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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [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: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Parker MM, Pinsky MR, Takala J, Vincent JL. The Story of the Pulmonary Artery Catheter: Five Decades in Critical Care Medicine. Crit Care Med 2023; 51:159-163. [PMID: 36661446 DOI: 10.1097/ccm.0000000000005718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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"Fighting the Minotaur" a Complex Blunt Chest Trauma Due to a Bull Attack: A Case Report. Rom J Anaesth Intensive Care 2022; 28:36-39. [PMID: 36846540 PMCID: PMC9949006 DOI: 10.2478/rjaic-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Bull-related injury continues to contribute to an unacceptable number of serious injuries and deaths, and bullfighting continues to be a popular, deeply traditional celebration of the culture of many Iberic-American countries. Most accidents due to bull attacks are horn-related penetrating traumas. Blunt chest trauma can cause a wide range of clinical presentations and injuries, making the diagnostics and therapies extremely challenging. Consequently, it is vital to quickly identify major life-threatening chest wall and intrathoracic injuries. In this case report, we aimed to describe the complexity of the management and the treatment of a blunt trauma patient hit by a bull.
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Wu J, Liang Q, Hu H, Zhou S, Zhang Y, An S, Sha T, Li L, Zhang Y, Chen Z, An S, Zeng Z. Early pulmonary artery catheterization is not associated with survival benefits in critically ill patients with cardiac disease: An analysis of the MIMIC-IV database. Surgery 2022; 172:1285-1290. [PMID: 35953307 DOI: 10.1016/j.surg.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many studies demonstrated no improved survival in patients with pulmonary artery catheter placement. However, no consistent conclusions have been drawn regarding the impact of pulmonary artery catheter in critically ill patients with heart disease. This study aimed to investigate the association of early pulmonary artery catheter use with 28-day mortality in that population. METHODS The Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database, a single-center critical care database, was employed to investigate this issue. This study enrolled a total of 11,887 critically ill patients with cardiac disease with or without pulmonary artery catheter insertion. The primary outcome was 28-day mortality. The multivariate regression was modeled to examine the association between pulmonary artery catheter and outcomes. Additionally, we examined the effect modification by cardiac surgeries. Propensity score matching was conducted to validate our findings. RESULTS No improvement in 28-day mortality was observed among the pulmonary artery catheter group compared to the non-pulmonary artery catheter group (odds ratio 95% confidence interval: 1.18 [1.00-1.38], P = .049). When stratified by cardiac surgeries, the results were consistent. The patients in the pulmonary artery catheter group had fewer ventilation-free days and vasopressor-free days than those in the nonpulmonary artery catheter group after surgery stratification. In the surgical patients, pulmonary artery catheter insertion was not associated with the occurrence of acute kidney injury, and it was associated with a higher daily fluid input (mean difference 95% confidence interval: 0.13 [0.05-0.20], P = .001). In nonsurgical patients, the pulmonary artery catheter group had a higher risk of acute kidney injury occurrence (odds ratio 95% confidence interval: 1.94 [1.32-2.84], P = .001). CONCLUSION Early pulmonary artery catheter placement is not associated with survival benefits in critically ill patients with cardiac diseases, either in surgical or nonsurgical patients.
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Affiliation(s)
- Jie Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qihong Liang
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Hongbin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiyu Zhou
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Yuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng An
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tong Sha
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lulan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaoyuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China.
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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5
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The Pulmonary Artery Catheter in the Perioperative Setting: Should It Still Be Used? Diagnostics (Basel) 2022; 12:diagnostics12010177. [PMID: 35054343 PMCID: PMC8774775 DOI: 10.3390/diagnostics12010177] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/29/2021] [Accepted: 01/10/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Güllüpınar B, Aytemiz F, Karagöz A, Tandon S, Sağlam C, Şehitoğlu Alpağut G, Turhan A, Serin S, Keskinoğlu P, Ünlüer EE. The role of tricuspite annular plane systolic excursion as a marker of hypovolemia in healthy blood donor volunteers. Am J Emerg Med 2021; 51:320-324. [PMID: 34800904 DOI: 10.1016/j.ajem.2021.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/15/2021] [Indexed: 01/02/2023] Open
Abstract
AIM The aim of this study is to compare the diameter of the inferior vena cava with tricuspid annular plane systolic excursion (TAPSE) measurement in order to determine the volume loss before and after blood donation in healthy volunteers. METHODS This Institutional Review Board-approved single center, prospective, cross-sectional study included 60 healthy blood donors donating in a tertiary care hospital's blood bank. After obtaining written consent, systolic, diastolic, and mean arterial blood pressures along with pulse rate of the donors were measured in sitting and supine positions by the attending physician, then, inferior vena cava (IVC) and TAPSE measurements were made before and after blood donation. RESULTS Statistically significant differences was found between standing systolic blood pressure and pulse rate, lying systolic blood pressure and pulse rate, IVC and TAPSE values before and after blood donation (p < 0.05). There was no difference between the other variables before and after blood donation. CONCLUSION Our study revealed that, low IVC and TAPSE values correlated in determining blood loss after blood donation. TAPSE may be useful to predict blood loss in early stages of hypovolemic shock.
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Affiliation(s)
- Birdal Güllüpınar
- Izmir Bozyaka Training and Resarch Hospital, Department of Emergency Medicine, İzmir, TURKEY.
| | - Fatih Aytemiz
- Manisa City Hospital, Department of Cardiology, Manisa-İzmir, Turkey
| | - Arif Karagöz
- Izmir Çiğli Training Hospital, Department of Emergency Medicine, İzmir, Turkey
| | | | - Caner Sağlam
- Izmir Bozyaka Training and Resarch Hospital, Department of Emergency Medicine, İzmir, TURKEY
| | - Gülşah Şehitoğlu Alpağut
- Buca Seyfi Demirsoy Training and Resarch Hospital, Department of Emergency Medicine, İzmir, Turkey
| | | | - Sezen Serin
- Buca Seyfi Demirsoy Training and Resarch Hospital, Department of Emergency Medicine, İzmir, Turkey
| | - Pembe Keskinoğlu
- Dokuz Eylul University Faculyt of Medicine, Department of Biostatistics and Medical Informatics, İzmir, TURKEY
| | - Erden Erol Ünlüer
- Izmir Bozyaka Training and Resarch Hospital, Department of Emergency Medicine, İzmir, TURKEY
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Wise ES, Hocking KM, Polcz ME, Beilman GJ, Brophy CM, Sobey JH, Leisy PJ, Kiberenge RK, Alvis BD. Hemodynamic Parameters in the Assessment of Fluid Status in a Porcine Hemorrhage and Resuscitation Model. Anesthesiology 2021; 134:607-616. [PMID: 33635950 PMCID: PMC7946734 DOI: 10.1097/aln.0000000000003724] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Measuring fluid status during intraoperative hemorrhage is challenging, but detection and quantification of fluid overload is far more difficult. Using a porcine model of hemorrhage and over-resuscitation, it is hypothesized that centrally obtained hemodynamic parameters will predict volume status more accurately than peripherally obtained vital signs. METHODS Eight anesthetized female pigs were hemorrhaged at 30 ml/min to a blood loss of 400 ml. After each 100 ml of hemorrhage, vital signs (heart rate, systolic blood pressure, mean arterial pressure, diastolic blood pressure, pulse pressure, pulse pressure variation) and centrally obtained hemodynamic parameters (mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure, cardiac output) were obtained. Blood volume was restored, and the pigs were over-resuscitated with 2,500 ml of crystalloid, collecting parameters after each 500-ml bolus. Hemorrhage and resuscitation phases were analyzed separately to determine differences among parameters over the range of volume. Conformity of parameters during hemorrhage or over-resuscitation was assessed. RESULTS During the course of hemorrhage, changes from baseline euvolemia were observed in vital signs (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) after 100 ml of blood loss. Central hemodynamic parameters (mean pulmonary artery pressure and pulmonary capillary wedge pressure) were changed after 200 ml of blood loss, and central venous pressure after 300 ml of blood loss. During the course of resuscitative volume overload, changes were observed from baseline euvolemia in mean pulmonary artery pressure and central venous pressure after 500-ml resuscitation, in pulmonary capillary wedge pressure after 1,000-ml resuscitation, and cardiac output after 2,500-ml resuscitation. In contrast to hemorrhage, vital sign parameters did not change during over-resuscitation. The strongest linear correlation was observed with pulmonary capillary wedge pressure in both hemorrhage (r2 = 0.99) and volume overload (r2 = 0.98). CONCLUSIONS Pulmonary capillary wedge pressure is the most accurate parameter to track both hemorrhage and over-resuscitation, demonstrating the unmet clinical need for a less invasive pulmonary capillary wedge pressure equivalent. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Eric S Wise
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kyle M Hocking
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Monica E Polcz
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Colleen M Brophy
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jenna H Sobey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip J Leisy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Roy K Kiberenge
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Bret D Alvis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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10
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Bootsma IT, Boerma EC, de Lange F, Scheeren TWL. The contemporary pulmonary artery catheter. Part 1: placement and waveform analysis. J Clin Monit Comput 2021; 36:5-15. [PMID: 33564995 PMCID: PMC8894225 DOI: 10.1007/s10877-021-00662-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular (RV) performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using cold bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which at random heats up the blood. In this first part, the insertion techniques, interpretation of waveforms of the PAC, the interaction of waveforms with the respiratory cycle and airway pressure as well as pitfalls in waveform analysis are discussed. The second part will cover the measurements of the contemporary PAC including measurement of continuous cardiac output, RV ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements will be highlighted there as well. We conclude that thorough understanding of measurements obtained from the PAC are the first step in successful application of the PAC in daily clinical practice.
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Affiliation(s)
- I T Bootsma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, P.O. Box 888. 8901, Leeuwarden, The Netherlands.
| | - E C Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, P.O. Box 888. 8901, Leeuwarden, The Netherlands
| | - F de Lange
- Department of Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, P.O. Box 888. 8901, Leeuwarden, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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11
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Szabo C, Betances-Fernandez M, Navas-Blanco JR, Modak RK. PRO: The pulmonary artery catheter has a paramount role in current clinical practice. Ann Card Anaesth 2021; 24:4-7. [PMID: 33938823 PMCID: PMC8081135 DOI: 10.4103/aca.aca_125_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ever since its clinical introduction, the utilization of the pulmonary artery catheter (PAC) has been surrounded by multiple controversies, mostly related to imprecise clinical indications and the complications derived from its placement. Currently, one of the most important criticisms of the PAC is the ambiguity in the interpretation of its hemodynamic measurements and therefore, in the translation of this data into specific therapeutic interventions. The popularity of the PAC stems from the fact that it provides hemodynamic data that cannot be obtained from clinical examination. The assumption is that this information would allow better understanding of the individual's hemodynamic profile which would trigger therapeutic interventions that improve patient outcomes. Nevertheless, even with the current diversity of hemodynamic devices available, the PAC remains a valuable tool in a wide variety of clinical settings. The authors present a review exposing the benefits of the PAC, current clinical recommendations for its use, mortality and survival profile, its role in goal-directed therapy, and other applications of the PAC beyond cardiac surgery and the intensive care unit.
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Affiliation(s)
- Christian Szabo
- Department of Anesthesia, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maria Betances-Fernandez
- Department of Anesthesia, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jose R Navas-Blanco
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Raj K Modak
- Department of Anesthesia, Pain Management and Perioperative Medicine, Divisions of Cardiothoracic Anesthesia and Critical Care Anesthesiology, Henry Ford Hospital, Detroit, Michigan, USA
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12
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13
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Bilgin S, Topal FE, Yamanoğlu A, Payza U, Karakaya Z, Akyol PY, Tahtaci R, Topal F. Effect of Changes in Intravascular Volume on Inferior Vena Cava and Aorta Diameters and the Caval/Aorta Index in Healthy Volunteers. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:231-238. [PMID: 31283047 DOI: 10.1002/jum.15093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 06/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring. METHODS This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests. RESULTS Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059). CONCLUSIONS The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.
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Affiliation(s)
- Serkan Bilgin
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Fatih Esad Topal
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Adnan Yamanoğlu
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Umut Payza
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Zeynep Karakaya
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Pınar Yesim Akyol
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Rezan Tahtaci
- Departments of Emergency Medicine, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
| | - Firdes Topal
- Departments of Gastroenterology, Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey
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14
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Mehmood M, Biederman RWW, Markert RJ, McCarthy MC, Tchorz KM. Right Heart Function in Critically Ill Patients at Risk for Acute Right Heart Failure: A Description of Right Ventricular-Pulmonary Arterial Coupling, Ejection Fraction and Pulmonary Artery Pulsatility Index. Heart Lung Circ 2019; 29:867-873. [PMID: 31257001 DOI: 10.1016/j.hlc.2019.05.186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The gold standard for right heart function is the assessment of right ventricular-pulmonary arterial coupling defined as the ratio of arterial to end-systolic elastance (Ea/Emax). This study demonstrates the use of the volumetric pulmonary artery (PA) catheter for estimation of Ea/Emax and describes trends of Ea/Emax, right ventricular ejection fraction (RVEF), and pulmonary artery pulsatility index (PAPi) during initial 48hours of resuscitation in the trauma surgical intensive care unit (ICU). METHODS Review of prospectively collected data for 32 mechanically ventilated adult trauma and emergency general surgery patients enrolled within 6hours of admission to the ICU. Haemodynamics, recorded every 12hours for 48hours, were compared among survivors and non-survivors to hospital discharge. RESULTS Mean age was 49±20 years, 69% were male, and 84% were trauma patients. Estimated Ea/Emax was associated with pulmonary vascular resistance and inversely related to pulmonary arterial capacitance and PA catheter derived RVEF. Seven (7) trauma patients did not survive to hospital discharge. Non-survivors had higher estimated Ea/Emax, suggesting right ventricular-pulmonary arterial uncoupling, with a statistically significant difference at 48hours (2.3±1.7 vs 1.0±0.58, p=0.018). RVEF was significantly lower in non-survivors at study initiation and at 48hours. PAPi did not show a consistent trend. CONCLUSIONS Estimation of Ea/Emax using volumetric PA catheter is feasible. Serial assessment of RVEF and Ea/Emax may help in early identification of right heart dysfunction in critically ill mechanically ventilated patients at risk for acute right heart failure.
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Affiliation(s)
- Muddassir Mehmood
- Wright State University, Boonshoft School of Medicine, Dept. of Internal Medicine, Dayton, OH, USA.
| | - Robert W W Biederman
- Allegheny General Hospital, Division of Cardiology, Center for Cardiac MRI, Pittsburgh, PA, USA
| | - Ronald J Markert
- Wright State University, Boonshoft School of Medicine, Dept. of Internal Medicine, Dayton, OH, USA
| | - Mary C McCarthy
- Wright State University, Boonshoft School of Medicine, Dept. of Surgery, Dayton, OH, USA
| | - Kathryn M Tchorz
- Wright State University, Boonshoft School of Medicine, Dept. of Surgery, Dayton, OH, USA
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Abstract
PURPOSE OF REVIEW The present review discusses the current role of the pulmonary artery catheter (PAC) in the hemodynamic monitoring of critically ill patients. RECENT FINDINGS The PAC has an important role in the characterization and management of hemodynamic alterations in critically ill patients. Use of the PAC has decreased in the last 30 years because of recent advances in less invasive hemodynamic monitoring techniques, in particular transpulmonary thermodilution and echocardiography, combined with the publication of the results of several randomized trials that failed to show improvements in outcome with the use of the PAC in various settings. Although it is obvious that the PAC should not be used in most critically ill patients, the PAC is still indicated in some patients with circulatory and/or respiratory failure, especially when associated with pulmonary hypertension or left heart dysfunction. As for any technique, optimal PAC use requires expertise in insertion, acquisition, and interpretation of measurements. The decrease in use of the PAC may unfortunately limit exposure of junior doctors and nurses to this device, so that they become less familiar with using the PAC, making it more complicated and less optimal. SUMMARY The PAC still has an important role in the cardiopulmonary monitoring of critically ill patients.
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De Backer D, Hajjar LA, Pinsky MR. Is there still a place for the Swan‒Ganz catheter? We are not sure. Intensive Care Med 2018; 44:960-962. [PMID: 29796917 DOI: 10.1007/s00134-018-5140-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/16/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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17
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Alternatives to the Swan–Ganz catheter. Intensive Care Med 2018; 44:730-741. [DOI: 10.1007/s00134-018-5187-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
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Stawicki SP, Prosciak MP. The pulmonary artery catheter in 2008 - A (finally) maturing modality? Int J Crit Illn Inj Sci 2017; 7:172-176. [PMID: 28971032 PMCID: PMC5613410 DOI: 10.4103/ijciis.ijciis_57_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The first description of the flow-directed pulmonary artery catheter (PAC) was published in the 1970s by Jeremy Swan and William Ganz. Ever since its clinical debut, many controversies surrounded the use of the PAC. Regardless of these controversies, the most fundamental issues surrounding this hemodynamic monitoring device remain unresolved, including the exact indications, contraindications, identification of patients who potentially benefit from this technology, and the way we interpret and use PAC-derived parameters. Despite recent intensification of attacks against the use of the PAC by its opponents, it seems overly harsh to discount a technology that might be beneficial in appropriately selected clinical situations, especially when considering the fact that our true knowledge of this technology is somewhat limited. In fact, the PAC may still play an important role considering the resurgence of the concepts of euvolemic resuscitation and hemodynamic sufficiency. Republished with Permission from: Stawicki SP, Prosciak MP. The pulmonary artery catheter in 2008 – a (finally) maturing modality? OPUS 12 Scientist 2008;2(4):5-9.
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Affiliation(s)
- Stanislaw P Stawicki
- Ohio Chapter, OPUS, 12 Foundation, USA.,Department of Surgery, The Ohio State University Medical Center, Division of Critical Care, Trauma, and Burn, Columbus, OH, USA
| | - Mark P Prosciak
- Department of Surgery, The Ohio State University Medical Center, Division of Critical Care, Trauma, and Burn, Columbus, OH, USA
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Risk factors associated with bladder and urethral injuries in female children with pelvic fractures: An analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2016; 80:472-6. [PMID: 26713981 DOI: 10.1097/ta.0000000000000947] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bladder and/or urethral injuries (BUIs) secondary to pelvic fractures are rare in children and are associated with a high morbidity. These injuries are much less likely to occur in females and are often missed in the emergency department. To help clinicians detect these injuries in female children, larger studies are needed to identify risk factors specific to this patient population. This study aimed to identify risk factors associated with BUI in female children with a pelvic fracture. METHODS We reviewed the National Trauma Data Bank for females younger than 16 years who sustained a pelvic fracture from 2010 to 2012. Patients with penetrating injuries were excluded. Variables including patient characteristics, mechanism of injury, and type of pelvic fracture were selected for bivariate analysis. Variables with an association of p < 0.05 were then tested using binary logistic regression. RESULTS Of the 149,091 females younger than 16 years in the National Trauma Data Bank, 2,639 patients (2%) with pelvic fractures were identified. The median patient age was 12 years (interquartile range [IQR], 7-14 years). BUI was identified in 81 patients (3%). Patients with BUI had a significantly higher median Injury Severity Score (ISS) (25 [IQR, 17-34] vs. 13 [IQR, 6-22], p < 0.001). Four variables were found to be independently associated with BUI in the logistic regression model: vaginal laceration (adjusted odds ratio [OR], 9.1; 95% confidence interval [CI], 4.4-18.7), disruption of the pelvic circle (adjusted OR, 3.0; 95% CI, 1.6-5.6), multiple pelvic fractures (adjusted OR, 2.3; 95% CI, 1.3-3.9), and sacral spine injury (adjusted OR, 1.6; 95% CI, 1.0-2.6). In total, 62 patients (77%; 95% CI, 67-86%) with BUI had at least one of these findings. CONCLUSION Female children who sustained a pelvic fracture and have a vaginal laceration, disruption of the pelvic circle, multiple pelvic fractures, or a sacral spine injury seem to be at highest risk for BUI. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Zochios VA, Wilkinson J. What is the value of the pulmonary artery catheter in critical care and anaesthesia? Br J Hosp Med (Lond) 2016; 74:478. [PMID: 23958995 DOI: 10.12968/hmed.2013.74.8.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vasileios A Zochios
- Acute Care Common Stem Anaesthesia Core Trainee in the Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS, Leicester Royal Infirmary NHS Trust, Leicester
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Downs EA, Isbell JM. Impact of hemodynamic monitoring on clinical outcomes. Best Pract Res Clin Anaesthesiol 2014; 28:463-76. [PMID: 25480775 DOI: 10.1016/j.bpa.2014.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 01/19/2023]
Abstract
In recent years, there has been a tremendous growth in available hemodynamic monitoring devices to support clinical decision-making in the operating room and intensive care unit. In addition to the "tried and true" heart rate and blood pressure monitors, there are several newer applications of existing technologies including arterial waveform analysis, intraoperative and bedside critical care echocardiography, esophageal Doppler, and tissue oximetry, among others. Several monitoring devices demonstrate positive effect on outcomes, especially when used in conjunction with specific goal-directed therapy protocols to achieve a desired clinical effect. Other devices remain in the validation stage, awaiting comprehensive comparison to established techniques. While these new technologies offer promising advances in intraoperative and critical care, they are often quite costly and many devices lack strong evidence for widespread adoption into clinical practice. In this review, we highlight the current data on clinical outcomes with the use of available hemodynamic monitoring devices.
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Affiliation(s)
- Emily A Downs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA.
| | - James M Isbell
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA 22908, USA.
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Cheatham ML, Malbrain MLNG. Cardiovascular implications of abdominal compartment syndrome. Acta Clin Belg 2014; 62 Suppl 1:98-112. [PMID: 24881706 DOI: 10.1179/acb.2007.62.s1.013] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cardiovascular dysfunction and failure are commonly encountered in the patient with intra-abdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload, in conjunction with appropriate goal-directed resuscitation and abdominal decompression when indicated, are essential to restoring end-organ perfusion and maximizing patient survival. The validity of traditional hemodynamic resuscitation endpoints, such as pulmonary artery occlusion pressure and central venous pressure, must be reconsidered in the patient with intra-abdominal hypertension as these pressure-based estimates of intravascular volume have significant limitations in patients with elevated intra-abdominal pressure. If such limitations are not recognized, misinterpretation of the patient's cardiac status is likely, resulting in inappropriate and potentially detrimental therapy. Appropriate fluid administration is mandatory as under-resuscitation leads to organ failure and over-resuscitation the development of secondary abdominal compartment syndrome, both of which are associated with increased morbidity and mortality. Volumetric monitoring techniques have been proven to be superior to traditional intra-cardiac filling pressures in directing the appropriate resuscitation of this patient population. Calculation of the "abdominal perfusion pressure", defined as mean arterial pressure minus intra-abdominal pressure, has been shown to be a beneficial resuscitation endpoint as it assesses not only the severity of the patient's intra-abdominal hypertension, but also the adequacy of abdominal blood flow. Application of a goal-directed resuscitation strategy, including abdominal decompression when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.
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Maybauer MO, Asmussen S, Platts DG, Fraser JF, Sanfilippo F, Maybauer DM. Transesophageal echocardiography in the management of burn patients. Burns 2014; 40:630-5. [DOI: 10.1016/j.burns.2013.08.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 10/26/2022]
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Abstract
BACKGROUND Post-trauma resuscitation has evolved based on civilian and wartime experiences over the last decade. Similarly, data from large multicenter randomized trials have changed the management of critically ill trauma patients in the intensive care unit. METHODS This is a review of the literature focusing on areas relevant to the management of trauma patients in the intensive care unit. RESULTS The following topics are included: (1) ventilator management, (2) trauma sepsis, (3) use of vasopressors in hemorrhage, (4) glucose control, (5) nutrition, and (6) hemodynamic monitoring. CONCLUSION This review demonstrated the most recent data of trauma-related critical care. Further studies will be needed to settle growing controversies in the management of critically injured patients.
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Affiliation(s)
- K Matsushima
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - M Khan
- Defense Medical Services, Doncaster, UK
| | - H L Frankel
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
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Molnár Z, Vincent JL. Still a (valuable) place for the pulmonary artery catheter. Int J Cardiol 2014; 173:131-2. [PMID: 24681015 DOI: 10.1016/j.ijcard.2014.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 03/09/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Zsolt Molnár
- Department of Anesthesia and Intensive Therapy, University of Szeged, 6. Semmelweis St, 6725 Szeged, Hungary.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium.
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Friese RS, Wynne J, Joseph B, Hashmi A, Diven C, Pandit V, O'Keeffe T, Zangbar B, Kulvatunyou N, Rhee P. Age and mortality after injury: is the association linear? Eur J Trauma Emerg Surg 2014; 40:567-72. [PMID: 26814513 DOI: 10.1007/s00068-014-0380-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/20/2014] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists. METHODS We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05. RESULTS A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of -0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline. CONCLUSIONS The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.
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Affiliation(s)
- R S Friese
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - J Wynne
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - B Joseph
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA.
| | - A Hashmi
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - C Diven
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - V Pandit
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - T O'Keeffe
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - B Zangbar
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - N Kulvatunyou
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
| | - P Rhee
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona College of Medicine, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ, 85727, USA
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Romagnoli S. Circulatory failure: Exploring macro- and micro-circulation. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
OBJECTIVE With important technological advances in healthcare delivery and the Internet, clinicians and scientists now have access to overwhelming number of available databases capturing patients with critical illness. Yet, investigators seeking to answer important clinical or research questions with existing data have few resources that adequately describe the available sources and the strengths and limitations of each. This article reviews an approach to selecting a database to address health services and outcomes research questions in critical care, examines several databases that are commonly used for this purpose, and briefly describes some strengths and limitations of each. DATA SOURCES Narrative review of the medical literature. SUMMARY The available databases that collect information on critically ill patients are numerous and vary in the types of questions they can optimally answer. Selection of a data source must consider not only accessibility but also the quality of the data contained within the database, and the extent to which it captures the necessary variables for the research question. Questions seeking causal associations (e.g., effect of treatment on mortality) usually either require secondary data that contain detailed information about demographics, laboratories, and physiology to best address nonrandom selection or sophisticated study design. Purely descriptive questions (e.g., incidence of respiratory failure) can often be addressed using secondary data with less detail such as administrative claims. Although each database has its own inherent limitations, all secondary analyses will be subject to the same challenges of appropriate study design and good observational research. CONCLUSION The literature demonstrates that secondary analyses can have significant impact on critical care practice. While selection of the optimal database for a particular question is a necessary part of high-quality analyses, it is not sufficient to guarantee an unbiased study. Thoughtful and well-constructed study design and analysis approaches remain equally important pillars of robust science. Only through responsible use of existing data will investigators ensure that their study has the greatest impact on critical care practice and outcomes.
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Abstract
The older adult patient with trauma is becoming a growing part of the overall trauma population. With the world population increasing in age, the rate of the traumatically injured older adult will continue to increase. Recognizing this problem and the fact that the elderly are at higher risk for injury and its complications will be necessary if the increasing volume of patients is to be dealt with. This review discusses these issues, as well as appropriate triage and treatment of injuries and associated comorbidities. Early recognition of injury, even minor, and expedited care using specialized teams will help to improve outcomes for these patients.
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Newell MA, Skarupa DJ, Rotondo MF. The damage control sequence in the elderly: Strategy, complexities, and outcomes. TRAUMA-ENGLAND 2012. [DOI: 10.1177/1460408612463867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traditional management in cases of exsanguinating abdominal trauma led to poor outcomes in critically injured patients. Because prolonged operations were not well tolerated due to the severe physiologic derangements, an abbreviated laparotomy began to be used. Patients were then resuscitated in the intensive care unit and brought back to the operating room once their physiology had been normalised. This approach has been termed the damage control sequence. Elderly trauma patients are susceptible to significant injury that may mandate a damage control sequence. For myriad reasons, including pre-existing medical conditions, decreased physiologic reserve, and the emergent nature of their injuries, the application of this management approach in the elderly is fraught with challenges. The purpose of this review is to enumerate the damage control sequence, describe the complexities of its use in the elderly, and discuss associated outcomes in this challenging patient population.
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Affiliation(s)
- Mark A Newell
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - David J Skarupa
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - Michael F Rotondo
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
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Manoach S, Weingart SD, Charchaflieh J. The evolution and current use of invasive hemodynamic monitoring for predicting volume responsiveness during resuscitation, perioperative, and critical care. J Clin Anesth 2012; 24:242-50. [PMID: 22537573 DOI: 10.1016/j.jclinane.2011.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 10/28/2011] [Accepted: 11/03/2011] [Indexed: 11/25/2022]
Abstract
Traditional hemodynamic monitors such as pulmonary artery and central venous catheters provide continuous data and secure intravenous access, but their diagnostic efficacy has been criticized. Dynamic arterial waveform monitoring is promising, but studies suggest it is reliable only within narrow ventilation and rhythm parameters. Newer algorithm-based hemodynamic monitors have emerged; they, too, are limited in their accuracy and applicability. Intravascular monitors are used to predict fluid responsiveness and need for alternative therapies, such as vasomotor or inotropic support. Recent efficacy data, along with other important clinical findings, are reviewed with regard to invasive monitors. We caution against over-generalizing from existing studies, and provide guidance for clinicians wishing to target monitoring techniques for appropriate patients.
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Affiliation(s)
- Seth Manoach
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.
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Vincent JL. The pulmonary artery catheter. J Clin Monit Comput 2012; 26:341-5. [PMID: 22886686 DOI: 10.1007/s10877-012-9389-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 08/03/2012] [Indexed: 01/20/2023]
Abstract
The pulmonary artery catheter (PAC) has been widely used for monitoring of critically ill patients over the years, but with advances in less invasive monitoring techniques, notably echocardiography, there are fewer indications for PAC insertion. Nevertheless, the PAC provides simultaneous monitoring of pulmonary artery pressures, cardiac filling, cardiac output and mixed venous oxygen saturation, and still has an important role in complex cases. Adequate and continued training are required to ensure that PAC-derived data are correctly interpreted and applied.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Comparison of hemodynamic measurements from invasive and noninvasive monitoring during early resuscitation. J Trauma Acute Care Surg 2012; 72:852-60. [PMID: 22491596 DOI: 10.1097/ta.0b013e31824b1764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Measurements obtained from the insertion of a pulmonary artery catheter (PAC) in critically ill and/or injured patients have traditionally assisted with resuscitation efforts. However, with the recent utilization of ultrasound in the intensive care unit setting, transthoracic echocardiography (TTE) has gained popularity. The purpose of this study is to compare serial PAC and TTE measurements and document levels of serum biomarkers during resuscitation. METHODS Over a 25-month period, critically ill and/or injured patients admitted to a Level I adult trauma center were enrolled in this 48-hour intensive care unit study. Serial PAC and TTE measurements were obtained every 12 hours (total = 5 points/patient). Serial levels of lactate, Δ base, troponin-1, and B-type natriuretic peptide were obtained. Pearson correlation coefficient and intraclass correlation (ICC) assessed relationship and agreement, respectively, between PAC and TTE measures of cardiac output (CO) and stroke volume (SV). Analysis of variance with post hoc pairwise determined differences over time. RESULTS Of the 29 patients, 69% were male, with a mean age of 47.4 years ± 19.5 years and 79.3% survival. Of these, 25 of 29 were trauma with a mean Injury Severity Score of 23.5 ± 10.7. CO from PAC and TTE was significantly related (Pearson correlations, 0.57-0.64) and agreed with moderate strength (ICC, 0.66-0.70). SV from PAC and TTE was significantly related (Pearson correlations, 0.40-0.58) and agreed at a weaker level (ICC, 0.41-0.62). Tricuspid regurgitation was noted in 80% and mitral regurgitation in 50% to 60% of patients. CONCLUSION Measurements of CO and SV were moderately strong in correlation and agreement which may suggest PAC measurements overestimate actual values. The significance of tricuspid regurgitation and mitral regurgitation during early resuscitation is unknown.
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Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012; 214:756-68. [PMID: 22321521 PMCID: PMC3334459 DOI: 10.1016/j.jamcollsurg.2011.12.013] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/08/2011] [Accepted: 12/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. STUDY DESIGN A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. RESULTS Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. CONCLUSIONS There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.
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Affiliation(s)
- Adil H Haider
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21212, USA.
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Barmparas G, Inaba K, Georgiou C, Hadjizacharia P, Chan LS, Demetriades D, Friese R, Rhee P. Swan-Ganz catheter use in trauma patients can be reduced without negatively affecting outcomes. World J Surg 2011; 35:1809-17. [PMID: 21604050 DOI: 10.1007/s00268-011-1149-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The use of pulmonary artery catheter (PAC) is controversial. The purpose of this study was to document the changing pattern of PAC use and to determine its effect on outcome. METHODS The use of PAC was analyzed in patients ≥16 years old admitted to the surgical intensive care unit (SICU) over a 9-year period starting in 2000. Patients with SICU length of stay exceeding 30 days were excluded. For the evaluation of PAC's effect on outcome, PAC and no-PAC patients were matched utilizing propensity scores. RESULTS During the 9-year study period, a total of 5,192 trauma patients were admitted to the SICU. Of these, 426 (8.2%) were <16 years old, and 174 (3.4%) had a SICU length of stay that exceeded 30 days. For the remaining 4,592 patients, the mean ± SD age was 39.5 ± 18.8 years, and the mean ISS was 19.9 ± 12.4. PAC was utilized in 19.5% (n = 896) of all the patients admitted to the SICU. The trend for PAC use decreased significantly over the years (P value for trend <0.001), from 38.6% in the year 2000 to 4.2% in the year 2008. This decrease was noted in all age and injury severity groups of patients. The overall mortality, however, remained at the same levels (P value for trend = 0.111). Patients managed with a PAC were significantly older, more severely injured, more frequently injured by a blunt mechanism, and were admitted more often in a hypotensive or comatose status. In the early part of the study, the PAC was utilized on the first day and for 4.1 days on average. In the later part of the study, however, the PAC was used on the second day and for a shorter period of time (3 days on average, P < 0.001). In the matched study population, patients in the PAC group had almost twofold higher odds for death, when compared to the no-PAC group [34.2% vs. 22.5%, Odds Ratio (95% CI): 1.78 (1.42, 2.26), P < 0.001]. Patients younger than 50 years of age who had an ISS ≥16 had worse outcome when managed with a PAC, whereas patients aged 30-69 years with an ISS <16 had a higher survival. The overall complication rate was fivefold higher in patients receiving a PAC [46.3% vs. 14.2%, Odds Ratio (95% CI): 5.22 (4.04, 6.74), P < 0.001]. CONCLUSION The use of PAC has decreased almost 10-fold over the last decade at our institution. The PAC is being used later during the ICU course and for a shorter period of time. In a matched population, the use of PAC is associated with a significantly higher mortality and complication rate, but the reason for this association remains uncertain. The use of PAC is invasive and is associated with known complications and financial costs. While the use of PAC maybe useful in a select population, routine and widespread use of the PAC should be avoided.
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Affiliation(s)
- Galinos Barmparas
- Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA
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Murthi SB, Dutton RP, Edelman BB, Scalea TM, Hess JR. Transfusion medicine in trauma patients. Expert Rev Hematol 2011; 1:99-109. [PMID: 21083009 DOI: 10.1586/17474086.1.1.99] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Injured patients stress the transfusion service with frequent demands for uncrossmatched red cells and plasma, occasional requirements for large amounts of blood products and the need for new and better blood products. Transfusion services stress trauma centers with demands for strict accountability for individual blood component units and adherence to indications in a clinical field where research has been difficult, and guidance opinion-based. New data suggest that the most severely injured patients arrive at the trauma center already coagulopathic and that these patients benefit from prompt, specific, corrective treatment. This research is clarifying trauma system requirements for new blood products and blood-product usage patterns, but the inability to obtain informed consent from severely injured patients remains an obstacle to further research.
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Affiliation(s)
- Sarah B Murthi
- University of Maryland School of Medicine, Baltimore, MD, USA
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Abstract
Monitoring oxygen saturation of blood drawn from a catheter placed within the superior vena cava (Scvo2) has recently been promoted as a substitute for evaluating oxygen saturation of mixed venous blood drawn from the pulmonary artery (Svo2). The Svo2 reflects the balance between oxygen delivery and oxygen consumption throughout the body and, among critically ill patients, may be helpful for assessing resuscitation, cardiac function, or oxygen homeostasis end points. Use of Scvo2 instead has been promoted because of its easier access and recent use during resuscitation of patients with severe infections. Although data from healthy subjects and critically ill patients are available, no study has been done among organ donors to evaluate customary values for either Scvo2 or Svo2 or how well the values correspond. After loss of oxygen consumption in the brain following brain death, the customary values for these variables may be different from values in other groups of patients. Therefore, until donor-specific normative values for these important parameters are identified, we do not recommend that Scvo2 be used to evaluate the balance between donor oxygen consumption and delivery or as a variable to guide treatment.
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Affiliation(s)
- David J Powner
- Neurosurgery Department, University of Texas Health Science Center at Houston Medical School, 77030, USA.
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Powner DJ, Doshi PB. Central Venous Oxygen Saturation Monitoring: Role in Adult Donor Care? Prog Transplant 2010; 20:401-5; quiz 406. [DOI: 10.1177/152692481002000414] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Monitoring oxygen saturation of blood drawn from a catheter placed within the superior vena cava (ScvO2) has recently been promoted as a substitute for evaluating oxygen saturation of mixed venous blood drawn from the pulmonary artery (Sv̄O2). The Sv̄O2 reflects the balance between oxygen delivery and oxygen consumption throughout the body and, among critically ill patients, may be helpful for assessing resuscitation, cardiac function, or oxygen homeostasis end points. Use of ScvO2 instead has been promoted because of its easier access and recent use during resuscitation of patients with severe infections. Although data from healthy subjects and critically ill patients are available, no study has been done among organ donors to evaluate customary values for either ScvO2 or Sv̄O2 or how well the values correspond. After loss of oxygen consumption in the brain following brain death, the customary values for these variables may be different from values in other groups of patients. Therefore, until donor-specific normative values for these important parameters are identified, we do not recommend that ScvO2 be used to evaluate the balance between donor oxygen consumption and delivery or as a variable to guide treatment.
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Affiliation(s)
- David J. Powner
- University of Texas Health Science, Center at Houston Medical School
| | - Pratik B. Doshi
- University of Texas Health Science, Center at Houston Medical School
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Abstract
Patients undergoing emergency surgery typically require resuscitation, either because they are hemorrhaging or because they are experiencing significant internal fluid shifts. Intravascular hypovolemia is common at the time of anesthesia induction and can lead to hemodynamic collapse if not promptly treated. Central pressure monitoring is associated with technical complications and does not improve outcomes in this population. Newer modalities are in use, but they lack validation. Fluid resuscitation is different in bleeding and septic patients. In the former group, it is advisable to maintain a deliberately low blood pressure to facilitate clot formation and stabilization. If massive transfusion is anticipated, blood products should be administered from the outset to prevent the coagulopathy of trauma. Early use of plasma in a ratio approaching 1:1 with red blood cells (RBCs) has been associated with improved outcomes. In septic patients, early fluid loading is recommended. The concept of "goal-directed resuscitation" is based on continuing resuscitation until venous oxygen saturation is normalized. In either bleeding or septic patients, however, the most important goal remains surgical control of the source of pathology, and nothing should be allowed to delay transfer to the operating room. We review the current literature and recommendations for the resuscitation of patients coming for emergency surgery procedures.
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Wang Z, Baumann BM, Slutsky K, Gruber KN, Jean S. Respiratory sound energy and its distribution patterns following clinical improvement of congestive heart failure: a pilot study. BMC Emerg Med 2010; 10:1. [PMID: 20078862 PMCID: PMC2821310 DOI: 10.1186/1471-227x-10-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 01/15/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although congestive heart failure (CHF) patients typically present with abnormal auscultatory findings on lung examination, respiratory sounds are not normally subjected to additional analysis. The aim of this pilot study was to examine respiratory sound patterns of CHF patients using acoustic-based imaging technology. Lung vibration energy was examined during acute exacerbation and after clinical improvement. METHODS Respiratory sounds throughout the respiratory cycle were captured using an acoustic-based imaging technique. Twenty-three consecutive CHF patients were imaged at the time of presentation to the emergency department and after clinical improvement. Digital images were created (a larger image represents more homogeneously distributed vibration energy of respiratory sound). Geographical area of the images and respiratory sound patterns were quantitatively analyzed. Data from the CHF patients were also compared to healthy volunteers. RESULTS The median (interquartile range) geographical areas of the vibration energy image of acute CHF patients without and with radiographically evident pulmonary edema were 66.9 (9.0) and 64.1(9.0) kilo-pixels, respectively (p < 0.05). After clinical improvement, the geographical area of the vibration energy image of CHF patients without and with radiographically evident pulmonary edema were increased by 18 +/- 15% (p < 0.05) and 25 +/- 16% (p < 0.05), respectively. CONCLUSIONS With clinical improvement of acute CHF exacerbations, there was more homogenous distribution of lung vibration energy, as demonstrated by the increased geographical area of the vibration energy image.
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Affiliation(s)
- Zhen Wang
- Division of Critical Care Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
- Department of Emergency Medicine, Beijing Shi-ji-tan Hospital, 10 Tie Yi Rd., Haidian District Beijing 100038, PR China
| | - Brigitte M Baumann
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Karen Slutsky
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Karen N Gruber
- Department of Emergency Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
| | - Smith Jean
- Division of Critical Care Medicine, Robert Wood Johnson School of Medicine - University of Medicine and Dentistry of New Jersey - Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA
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Genitourinary Injuries in Pelvic Fracture Morbidity and Mortality Using the National Trauma Data Bank. ACTA ACUST UNITED AC 2009; 67:1033-9. [DOI: 10.1097/ta.0b013e3181bb8d6c] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ang DN, Rivara FP, Nathens A, Jurkovich GJ, Maier RV, Wang J, MacKenzie EJ. Complication rates among trauma centers. J Am Coll Surg 2009; 209:595-602. [PMID: 19854399 PMCID: PMC2768077 DOI: 10.1016/j.jamcollsurg.2009.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Revised: 08/04/2009] [Accepted: 08/07/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The goal of this study was to examine the association between patient complications and admission to Level I trauma centers (TC) compared with nontrauma centers (NTC). STUDY DESIGN This was a retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 Level I TCs and 51 NTCs in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified, as was the presence or absence of 13 specific complications. RESULTS Patients treated in TCs were more likely to have any complication compared with patients in NTCs, with an adjusted relative risk (RR) of 1.34 (95% CI, 1.03, 1.74). For individual complications, only the urinary tract infection RR of 1.94 (95% CI, 1.07, 3.17) was significantly higher in TCs. TC patients were more likely to have 3 or more complications (RR, 1.83; 95% CI, 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500 mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TCs. CONCLUSIONS Trauma centers have a slightly higher incidence rate of complications, even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. Pulmonary artery catheter use and intubation had the most influence on overall TC complication rates. Additional study is needed to provide accurate benchmark measures of complication rates and to determine their causes.
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Affiliation(s)
- Darwin N Ang
- Department of Surgery, University of Washington, Seattle, WA
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Zochios V, Gopal S. The Current Role of the Pulmonary Artery Catheter in Critical Care: A Case Report and Review of the Literature. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The clinical use of the pulmonary artery catheter (PAC) has changed the modern practice of intensive care medicine. However, the effect of invasive haemodynamic monitoring on patient outcome remains uncertain. We report an unusual case of malposition of a PAC in the left internal mammary vein and we discuss the role of this monitor in the intensive care setting. Overall, the literature does not suggest a positive effect of PAC use on patient outcome. It has been suggested that PAC insertion may be of little benefit unless linked to specific therapies which may alter outcome. It is essential to understand the capabilities and limitations of the PAC in order to minimise potential complications and maximise benefits.
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Affiliation(s)
- Vasileios Zochios
- Core Trainee in Anaesthetics, (Currently ACCS-Anaesthetic Core Trainee at Northampton General Hospital)
| | - Shameer Gopal
- Consultant in Anaesthesia and Intensive Care Medicine, Critical Care Unit, The Royal Wolverhampton Hospitals NHS Trust
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Abstract
PURPOSE OF REVIEW The pulmonary artery catheter is one of the most scrutinized monitors used in intensive care today. Pulmonary artery catheter use is declining due to limited demonstrated beneficial outcomes and the advancement of less invasive monitoring. This study discusses the current use of the pulmonary artery catheter and problems associated with its use including inaccuracy of measurements and data interpretation, inappropriately applied therapeutic interventions, inappropriate delays in applying interventions, and inappropriate patient selection. RECENT FINDINGS This overview presents current controversies surrounding the pulmonary artery catheter. It also discusses commonly used monitors and their lack of demonstrated benefits. In addition, data show that intensivists do not have sufficient knowledge to effectively use the pulmonary artery catheter. When utilized in a timely appropriate manner, pulmonary artery catheter monitoring may benefit a selected patient population. SUMMARY In summary, the pulmonary artery catheter monitor continues to be used for intensive care patients. To date, no single monitor is associated with an abundance of clear outcome benefits. There are some clinical data showing that the pulmonary artery catheter may still be useful when applied to the right patient population using appropriately timed therapies.
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Stewart RM, Park PK, Hunt JP, McIntyre RC, McCarthy J, Zarzabal LA, Michalek JE. Less Is More: Improved Outcomes in Surgical Patients with Conservative Fluid Administration and Central Venous Catheter Monitoring. J Am Coll Surg 2009; 208:725-35; discussion 735-7. [DOI: 10.1016/j.jamcollsurg.2009.01.026] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 01/16/2009] [Accepted: 01/20/2009] [Indexed: 02/09/2023]
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Abstract
The measurement of cardiac output in critical care appears to be increasingly common. However, both the monitoring technologies and the therapeutic approaches they inform have often proved highly controversial. As the range of alternative technologies available continues to increase, it seems worthwhile to question whether this monitoring modality should be used at all. The aim of this pro-con debate is to review the key evidence and to explain the often quite widely differing interpretations placed upon it. The term cardiac output monitoring refers to technology, whose primary purpose is to monitor global blood flow. The principles of the various technologies have been reviewed elsewhere.1
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Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. ACTA ACUST UNITED AC 2008; 65:509-16. [PMID: 18784562 DOI: 10.1097/ta.0b013e3181825bc5] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Critically ill patients often require invasive monitoring to evaluate and optimize cardiac function and preload. With questionable outcomes associated with pulmonary artery catheters (PACs), some have evaluated the role of less invasive monitors. We hypothesized that the Bedside Echocardiographic Assessment in Trauma (BEAT) examination would generate cardiac index (CI) and central venous pressure (CVP) estimates that correlate with that of a PAC. METHODS BEAT was performed on all SICU patients with a PAC in place. Prospective data included stroke volume and the inferior vena cava (IVC) diameter. The CI was calculated and correlated with that from the PAC. Each CI was then categorized as low, normal, or high. The IVC diameter was used to estimate the CVP. The association between the BEAT and PAC estimates of CI and CVP was evaluated using chi. RESULTS Eighty-five BEAT examinations were performed, 57% on trauma and 37% on general surgery patients. Fifty-nine percent of the CI examinations and 97% of the IVC examinations contained quality images. Of these, the overall correlation coefficient was 0.70 (p < 0.0001). When CI was categorized, there was a significant association between the BEAT and PAC (p = 0.021). There was a significant association between the CVP estimate from the BEAT examination and the PAC (p = 0.031). CONCLUSION Our data show a significant correlation between the CI and CVP estimates obtained from the BEAT examination and that from a PAC. BEAT provides a noninvasive method of evaluating cardiac function and volume status. Bedside echocardiography is teachable and should become a part of future critical care curricula.
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Abstract
In terms of cost and years of potential lives lost, injury arguably remains the most important public health problem facing the United States. Care of traumatically injured patients depends on early surgical intervention and avoiding delays in the diagnosis of injuries that threaten life and limb. In the critical care phase, successful outcomes after injury depend almost solely on diligence, attention to detail, and surveillance for iatrogenic infections and complications.
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Affiliation(s)
- Hugo Bonatti
- University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA 22908, USA
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