (n = 110 each). The primary outcome was a composite of complications within 30 postoperative days. The secondary outcomes were cardiopulmonary complications, time to first flatus, postoperative nausea and vomiting, and postoperative length of stay.

RESULTS

The total volumes of fluid administered were less in the GDFT group than in the CFT group (2.075 L versus [vs.] 2.5 L, P = 0.008). In intention-to-treat analysis, there was no difference in overall complications between the CFT group (41.3%) and GDFT group (43.0%) (odds ratio [OR] = 0.935; 95% confidence interval [CI], 0.541-1.615; P = 0.809). The proportion of cardiopulmonary complications was higher in the CFT group than in the GDFT group (19.2% vs. 8.4%; OR = 2.593, 95% CI, 1.120-5.999; P = 0.022). No other differences were identified between the two groups.

CONCLUSIONS

Among elderly patients undergoing GI surgery, intraoperative GDFT based on the simple and non-invasive PVI did not reduce the occurrence of composite postoperative complications but was associated with a lower cardiopulmonary complication rate than usual fluid management.

TRIAL REGISTRATION

This trial was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-17012220) on 1 August 2017.

Accuracy of a noninvasive estimated continuous cardiac output measurement under different respiratory conditions: a prospective observational study

PURPOSE

The estimated continuous cardiac output (esCCO) system was recently developed as a noninvasive hemodynamic monitoring alternative to the thermodilution cardiac output (TDCO). However, the accuracy of continuous cardiac output measurements by the esCCO system compared to TDCO under different respiratory conditions remains unclear. This prospective study aimed to assess the clinical accuracy of the esCCO system by continuously measuring the esCCO and TDCO.

METHODS

Forty patients who had undergone cardiac surgery with a pulmonary artery catheter were enrolled. We compared the esCCO with TDCO from mechanical ventilation to spontaneous respiration through extubation. Patients undergoing cardiac pacing during esCCO measurement, those receiving treatment with an intra-aortic balloon pump, and those with measurement errors or missing data were excluded. In total, 23 patients were included. Agreement between the esCCO and TDCO measurements was evaluated using Bland-Altman analysis with a 20 min moving average of the esCCO.

RESULTS

The paired esCCO and TDCO measurements (939 points before extubation and 1112 points after extubation) were compared. The respective bias and standard deviation (SD) values were 0.13 L/min and 0.60 L/min before extubation, and - 0.48 L/min and 0.78 L/min after extubation. There was a significant difference in bias before and after extubation (P < 0.001); the SD before and after extubation was not significant (P = 0.315). The percentage errors were 25.1% before extubation and 29.6% after extubation, which is the criterion for acceptance of a new technique.

CONCLUSION

The accuracy of the esCCO system is clinically acceptable to that of TDCO under mechanical ventilation and spontaneous respiration.

The influence of intra-aortic balloon counter pulsation on central venous blood oxygen saturation

OBJECTIVES

We aim at identifying the changes in venous blood saturation values that associates intra-aortic balloon pump (IABP) in cardiac surgery patients with reduced left ventricular function (LVF).

METHODS

A retrospective observational study was conducted in a cardiothoracic intensive care unit (CTICU) in a tertiary cardiac center over 5 years in Qatar. A total of 114 patients with at least moderate impairment of LVF with ejection fraction (EF) less than 40% were enrolled. According to the association of IABP, patients were segregated into two groups with and without IABP (groups 1, 40 patients and group 2, 74 patients). Sequential arterial and venous blood gases were analyzed. The primary outcome was to analyze the changes in the central venous saturation (ScvO₂) in both groups and the secondary outcome was to analyze whether these changes affect the overall outcome in terms of intensive care unit (ICU) length of stay.

RESULTS

There was no significant difference between both groups with regard to age, preoperative EF, hemoglobin, and arterial oxygen saturation (SaO₂) in blood gases. Patients with IABP have a higher cScvO₂ when compared to the other group (71.5 ± 12.5 vs 63.5 ± 9.3, 68.3 ± 12.6 vs 60.1 ± 9.5, 62.7 ± 10.8 vs 55.63 ± 8.1, and 60.6 ± 7.6 vs 54.9 ± 8.1; p = 0.04, 0.05, 0.03, and 0.5, respectively). However, generalized estimating equations (GEE) analysis showed that compared with the participants showing that there is a decreasing trend in mean levels within the groups during follow-ups, overall difference between both groups' mean levels was not statistically significant.

CONCLUSIONS

In this study, we observed that after cardiac surgeries, patients with IABP had non-significant higher ScvO₂ when compared with a corresponding group with moderate impairment of LVF. Further prospective studies are required to validate these findings.

Correlation of Impedance Cardiography-Derived and Cardiac Magnetic Resonance-Derived Stroke Volumes

Cardiac output (CO) and other hemodynamic parameter measurements play an important role in the management of cardiovascular conditions; however, due to limitations of current day technologies, such measurements are either not routinely performed or incorporated into clinical practice. Moreover, measurement of these hemodynamic parameters in the outpatient setting at different time points to assess interval change is currently not feasible. We attempted to validate total-body impedance cardiography-based Non-Invasive Cardiac System (NICaS) derived stroke volume (SV) with that from cardiac magnetic resonance (CMR), a current day gold standard method of assessment. We compared SV, as it is the primary unit of measurement utilized by both technologies. Forty-one consecutive patients undergoing CMR were also investigated by NICaS following CMR. The consistency of non-invasive technology-derived SV measurement was validated by NICaS measurement in 10 subjects, both before and after CMR. Of the 41 enrolled patients; data from 38 patients was adequate for comparison (motion artifact prevented CMR measures in 3 patients). Fourteen patients (37%) were female; mean age was 55 ± 15 years (28-87 years) and body-mass index was 28.7 ± 5.5 kg/m² (20.5-41.9 kg/m²). Hypertrophic cardiomyopathy (9/41) was the most common study indication for CMR. NICaS-derived SV strongly correlated with CMR [NICaS 77 ± 20 ml (31-123 ml) and CMR 84 ± 23 ml (47-132 ml); P < 0.001; r = 0.77; ICC = 0.73]. The Bland-Altman limits of agreement between NICaS and CMR were -26.7% and 39.9%. NICaS-derived SV collected before and after MRI did not differ [80 ± 18 ml (51-102 ml) pre and 76 ± 17 ml (50-99 ml) post; P = 0.0007, Kappa = 1]. Agreement between NICaS-derived and CMR-derived SV was within the acceptable range of boundaries set by the US Food and the Drug Administration. Consistency in SV measurement at different time-points may allow use of this technology to identify interval hemodynamic changes noninvasively.

Management of Post-Myocardial Infarction Right Ventricular Failure

Right ventricular failure (RVF) due to an acute myocardial infarction (MI) has been associated with high morbidity and mortality. Initial treatment is guided by early recognition and prompt revascularization. Current management of post-MI RVF is built upon expert consensus and is also informed by RVF from other etiologies, including massive pulmonary embolism, left ventricular assist device-associated right ventricular dysfunction, postcardiotomy shock, etc.; this speaks to the limited data available on the specific management of RVF in acute MI. The goal of this review is to discuss the current literature on the pathophysiology, general management considerations, interventional management, hemodynamic monitoring, medical management, and mechanical circulatory support of MI-induced RVF.

Association of low mixed venous oxygen saturations during early ICU stay with increased 30-day and 1-year mortality after cardiac surgery: a single-center retrospective study

Background

Low postoperative mixed venous oxygen saturation (SvO₂) values have been linked to poor outcomes after cardiac surgery. The present study was designed to assess whether SvO₂ values of < 60% at intensive care unit (ICU) admission and 4 h after admission are associated with increased mortality after cardiac surgery.

Methods

During the years 2007–2020, 7046 patients (74.4% male; median age, 68 years [interquartile range, 60–74]) underwent cardiac surgery at an academic medical center in Finland. All patients were monitored with a pulmonary artery catheter. SvO₂ values were obtained at ICU admission and 4 h later. Patients were divided into four groups for analyses: SvO₂ ≥ 60% at ICU admission and 4 h later; SvO₂ ≥ 60% at admission but < 60% at 4 h; SvO₂ < 60% at admission but ≥ 60% at 4 h; and SvO₂ < 60% at both ICU admission and 4 h later. Kaplan–Meier survival curves, Cox regression models, and receiver operating characteristic curve analysis were used to assess differences among groups in 30-day and 1-year mortality.

Results

In the overall cohort, 52.9% underwent coronary artery bypass grafting (CABG), 29.1% valvular surgery, 12.1% combined CABG and valvular procedures, 3.5% surgery of the ascending aorta or aortic dissection, and 2.4% other cardiac surgery. The 1-year crude mortality was 4.3%. The best outcomes were associated with SvO₂ ≥ 60% at both ICU admission and 4 h later. Hazard ratios for 1-year mortality were highest among patients with SvO₂ < 60% at both ICU admission and 4 h later, regardless of surgical subgroup.

Conclusion

SvO₂ values < 60% at ICU admission and 4 h after admission are associated with increased 30-day and 1-year mortality after cardiac surgery. Goal-directed therapy protocols targeting SvO₂ ≥ 60% may be beneficial. Prospective studies are needed to confirm these observational findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01862-8.

Is There a Correlation Between Left Ventricular Outflow Tract Velocity Time Integral and Stroke Volume Index in Patients Undergoing Cardiac Surgery?

Introduction

Left ventricular outflow tract velocity time integral (LVOT VTI) is a promising surrogate for stroke volume (SV). However, there is controversy in the literature regarding its correlation with thermodilution or newer cardiac output measurement techniques. This study was conducted to determine the correlation between LVOT VTI determined by transesophageal echocardiography (TEE) with stroke volume index (SVI) calculated by thermodilution.

Methods

Consecutive patients older than 17 years undergoing elective cardiac surgery with pulmonary artery catheter (PAC) and TEE monitoring between September 2021 and February 2022 were included in this prospective, descriptive, single-center study. LVOT VTI was measured using TEE after induction of anesthesia but before skin incision and at least four hours after initial LVOT VTI measurement. SVI was simultaneously measured using the continuous thermodilution technique with a PAC. The correlation between LVOT VTI and SVI was determined with Pearson’s correlation index.

Results

Twelve patients were included and 21 paired measurements were compared. Mean SVI was 31.62 ± 10.71 mL/m² and mean LVOT VTI was 14.74 ± 4.79 cm. The Pearson's correlation index for the two measurements was r = 0.257, p = 0.262.

Conclusion

This prospective study demonstrated a weak correlation between LVOT VTI and SVI in patients undergoing cardiac surgery.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting

Hemodynamic assessment remains the most valuable adjunct to physical examination and laboratory assessment in the diagnosis and management of shock. Through the years, multiple modalities to measure and trend hemodynamic indices have evolved with varying degrees of invasiveness. Pulmonary artery catheter (PAC) has long been considered the gold standard of hemodynamic assessment in critically ill patients and in recent years has been shown to improve clinical outcomes among patients in cardiogenic shock. The invasive nature of PAC is often cited as its major limitation and has encouraged development of less invasive technologies. In this review, the authors summarize the literature on the mechanism and validation of several minimally invasive and noninvasive modalities available in the contemporary intensive care unit. They also provide an update on the use of focused bedside echocardiography.

Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal?

Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.

Recommendation Reversals in Gastroenterology Clinical Practice Guidelines

Background

Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs.

Methods

We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals.

Results

Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals.

Conclusion

Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.

Do pulmonary artery catheters have a role in the 21st century intensive care unit?

Use of pulmonary artery catheters on general intensive care units has declined. Reasons for this decline are explored and the evidence for and against their use is re-examined. We conclude that the growing consensus for a lack of benefit is not justified, and use of pulmonary artery catheters can still be appropriate.

Association of pulmonary arterial pressure with volume status in patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation

Background

Data on pulmonary hemodynamic parameters in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) are scarce.

Methods

The associations between pulmonary artery catheter parameters for the first 7 days of ECMO, fluid balance, and hospital mortality were investigated in adult patients (aged ≥19 years) who received venovenous ECMO for refractory ARDS between 2015 and 2017.

Results

Twenty patients were finally included in the analysis (median age, 56.0 years; interquartile range, 45.5-68.0; female, n=10). A total of 140 values were collected for each parameter (i.e., 7 days×20 patients). Net fluid balance was weakly but significantly correlated with systolic and diastolic pulmonary arterial pressures (PAPs; r=0.233 and P<0.001; r=0.376 and P<0.001, respectively). Among the mechanical ventilation parameters, above positive end-expiratory pressure was correlated with systolic PAP (r=0.191 and P=0.025), and static compliance was negatively correlated with diastolic PAP (r=-0.169 and P=0.048). Non-survivors had significantly higher systolic PAPs than in survivors. However, in multivariate analysis, there was no significant association between mean systolic PAP and hospital mortality (odds ratio, 1.500; 95% confidence interval, 0.937-2.404; P=0.091).

Conclusion

Systolic PAP was weakly but significantly correlated with net fluid balance during the early ECMO period in patients with refractory ARDS receiving ECMO.

Hemodynamic Monitoring Using a Pulmonary Artery Catheter Versus the Vigileo/FloTrac System during Elective Cardiac Surgery Based on Real-world Data in Japan

BACKGROUND

The controversy concerning the benefits of pulmonary artery catheter (PAC)-based hemodynamic monitoring in cardiac surgeries has not been adequately addressed. This study aims to compare the all-cause mortality between the PAC with venous oxygen saturation monitoring and the Vigileo/FloTrac (FloTrac) system with central venous oxygen saturation monitoring in cardiac surgeries.

METHODS

This nationwide retrospective study includes adult patients who underwent elective cardiac surgeries between April 2010 and October 2014, based on the Japanese health insurance claims database. The main outcome was 30-day all-cause mortality. Propensity scores (PS) were used to adjust for the confounding factors. Treatment effects were estimated using multivariable logistic regression analysis, including PS.

RESULTS

A total of 5,838 patients were included in this study. The crude 30-day mortality rates were 2.4% (8/334) and 1.7% (96/5,504) in the FloTrac and PAC groups, respectively. After PS matching, the ORs for 30-day all-cause mortality, in-hospital mortality after PAC placement (vs. FloTrac) were 0.36 (95% CI: 0.05-2.37; p = 0.28) and 0.59 (95% CI: 0.16-2.20; p = 0.43), respectively. The amount of dobutamine was larger in the PAC group (281 ± 31 mg vs 155 ± 19 mg; p < 0.001). There were no significant differences in the amounts of other inotropes, the volume of fluids, or blood transfusions.

CONCLUSIONS

The association between PAC (with venous oxygen saturation monitoring) and mortality in patients who underwent elective cardiac surgeries was unclear compared to FloTrac (with central venous oxygen saturation monitoring). Additional investigation is needed to evaluate the benefits of PAC-specific hemodynamic parameters in this population.

A Deep Learning Model for Inferring Elevated Pulmonary Capillary Wedge Pressures From the 12-Lead Electrocardiogram

Background

Central hemodynamic parameters are typically measured via pulmonary artery catherization-an invasive procedure that involves some risk to the patient and is not routinely available in all settings.

Objectives

This study sought to develop a noninvasive method to identify elevated mean pulmonary capillary wedge pressure (mPCWP).

Methods

We leveraged data from 248,955 clinical records at the Massachusetts General Hospital to develop a deep learning model that can infer when the mPCWP >15 mmHg using the 12-lead electrocardiogram (ECG). Of these data, 242,216 records were used to pre-train a model that generates useful ECG representations. The remaining 6,739 records contain encounters with direct measurements of the mPCWP. Eighty percent of these data were used for model development and testing (5,390), and the remaining records comprise a holdout set (1,349) that was used to evaluate the model. We developed an associated unreliability score that identifies when model predictions are likely to be untrustworthy.

Results

The model achieves an area under the receiver operating characteristic curve (AUC) of 0.80 ± 0.02 (test set) and 0.79 ± 0.01 (holdout set). Model performance varies as a function of the unreliability, where patients with high unreliability scores correspond to a subgroup where model performance is poor: for example, patients in the holdout set with unreliability scores in the highest decile have a reduced AUC of 0.70 ± 0.06.

Conclusions

The mPCWP can be inferred from the ECG, and the reliability of this inference can be measured. When invasive monitoring cannot be expeditiously performed, deep learning models may provide information that can inform clinical care.

The Pulmonary Artery Catheter in the Perioperative Setting: Should It Still Be Used?

The pulmonary artery catheter (PAC) was introduced into clinical practice in the 1970s and was initially used to monitor patients with acute myocardial infarctions. The indications for using the PAC quickly expanded to critically ill patients in the intensive care unit as well as in the perioperative setting in patients undergoing major cardiac and noncardiac surgery. The utilization of the PAC is surrounded by multiple controversies, with literature claiming its benefits in the perioperative setting, and other publications showing no benefit. The right interpretation of the hemodynamic parameters measured by the PAC and its clinical implications are of the utmost essence in order to guide a specific therapy. Even though clinical trials have not shown a reduction in mortality with the use of the PAC, it still remains a valuable tool in a wide variety of clinical settings. In general, the right selection of the patient population (high-risk patients with or without hemodynamic instability undergoing high-risk procedures) as well as the right clinical setting (centers with experience and expertise) are essential in order for the patient to benefit most from PAC use.

A Tale of Two Pulmonary Artery Catheters

Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report.

Protocol for a systematic review and meta-analysis of studies on the use of brain natriuretic peptide and N-terminal brain natriuretic peptide levels in the diagnosis of cardiopulmonary edema in acute respiratory failure

BACKGROUND

Dyspnea with bilateral pulmonary edema is common among patients in emergency departments (EDs) or intensive care units (ICUs). For the initial management of patients with this condition, cardiopulmonary edema (CPE) must be differentiated from acute respiratory distress syndrome (ARDS) in clinical settings. Brain natriuretic peptide (BNP) and N-terminal brain natriuretic peptide (NT-proBNP) are useful in distinguishing these conditions. However, current data about the use of these indexes are limited. Hence, we planned to perform a systematic review and meta-analysis to determine the accuracy of the two indexes for the diagnosis of CPE.

METHODS

We designed and registered a study protocol for a systematic review and meta-analysis. This study aims to determine the diagnostic accuracy of BNP and NT-proBNP based on the standards of the methodology of the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies in reporting the findings of this review. We will search PubMed (MEDLINE), Cochrane Library, Embase, www.ClinicalTrials.gov , International Clinical Trials Registry Platform, and Google Scholar. Randomized controlled trials, cross-sectional studies, and observational cohort studies reporting the accuracy in diagnosing CPE among adult patients with dyspnea and bilateral pulmonary edema will be included in the analysis. There will be no limits regarding language and publication date for this review. Two reviewers will independently screen articles, extract data, evaluate for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2), and use Grading of Recommendations Assessment, Development and Evaluation to summarize the strength of body of evidence. Then, a meta-analysis will be performed, and different statistical methods will be used to investigate heterogeneity among studies. A subgroup analysis of elderly patients with left ventricular dysfunction or chronic renal dysfunction will be performed. In the meta-analysis, a hierarchical summary receiver operating characteristic model or a bivariate model will be used in each index test, as appropriate.

DISCUSSION

A systematic review and meta-analysis of the accuracy of BNP and NT-proBNP for the diagnosis of CPE will be conducted. The result of this study can help clinicians to identify an appropriate initial treatment for patients with acute respiratory failure, including those with ARDS and CPE. To the best of our knowledge, this will be the first comprehensive systematic review focusing on ARDS management in a specific population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020201576.