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The Association Between Extravascular Lung Water and Critical Care Outcomes Following Bilateral Lung Transplantation. Transplant Direct 2022; 8:e1376. [PMID: 36176725 PMCID: PMC9514832 DOI: 10.1097/txd.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 11/26/2022] Open
Abstract
Primary graft dysfunction (PGD) is a form of acute respiratory failure that complicates 30% of bilateral lung transplants. Higher grades of PGD correlate with higher severity of respiratory failure and unfavorable outcomes. Immediate PGD determination posttransplant‚ however, is not always predictive of PGD over subsequent days or intensive care unit outcomes. We aimed to evaluate whether extravascular lung water index (ELWI) measured immediately post bilateral lung transplant was associated with higher severity of PGD at 72 h and duration of mechanical ventilation.
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Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, Pichamuthu K, Jog SA, Divatia JV, Myatra SN. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022; 26:S66-S76. [PMID: 36896359 PMCID: PMC9989872 DOI: 10.5005/jp-journals-10071-24301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
| | | | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sameer Arvind Jog
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Li X, Tuerxun T, Xie Z, Ma L, Wang Y, Liu B, Yu X. Extravascular Lung Water and Intrathoracic Blood Volume Index Are Associated With Liver Function in Brain Dead Donors for Organ Transplant. EXP CLIN TRANSPLANT 2021; 19:450-456. [PMID: 33736588 DOI: 10.6002/ect.2020.0492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Hemodynamic measurements during organ transplant procedures are essential. MATERIALS AND METHODS In this observational study, we measured clinical and hemodynamic parameters in 11 patients with advanced pulse indicator continuous cardiac output monitoring. Normally distributed clinical data were calculated as means ± standard deviation; hemodynamic, metabolic, and respiratory parameters related to liver and renal function were compared by linear regression analysis using Pearson correlation. RESULTS Compared with the normal range, systemic vascular resistance was high (2278.02 ± 719.6 dyne·s/cm²/m²) and intrathoracic blood volume was low (787.37 ± 224.01 mL/m²) in our patient group. C-reactive protein and interleukin 6 levels were 96.26 ± 68.10 mg/mL and 246.24 ± 355.74 mmol/L, respectively. Liver and renal function parameters were in normal ranges. Extravascular lung water was correlated with total, conjugated, and unconjugated bilirubin and albumin (r = 0.342/P = .005; r = 0.338/ P = .005; r = 0.394/P = .001, and r = 0.358/P = .003) but not with aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine. Intrathoracic blood volume index was correlated with total bilirubin, unconjugated bilirubin, and albumin (r = 0.324/P = .007; r = 0.394/P = .001, and r = 0.296/P = .015) but not with conjugated bilirubin, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and serum creatinine. Lactate was not correlated with total bilirubin, unconjugated bilirubin, albumin, and serum creatinine, but base excess was correlated with total bilirubin, unconjugated bilirubin, alanine aminotransferase, and albumin. PO₂ and Pco₂ were not correlated with liver function, although PO₂ was correlated with albumin. CONCLUSIONS No correlations were shown between intrathoracic blood volume index, extravascular lung water, and liver function, but metabolic parameters, including base excess and lactate, were correlated with liver function. Pulse indicator continuous cardiac output monitoring may be a useful method to assess organ function and tissue perfusion in organ transplant.
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Affiliation(s)
- Xiaopeng Li
- From the Department of Neurointensive Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Beijing
| | - Tuerhong Tuerxun
- From the Department of Neurointensive Care Medicine, The First Affiliated Hospital of Xinjiang Medical University, Beijing
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Wang F, Qiang X, Jiang S, Shao J, Fang B, Zhou L. The fluid management and hemodynamic characteristics of PiCCO employed on young children with severe hand, foot, and mouth disease-a retrospective study. BMC Infect Dis 2021; 21:208. [PMID: 33632141 PMCID: PMC7905911 DOI: 10.1186/s12879-021-05889-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hand, foot, and mouth disease (HFMD) is an acute infectious disease caused by human enterovirus 71 (EV71), coxsackievirus, or echovirus, which is particularly common in preschool children. Severe HFMD is prone to cause pulmonary edema before progressing to respiratory and circulatory failure; thus hemodynamic monitoring and fluid management are important to the treatment process. METHODS We did a review of young patients who had been successfully treated in our department for severe HFMD, which had been caused by EV71. A total of 20 patients met the inclusion criteria. Eight cases were monitored by the pulse indicator continuous cardiac output (PiCCO) technique, and fluid management was administered according to its parameters. With regard to the treatment with PiCCO monitoring, patients were divided into two groups: the PiCCO group (8 patients) and the control group (12 patients). The groups were then compared comprehensively to evaluate whether PiCCO monitoring could improve patients' clinical outcomes. RESULTS After analysis, the findings informed that although PiCCO failed to shorten the length of ICU stay, reduce the days of vasoactive drug usage, or lower the number of cases which required mechanical ventilation, PiCCO did reduce the incidence of fluid overload (p = 0.085) and shorten the days of mechanical ventilation (p = 0.028). After effective treatment, PiCCO monitoring indicated that the cardiac index (CI) increased gradually(p < 0.0001), in contrast to their pulse (P, p < 0.0001), the extra vascular lung water index (EVLWI, p < 0.0001), the global end diastolic volume index (GEDVI, p = 0.0043), and the systemic vascular resistance index (SVRI, p < 0.0001), all of which decreased gradually. CONCLUSION Our study discovered that PiCCO hemodynamic monitoring in young children with severe HFMD has some potential benefits, such as reducing fluid overload and the duration of mechanical ventilation. However, whether it can ameliorate the severity of the disease, reduce mortality, or prevent multiple organ dysfunction remain to be further investigated.
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Affiliation(s)
- Fengyun Wang
- Department of Critical Care Medicine, The First People's Hospital of Foshan, Lingnan Avenue North 81, Shiwan, Chancheng, Foshan, 528000, China
| | - Xinhua Qiang
- Department of Critical Care Medicine, The First People's Hospital of Foshan, Lingnan Avenue North 81, Shiwan, Chancheng, Foshan, 528000, China
| | - Suhua Jiang
- Department of Pediatric Intensive Care Units, The First People's Hospital of Foshan, Foshan, China
| | - Jingsong Shao
- Department of Critical Care Medicine, The First People's Hospital of Foshan, Lingnan Avenue North 81, Shiwan, Chancheng, Foshan, 528000, China
| | - Bin Fang
- Department of Critical Care Medicine, The First People's Hospital of Foshan, Lingnan Avenue North 81, Shiwan, Chancheng, Foshan, 528000, China.
| | - Lixin Zhou
- Department of Critical Care Medicine, The First People's Hospital of Foshan, Lingnan Avenue North 81, Shiwan, Chancheng, Foshan, 528000, China.
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Chang YR, Choi SH, Chang SW. Are management decisions in critical patients changed with use of hemodynamic parameters from transpulmonary thermodilution technique? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:370. [PMID: 31555684 DOI: 10.21037/atm.2019.06.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background The assessment of hemodynamic variables is a mainstay in the management of critically ill patients. Hemodynamic variables may help physicians to choose among use of a vasopressor, an inotropic agent, or discontinuation of drugs. In this study, we aimed to investigate the usefulness of advanced hemodynamic variables in clinical decision-making. Methods Surveys regarding the case were administered to 25 surgeons working in nationally designated trauma centers or on trauma teams, using a voting system at a medical conference. The patient was a 67-year-old male with a crush injury of the left leg after a pedestrian traffic accident, who had aggravated pulmonary edema after leg amputation. Three clinical situations were given and the decision choices were: immediately after amputation, in 8 hours, and on the second day after amputation. Three kinds of variables from hemodynamic monitoring systems were provided for each clinical situation: conventional hemodynamic variables, including central venous pressure; variables from pulse contour analysis (PCA) [cardiac output (CO), stroke volume index, stroke volume variation (SVV), and systemic vascular resistance index); and variables from transpulmonary thermodilution (TPTD) technique (global ejection fraction and extravascular lung water index). The changes in decisions according to each provided hemodynamic variable were investigated and analyzed. Results The advanced hemodynamic parameters were considered to have a decisive effect on choosing vasopressors and inotropic agents. The decision was changed in 88% (22/25) of physicians using variables from the advanced monitoring systems. Among them, 82% (18/22) of physicians chose hemodynamic variables from the TPTD technique as their reason for change regarding management of a patient with severe pulmonary edema. Conclusions Advanced monitoring systems might be helpful in decision-making for critically ill patients. Multiple parameters and trends in change could be more important than a single value. Clinicians should select the system most appropriate according to its advantages and limitations, and interpret the variables obtained correctly.
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Affiliation(s)
- Ye Rim Chang
- Department of Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Seok Ho Choi
- Department of Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
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Michard F. Lung water assessment: from gravimetry to wearables. J Clin Monit Comput 2018; 33:1-4. [PMID: 29752666 DOI: 10.1007/s10877-018-0154-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 05/06/2018] [Indexed: 12/18/2022]
Abstract
Several techniques are now available to detect and quantify pulmonary edema, from the laboratory postmortem method (gravimetry) to non-invasive wearable sensors. In critically ill patients with adult respiratory distress syndrome (ARDS), computed tomography scans are often performed to visualize lung lesions and quantify lung aeration, but their value seems somewhat limited to quantify pulmonary edema on a routine basis and of course to track changes with therapy. In this context, transpulmonary thermodilution is a convenient technique. It is invasive but most patients with ARDS have a central line and an arterial catheter in place. In addition to extravascular lung water measurements, transpulmonary thermodilution enables the measurement of hemodynamic variables that are useful to guide fluid and diuretic therapy. Echo probes are about to replace the stethoscope in our pocket and, if B lines (aka comet tails) do not allow a real quantification of pulmonary edema, they are useful to detect an increase in lung water. Finally, wireless and wearable sensors are now available to monitor patients on hospital wards and beyond (home monitoring). They should enable the detection of pulmonary congestion at a very early stage, and if combined with a proactive therapeutic strategy, have potential to improve outcome.
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Piccioni F, Ragazzi R. Anesthesia and analgesia: how does the role of anesthetists changes in the ERAS program for VATS lobectomy. J Vis Surg 2018; 4:9. [PMID: 29445595 DOI: 10.21037/jovs.2017.12.11] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/07/2017] [Indexed: 12/19/2022]
Abstract
Enhanced recovery after surgery (ERAS) programs are developed to prevent factors that delay postoperative recovery as well as issues that cause complications. The development of video-assist thoracoscopic surgery (VATS) techniques favors the fast recovery after thoracic procedures. ERAS strategies are based on multidisciplinary approach in which the anesthetist plays an important role from the preoperative to the postoperative phase with several goals. After preoperative evaluation and medical optimization, the anesthetist must ensure a tailored anesthetic plan aiming to a fast recovery and adequate pain relief to reduce the response to the surgical stress. The present narrative review presents the major parts of the ERAS anesthetic approach to VATS lobectomy like short-acting drugs, protective one-lung ventilation (OLV), fluid administration and opioid-sparing multimodal analgesia.
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Affiliation(s)
- Federico Piccioni
- Department of Critical Care Medicine and Support Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
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Validation of transpulmonary thermodilution variables in hemodynamically stable patients with heart diseases. Ann Intensive Care 2017; 7:86. [PMID: 28831765 PMCID: PMC5567579 DOI: 10.1186/s13613-017-0307-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 08/06/2017] [Indexed: 12/22/2022] Open
Abstract
Background Transpulmonary thermodilution is recommended in the treatment of critically ill patients presenting with complex shock. However, so far it has not been validated in hemodynamically stable patients with heart disease. Methods We assessed the validity of cardiac output, global end-diastolic volume index (GEDVI), an established marker of preload thought to reflect the volume of all four heart chambers, global ejection fraction (GEF) and cardiac function index (CFI) as variables of cardiac function, and extravascular lung water index (EVLWI) as indicator of pulmonary edema in 29 patients undergoing elective left and right heart catheterization including left ventricular angiography with stable coronary heart disease and normal cardiac function (controls, n = 11), moderate-to-severe aortic valve stenosis (AS, n = 10), or dilated cardiomyopathy (DCM, n = 8). Results Cardiac output was similar in controls, AS, and DCM, with good correlation between transpulmonary thermodilution and pulmonary artery catheter using the Fick method (r = 0.69, p < 0.0001). Left ventricular end-diastolic volume was normal in controls and AS, but significantly higher in DCM (104 ± 37 vs 135 ± 63 vs 234 ± 24 ml, p < 0.01). GEDVI did not differentiate between patients with normal and patients with enlarged left ventricular end-diastolic volume (848 ± 128 vs 882 ± 213 ml m−2, p = 0.60). No difference in GEF and CFI was found between patients with normal and patients with reduced left ventricular ejection fraction. Patients with AS but not DCM had higher EVLWI than controls (9 ± 2 vs 12 ± 4 vs 11 ± 3 ml kg−1, p = 0.04), while there was only a trend in pulmonary artery occlusion pressure (8 ± 3 vs 10 ± 5 vs 14 ± 7 mmHg, p = 0.05). Conclusions Cardiac output measurement by transpulmonary thermodilution is unaffected by differences in ventricular size and outflow obstruction. However, GEDVI did not identify markedly enlarged left ventricular end-diastolic volumes, and neither GEF nor CFI reflected the increased heart chamber volumes and markedly impaired left ventricular function in patients with DCM. In contrast, EVLWI is probably a sensitive marker of subclinical pulmonary edema particularly in patients with elevated left-ventricular-filling pressure irrespective of differences in left ventricular function.
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Assaad S, Shelley B, Perrino A. Transpulmonary Thermodilution: Its Role in Assessment of Lung Water and Pulmonary Edema. J Cardiothorac Vasc Anesth 2017; 31:1471-1480. [DOI: 10.1053/j.jvca.2017.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Indexed: 11/11/2022]
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Chung FT, Lee CS, Lin SM, Kuo CH, Wang TY, Fang YF, Hsieh MH, Chen HC, Lin HC. Alveolar recruitment maneuver attenuates extravascular lung water in acute respiratory distress syndrome. Medicine (Baltimore) 2017; 96:e7627. [PMID: 28746224 PMCID: PMC5627850 DOI: 10.1097/md.0000000000007627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The alveolar recruitment maneuver (RM) has been reported to improve oxygenation in acute respiratory distress syndrome (ARDS) and may be related to reduced extravascular lung water (EVLW) in animals. This study was designed to investigate the effects of RM on EVLW in patients with ARDS. METHODS An open label, prospective, randomized controlled trial including patients with ARDS was conducted in hospitals in North Taiwan between 2010 and 2016. The patients were divided into 2 groups (with and without RM). The primary endpoint was the comparison of the EVLW index between the 2 groups. RESULTS Twenty-four patients with ARDS on mechanical ventilator support were randomized to receive ventilator treatment with RM (RM group, n = 12) or without RM (non-RM group, n = 12). Baseline demographic characteristics were similar between the 2 groups. After recruitment, the day 3 extravascular lung water index (EVLWI) (25.3 ± 9.3 vs 15.5 ± 7.3 mL/kg, P = .008) and the arterial oxygen tension/fractional inspired oxygen ratio (PaO2/FiO2) (132.3 ± 43.5 vs 185.6 ± 38.8 mL/kg, P = .003) both improved over that of day 1. However, both EVLWI and PaO2/FiO2 did not significantly change from day 1 to 3 in the non-RM group. CONCLUSION RM is a feasible method for improving oxygenation and the EVLW index in patients with ARDS, as well as for decreasing ventilator days and intensive care unit stay duration.
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Affiliation(s)
- Fu-Tsai Chung
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Shu-Min Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Chih-Hsi Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Tsai-Yu Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Yueh-Fu Fang
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Meng-Heng Hsieh
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Hao-Cheng Chen
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Horng-Chyuan Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
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Arens C, Koch C, Veit M, Greenberg RS, Lichtenstern C, Weigand MA, Khaleeva A, Schuerg R, Kohl T. Anesthetic Management for Percutaneous Minimally Invasive Fetoscopic Surgery of Spina Bifida Aperta: A Retrospective, Descriptive Report of Clinical Experience. Anesth Analg 2017; 125:219-222. [DOI: 10.1213/ane.0000000000001896] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy. Crit Care Med 2017; 45:e409-e417. [DOI: 10.1097/ccm.0000000000002259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Effects of Early Continuous Venovenous Hemofiltration on E-Selectin, Hemodynamic Stability, and Ventilatory Function in Patients with Septic-Shock-Induced Acute Respiratory Distress Syndrome. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7463130. [PMID: 28044135 PMCID: PMC5156784 DOI: 10.1155/2016/7463130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/12/2016] [Accepted: 09/15/2016] [Indexed: 12/29/2022]
Abstract
Objective. To investigate the effects of 72-hour early-initiated continuous venovenous hemofiltration (ECVVH) treatment in patients with septic-shock-induced acute respiratory distress syndrome (ARDS) (not acute kidney injury, AKI) with regard to serum E-selectin and measurements of lung function and hemodynamic stability. Methods. This prospective nonblinded single institutional randomized study involved 51 patients who were randomly assigned to receive or not receive ECVVH, an ECVVH group (n = 24) and a non-ECVVH group (n = 27). Besides standard therapies, patients in ECVVH group underwent CVVH for 72 h. Results. At 0 and 24 h after initiation of treatment, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, extravascular lung water index (EVLWI), and E-selectin level were not significantly different between groups (all P > 0.05). Compared to non-ECVVH group, PaO2/FiO2 is significantly higher and EVLWI and E-selectin level are significantly lower in ECVVH group (all P < 0.05) at 48 h and 72 h after initiation of treatment. The lengths of mechanical ventilation and stay in intensive care unit (ICU) were shorter in ECVVH group (all P < 0.05), but there was no difference in 28-day mortality between two groups. Conclusions. In patients with septic-shock-induced ARDS (not AKI), treatment with ECVVH in addition to standard therapies improves endothelial function, lung function, and hemodynamic stability and reduces the lengths of mechanical ventilation and stay in ICU.
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Obata Y, Takeda J, Sato Y, Ishikura H, Matsui T, Isotani E. A multicenter prospective cohort study of volume management after subarachnoid hemorrhage: circulatory characteristics of pulmonary edema after subarachnoid hemorrhage. J Neurosurg 2015; 125:254-63. [PMID: 26613172 DOI: 10.3171/2015.6.jns1519] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECT Subarachnoid hemorrhage (SAH) is often accompanied by pulmonary complications, which may lead to poor outcomes and death. This study investigated the incidence and cause of pulmonary edema in patients with SAH by using hemodynamic monitoring with PiCCO-plus pulse contour analysis. METHODS A total of 204 patients with SAH were included in a multicenter prospective cohort study to investigate hemodynamic changes after surgical clipping or coil embolization of ruptured cerebral aneurysms by using a PiCCO-plus device. Changes in various hemodynamic parameters after SAH were analyzed statistically. RESULTS Fifty-two patients (25.5%) developed pulmonary edema. Patients with pulmonary edema (PE group) were significantly older than those without pulmonary edema (non-PE group) (p = 0.017). The mean extravascular lung water index was significantly higher in the PE group than in the non-PE group throughout the study period. The pulmonary vascular permeability index (PVPI) was significantly higher in the PE group than in the non-PE group on Day 6 (p = 0.029) and Day 10 (p = 0.011). The cardiac index of the PE group was significantly decreased biphasically on Days 2 and 10 compared with that of the non-PE group. In the early phase (Days 1-5 after SAH), the daily water balance of the PE group was slightly positive. In the delayed phase (Days 6-14 after SAH), the serum C-reactive protein level and the global end-diastolic volume index were significantly higher in the PE group than in the non-PE group, whereas the PVPI tended to be higher in the PE group. CONCLUSIONS Pulmonary edema that occurs in the early and delayed phases after SAH is caused by cardiac failure and inflammatory (i.e., noncardiogenic) conditions, respectively. Measurement of the extravascular lung water index, cardiac index, and PVPI by PiCCO-plus monitoring is useful for identifying pulmonary edema in patients with SAH.
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Affiliation(s)
- Yoshiki Obata
- Department of Neurosurgery, Tokyo Medical and Dental University;,SAH PiCCO Study Group
| | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University Takii Hospital, Osaka;,SAH PiCCO Study Group
| | - Yohei Sato
- Department of Neurosurgery, Tokyo Medical and Dental University;,SAH PiCCO Study Group
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, Fukuoka;,SAH PiCCO Study Group
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama;,SAH PiCCO Study Group
| | - Eiji Isotani
- Emergency and Critical Care Center, Tokyo Women's Medical University Medical Center East, Japan; and.,SAH PiCCO Study Group
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Vrancken SL, Nusmeier A, Hopman JC, Liem KD, van der Hoeven JG, Lemson J, van Heijst AF, de Boode WP. Estimation of extravascular lung water using the transpulmonary ultrasound dilution (TPUD) method: a validation study in neonatal lambs. J Clin Monit Comput 2015; 30:985-994. [PMID: 26563187 PMCID: PMC5081382 DOI: 10.1007/s10877-015-9803-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/03/2015] [Indexed: 11/25/2022]
Abstract
Increased extravascular lung water (EVLW) may contribute to respiratory failure in neonates. Accurate measurement of EVLW in these patients is limited due to the lack of bedside methods. The aim of this pilot study was to investigate the reliability of the transpulmonary ultrasound dilution (TPUD) technique as a possible method for estimating EVLW in a neonatal animal model. Pulmonary edema was induced in 11 lambs by repeated surfactant lavages. In between the lavages, EVLW indexed by bodyweight was estimated by TPUD (EVLWItpud) and transpulmonary dye dilution (EVLWItpdd) (n = 22). Final EVLWItpud measurements were also compared with EVLWI estimations by gold standard post mortem gravimetry (EVLWIgrav) (n = 6). EVLWI was also measured in two additional lambs without pulmonary edema. Bland–Altman plots showed a mean bias between EVLWItpud and EVLWItpdd of −3.4 mL/kg (LOA ± 25.8 mL/kg) and between EVLWItpud and EVLWIgrav of 1.7 mL/kg (LOA ± 8.3 mL/kg). The percentage errors were 109 and 43 % respectively. The correlation between changes in EVLW measured by TPUD and TPDD was r2 = 0.22. Agreement between EVLWI measurements by TPUD and TPDD was low. Trending ability to detect changes between these two methods in EVLWI was questionable. The accuracy of EVLWItpud was good compared to the gold standard gravimetric method but the TPUD lacked precision in its current prototype. Based on these limited data, we believe that TPUD has potential for future use to estimate EVLW after adaptation of the algorithm. Larger studies are needed to support our findings.
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Affiliation(s)
- S L Vrancken
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - A Nusmeier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J C Hopman
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K D Liem
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A F van Heijst
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - W P de Boode
- Department of Pediatrics - Neonatology, Radboud University Medical Center, Internal Postal Code 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care 2015; 5:38. [PMID: 26546321 PMCID: PMC4636545 DOI: 10.1186/s13613-015-0081-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/27/2015] [Indexed: 12/16/2022] Open
Abstract
Extravascular lung water (EVLW) is the amount of fluid that is accumulated in the interstitial and alveolar spaces. In lung oedema, EVLW increases either because of increased lung permeability or because of increased hydrostatic pressure in the pulmonary capillaries, or both. Increased EVLW is always potentially life-threatening, mainly because it impairs gas exchange and reduces lung compliance. The only technique that provides an easy measurement of EVLW at the bedside is transpulmonary thermodilution. The validation of EVLW measurements by thermodilution was based on studies showing reasonable correlations with gravimetry or thermo-dye dilution in experimental and clinical studies. EVLW should be indexed to predicted body weight. This indexation reduces the proportion of ARDS patients for whom EVLW is in the normal range. Compared to non-indexed EVLW, indexed EVLW (EVLWI) is better correlated with the lung injury score and the oxygenation and it is a better predictor of mortality of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution also provides the pulmonary vascular permeability index (PVPI), which is an indirect reflection of the integrity of the alveolocapillary barrier. As clinical applications, EVLWI and PVPI may be useful to guide fluid management of patients at risk of fluid overload, as during septic shock and ARDS. High EVLWI and PVPI values predict mortality in several categories of critically ill patients, especially during ARDS. Thus, fluid administration should be limited when EVLWI is already high. Whatever the value of EVLWI, PVPI may indicate that fluid administration is particularly at risk of aggravating lung oedema. In the acute phase of haemodynamic resuscitation during septic shock and ARDS, high EVLWI and PVPI values may warn of the risk of fluid overload and prevent excessive volume expansion. At the post-resuscitation phase, they may prompt initiation of fluid removal thereby achieving a negative fluid balance.
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Affiliation(s)
- Mathieu Jozwiak
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Jean-Louis Teboul
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Xavier Monnet
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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Early initiation of continuous renal replacement therapy improves clinical outcomes in patients with acute respiratory distress syndrome. Am J Med Sci 2015; 349:199-205. [PMID: 25494217 DOI: 10.1097/maj.0000000000000379] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) is a common devastating syndrome in intensive care unit in critically ill patients. Continuous renal replacement therapy (CRRT) has been shown beneficial effects on oxygenation and survival in patients with ARDS. However, it is still controversial about the timing of initiation of CRRT. METHODS Fifty-three patients with ARDS admitted to intensive care unit in Zhejiang Provincial People's Hospital, China from 2009 to 2013 were enrolled in the study. The authors compared ventilation parameter, including PaO2/FIO2, A-a gradient, positive end-expiratory pressure, plateau pressure, dynamic compliance and hemodynamic parameters, including central venous pressure, mean arterial pressure, cardiac index, extravascular lung water index, fluid balance between early initiation (within 12 hours after ARDS onset) and late initiation of CRRT (48 hours after ARDS onset) groups. The authors further investigated transforming growth factor (TGF)-β1 level changes in serum and bronchoalveolar lavage fluid (BALF) by enzyme-linked immunosorbent assay during 7 days of follow-up. RESULTS Significant improvement of oxygenation and shorter duration of mechanical ventilation were observed in early CRRT group during 7-day follow-up. In addition, TGF-β1 concentrations in serum and BALF were significantly decreased in patients with early initiation of CRRT compared to those with late initiation of CRRT on day 2 and day 7. Furthermore, patients who died of ARDS had higher levels of TGF-β1 in BALF than survivors. CONCLUSIONS Our findings showed that early initiation of CRRT is associated with favorable clinical outcomes in ARDS patients, which might be due to the reduced serum and BALF TGF-β1 levels through CRRT. However, large multi-center studies are needed to make further recommendations as to the optimal use of CRRT in ARDS patient populations.
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Kobayashi N, Lei J, Utecht L, Garwood M, Ingbar D, Bhargava M. 3D Cine Magnetic Resonance Imaging of Rat Lung ARDS using Gradient-modulated SWIFT with Retrospective Respiratory Gating. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2015; 9417. [PMID: 26380536 DOI: 10.1117/12.2081757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
SWeep Imaging with Fourier Transformation (SWIFT) with gradient modulation and DC navigator retrospective gating is introduced as a 3D cine magnetic resonance imaging (MRI) method for the lung. The quasi-simultaneous excitation and acquisition in SWIFT enabled extremely high sensitivity to the fast-decaying parenchymal signals (TE=~4 μs), which are invisible with conventional MRI techniques. Based on respiratory motion information extracted from DC navigator signals, the SWIFT data were reconstructed to 3D cine images with 16 respiratory phases. To test the capability of the proposed technique, rats exposed to > 95% O2 for 60 hours for induction of acute respiratory distress syndrome (ARDS), were imaged and compared with normal rat lungs (N=7 and 5 for ARDS and normal group, respectively). SWIFT images showed lung tissue density difference along the gravity direction. In the cine SWIFT images, parenchymal signal drop at the inhalation phase was consistently observed for both normal and ARDS rats due to inflation of the lung (i.e. decrease of the proton density), but the drop was less for ARDS rats. Depending on the respiration phase and lung region, the lungs from the ARDS rats showed 1-24% higher parenchymal signal intensities relative to the normal rat lungs, which would be mainly from accumulation of extravascular water (EVLW). Those results demonstrate that SWIFT has high enough sensitivity for detecting the lung proton density changes due to gravity, different respiration phases and accumulation of EVLW in the rat ARDS lungs.
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Affiliation(s)
- Naoharu Kobayashi
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455
| | - Jianxun Lei
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455
| | - Lynn Utecht
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455
| | - Michael Garwood
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455
| | - David Ingbar
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455
| | - Maneesh Bhargava
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455
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Laight NS, Levin AI. Transcardiopulmonary Thermodilution-Calibrated Arterial Waveform Analysis: A Primer for Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2015; 29:1051-64. [PMID: 26279223 DOI: 10.1053/j.jvca.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola S Laight
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew I Levin
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa.
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Successful fluid resuscitation in a patient with high extravascular lung water index by restricted fluid infusion strategy under pulse indicator continuous cardiac output monitoring. Am J Emerg Med 2015; 33:739.e1-4. [PMID: 25737415 DOI: 10.1016/j.ajem.2014.11.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/15/2014] [Indexed: 11/23/2022] Open
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Enghard P, Rademacher S, Nee J, Hasper D, Engert U, Jörres A, Kruse JM. Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:36. [PMID: 25656060 PMCID: PMC4335373 DOI: 10.1186/s13054-015-0756-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/19/2015] [Indexed: 12/04/2022]
Abstract
Introduction Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit. Methods Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale. Results Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement. Conclusion Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.
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Affiliation(s)
- Philipp Enghard
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Sibylle Rademacher
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Jens Nee
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Dietrich Hasper
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Ulrike Engert
- Abteilung für Radiologie, Charité Universitätsmedizin Berlin, Augstenburger Platz 1, 13353, Berlin, Germany.
| | - Achim Jörres
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Jan M Kruse
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivemdizin, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Abstract
OBJECTIVES To define near-normal values of extravascular lung water indexed to body weight in children. DESIGN Prospective multicenter observational study. SETTING Medical/surgical PICUs of 5 multinational hospitals. PATIENTS Fifty-eight children with a median age of 4 years (range 1 month to 17 year) with heterogeneous PICU admission diagnoses were included. Extravascular lung water measurements from these children were collected after resolution of their illness. Obtained values were indexed to actual body weight and height and subsequently related to age. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extravascular lung water indexed to body weight correlated with age (r2 = 0.7) and could be categorized in three-age groups consisting of significantly different median extravascular lung water indexed to body weight values (5th-95th percentile): less than 1 year, 9-29 mL/kg; 1-5 years, 7-25 mL/kg; and 5-17 years, 5-13 mL/kg. Extravascular lung water indexed to height did not correlate to age and resulted in an age-independent near-normal value of less than 315 mL/m. CONCLUSIONS Younger children have higher values of extravascular lung water indexed to actual body weight. Age categorized near-normal values of extravascular lung water indexed to body weight are presented for possible clinical use. Furthermore, we suggest to index extravascular lung water to height, which seems to be age independent.
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Cardiac preload responsiveness in children with cardiovascular dysfunction or dilated cardiomyopathy: a multicenter observational study. Pediatr Crit Care Med 2015; 16:45-53. [PMID: 25360857 DOI: 10.1097/pcc.0000000000000286] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To characterize cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy using global end-diastolic volume index, stroke volume index, cardiac index, and extravascular lung water index. DESIGN Prospective multicenter observational study. SETTING Medical/surgical PICUs of seven Spanish University Medical Centers. PATIENTS Seventy-five pediatric patients (42 male, 33 female), median age 36 months (range, 1-207 mo), were divided into three groups: normal cardiovascular status, cardiovascular dysfunction, and dilated cardiomyopathy. INTERVENTIONS All patients received hemodynamic monitoring with PiCCO2 (Pulsion Medical System SE, Munich, Germany). We evaluated 598 transpulmonary thermodilution sets of measurements. In 40 patients, stroke volume index, cardiac index, and global end-diastolic volume index were measured before and after 66 fluid challenges and loadings to test fluid responsiveness at different preload levels. MEASUREMENTS AND MAIN RESULTS Global end-diastolic volume versus predicted body surface area exhibits a power-law relationship: Global end-diastolic volume = 488.8·predicted body surface area (r = 0.93). Four levels of cardiac preload were established from the resulting "normal" global end-diastolic volume index (= 488.8·predicted body surface area). Stroke volume index and cardiac index versus global end-diastolic volume index/normal global end-diastolic volume index built using a linear mixed model analysis emulated Frank-Starling curves: in cardiovascular dysfunction group, stroke volume index (geometric mean [95% CI]) was 27 mL/m (24-31 mL/m) at "≤ 0.67 times normal global end-diastolic volume index," 37 mL/m (35-40 mL/m) at "> 0.67 ≤ 1.33 times normal global end-diastolic volume index" (Δ stroke volume index = 35%; p < 0.0001; area under the receiver-operating characteristic curve = 75%), 45 mL/ m (41-49 mL/m) at "> 1.33 ≤ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 21%; p < 0.0001; area under the receiver-operating characteristic curve = 73%), and 47 mL/m (43-51 mL/m) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 4%; p = 1; area under the receiver-operating characteristic curve = 54%). In dilated cardiomyopathy group, stroke volume index was 21 mL/m (17-26 mL/m) at "> 0.67 ≤ 1.33 times normal global end-diastolic volume index," 27 mL/m (21-34 mL/ m) at "> 1.33 ≤ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 29%; p = 0.005; area under the receiver-operating characteristic curve = 64%), and 25 mL/m (20-32 mL/m) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = -8%; p = 1; area under the receiver-operating characteristic curve = 54%). CONCLUSIONS This study provides "normal" values for global end-diastolic volume index and limits of cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy: 1.33 times normal global end-diastolic volume index represents the upper limit of patent cardiac preload responsiveness, with the highest expected responsiveness being below 0.67 times normal global end-diastolic volume index. The maximum response of the Frank-Starling relationship and therefore the level of no additional preload reserve is 1.33 to 1.51 times normal global end-diastolic volume index. Above 1.51 times normal global end-diastolic volume index preload responsiveness is unlikely, and the risk of pulmonary edema is maximal.
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Hemodynamic volumetry using transpulmonary ultrasound dilution (TPUD) technology in a neonatal animal model. J Clin Monit Comput 2014; 29:643-52. [PMID: 25500953 DOI: 10.1007/s10877-014-9647-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
To analyze changes in cardiac output and hemodynamic volumes using transpulmonary ultrasound dilution (TPUD) in a neonatal animal model under different hemodynamic conditions. 7 lambs (3.5-8.3 kg) under general anesthesia received arterial and central venous catheters. A Gore-Tex(®) shunt was surgically inserted between the descending aorta and the left pulmonary artery to mimic a patent ductus arteriosus. After shunt opening and closure, induced hemorrhagic hypotension (by repetitive blood withdrawals) and repetitive volume challenges, the following parameters were assessed using TPUD: cardiac output, active circulating volume index (ACVI), central blood volume index (CBVI) and total end-diastolic volume index (TEDVI). 27 measurement sessions were analyzed. After shunt opening, there was a significant increase in TEDVI and a significant decrease in cardiac output with minimal change in CBVI and ACVI. With shunt closure, these results reversed. After progressive hemorrhage, cardiac output and all volumes decreased significantly, except for ACVI. Following repetitive volume resuscitation, cardiac output increased and all hemodynamic volumes increased significantly. Correlations between changes in COufp and changes in hemodynamic volumes (ACVI 0.83; CBVI 0.84 and TEDVI 0.78 respectively) were (slightly) better than between changes in COufp and changes in heart rate (0.44) and central venous pressure (0.7). Changes in hemodynamic volumes using TPUD were as expected under different conditions. Hemodynamic volumetry using TPUD might be a promising technique that has the potential to improve the assessment and interpretation of the hemodynamic status in critically ill newborns and children.
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Ng RRG, Chew STH, Liu W, Ong P, Caleb MG, Ti LK. The inflammatory response between miniaturised and conventional cardiopulmonary bypass after cardiac surgery in an Asian population. Perfusion 2014; 30:487-94. [PMID: 25501623 DOI: 10.1177/0267659114563779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION We compared the systemic inflammatory response of the MCPB system to the CCPB system with cell salvage and phosphorylcholine-coated tubing amongst Asian patients undergoing coronary artery bypass grafting. METHODS Seventy-eight patients were randomly assigned to the MCPB or the CCPB groups equally and followed up in a prospective, single-blinded, randomised, controlled trial. Levels of TNF-α, IL-6, CRP and LDH were measured peri-operatively. RESULTS The systemic inflammatory response was similar in both groups (TNF-α: p=0.222; IL-6: p=0.991; CRP: p=0.258). Only haemolysis was significantly higher in the CCPB group (LDH: p=0.011). The MCPB system was twice more expensive, but had a near 4-fold cost saving in tranfusions. Overall, the MCPB system cost 20% more than the modified CCPB system. CONCLUSION These results corroborate with studies that demonstrated the avoidance of cardiotomy suction rather than the MCPB system, itself, leads to an attenuated inflammatory response. The absence of obvious clinical benefit and the higher costs involved with the MCPB system would preclude its routine use.
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Affiliation(s)
- R R G Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - S T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore Department of Cardiovascular and Metabolic Disorders, Duke-National University of Singapore Graduate Medical School, Singapore
| | - W Liu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - P Ong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - M G Caleb
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - L K Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore Department of Anaesthesia, National University Health System, Singapore
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Ashes C, Slinger P. Volume Management and Resuscitation in Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0081-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Veenstra G, Ince C, Boerma E. Direct markers of organ perfusion to guide fluid therapy: When to start, when to stop. Best Pract Res Clin Anaesthesiol 2014; 28:217-26. [DOI: 10.1016/j.bpa.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 06/19/2014] [Accepted: 06/24/2014] [Indexed: 10/25/2022]
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Abstract
PURPOSE OF REVIEW Advanced hemodynamic monitoring is indispensable for adequate management of patients undergoing major surgery. This article will summarize minimally invasive hemodynamic monitoring technologies and their potential use in thoracic anesthesia. RECENT FINDINGS According to their inherent principle, currently available technologies can be classified into four groups: bioimpedance and bioreactance, applied Fick's principle, pulse wave analysis and Doppler. All devices measure stroke volume and cardiac output. Functional hemodynamic variables and volumetric parameters have been integrated in some devices. Two major indications can be identified: the 'hemodynamically unstable' patient and the patient 'at risk' for hemodynamic instability. Although there is evidence for the first indication, pre-emptive hemodynamic therapy or perioperative hemodynamic optimization for the patient 'at risk' is still an issue of ongoing debate. There is a growing body of evidence that this approach can positively influence patients' outcome with less postoperative complications in selected patient groups. SUMMARY Many different minimally invasive hemodynamic monitoring devices have been developed and clinically introduced in the last years. They offer the advantage of being less invasive and easier to use. However, these techniques have several limitations and data are scarce in patients undergoing thoracic anesthesia, preventing their widespread use so far.
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Jurek SC, Hirano-Kobayashi M, Chiang H, Kohane DS, Matthews BD. Prevention of ventilator-induced lung edema by inhalation of nanoparticles releasing ruthenium red. Am J Respir Cell Mol Biol 2014; 50:1107-17. [PMID: 24405281 DOI: 10.1165/rcmb.2013-0163oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The acute respiratory distress syndrome (ARDS), a devastating lung disease that has no cure, is exacerbated by life-supportive mechanical ventilation that worsens lung edema and inflammation through the syndrome of ventilator-induced lung injury. Recently, the membrane ion channel transient receptor potential vanilloid 4 (TRPV4) on alveolar macrophages was shown to mediate murine lung vascular permeability induced by high-pressure mechanical ventilation. The objective of this study was to determine whether inhalation of nanoparticles (NPs) containing the TRPV4 inhibitor ruthenium red (RR) prevents ventilator-induced lung edema in mice. Poly-lactic-co-glycolic acid NPs containing RR were evaluated in vitro for their ability to block TRPV4-mediated calcium signaling in alveolar macrophages and capillary endothelial cells. Lungs from adult C57BL6 mice treated with nebulized NPs were then used in ex vivo ventilation perfusion experiments to assess the ability of the NPs to prevent high-pressure mechanical ventilation-induced lung edema. Poly-lactic-co-glycolic acid NPs (300 nm) released RR for 150 hours in vitro, and blocked TRPV4-mediated calcium signaling in cells up to 7 days after phagocytosis. Inhaled NPs deposited in alveoli of spontaneously breathing mice were rapidly phagocytosed by alveolar macrophages, and blocked increased vascular permeability from high-pressure mechanical ventilation for 72 hours in ex vivo ventilation perfusion experiments. These data offer proof of principle that inhalation of NPs containing a TRPV4 inhibitor prevents ventilator damage for several days, and imply that this novel drug delivery strategy could be used to target alveolar macrophages in patients at risk of ventilator-induced lung injury before initiating mechanical ventilation.
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Optimal range of global end-diastolic volume for fluid management after aneurysmal subarachnoid hemorrhage: a multicenter prospective cohort study. Crit Care Med 2014; 42:1348-56. [PMID: 24394632 DOI: 10.1097/ccm.0000000000000163] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Limited evidence supports the use of hemodynamic variables that correlate with delayed cerebral ischemia or pulmonary edema after aneurysmal subarachnoid hemorrhage. The aim of this study was to identify those hemodynamic variables that are associated with delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. DESIGN A multicenter prospective cohort study. SETTING Nine university hospitals in Japan. PATIENTS A total of 180 patients with aneurysmal subarachnoid hemorrhage. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were prospectively monitored using a transpulmonary thermodilution system in the 14 days following subarachnoid hemorrhage. Delayed cerebral ischemia was developed in 35 patients (19.4%) and severe pulmonary edema was developed in 47 patients (26.1%). Using the Cox proportional hazards model, the mean global end-diastolic volume index (normal range, 680-800 mL/m) was the independent factor associated with the occurrence of delayed cerebral ischemia (hazard ratio, 0.74; 95% CI, 0.60-0.93; p = 0.008). Significant differences in global end-diastolic volume index were detected between the delayed cerebral ischemia and non-delayed cerebral ischemia groups (783 ± 25 mL/m vs 870 ± 14 mL/m; p = 0.007). The global end-diastolic volume index threshold that best correlated with delayed cerebral ischemia was less than 822 mL/m, as determined by receiver operating characteristic curves. Analysis of the Cox proportional hazards model indicated that the mean global end-diastolic volume index was the independent factor that associated with the occurrence of pulmonary edema (hazard ratio, 1.31; 95% CI, 1.02-1.71; p = 0.03). Furthermore, a significant positive correlation was identified between global end-diastolic volume index and extravascular lung water (r = 0.46; p < 0.001). The global end-diastolic volume index threshold that best correlated with severe pulmonary edema was greater than 921 mL/m. CONCLUSIONS Our findings suggest that global end-diastolic volume index impacts both delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Maintaining global end-diastolic volume index slightly above normal levels has promise as a fluid management goal during the treatment of subarachnoid hemorrhage.
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Theerawit P, Touman N, Sutherasan Y, Kiatboonsri S. Transthoracic ultrasound assessment of B-lines for identifying the increment of extravascular lung water in shock patients requiring fluid resuscitation. Indian J Crit Care Med 2014; 18:195-9. [PMID: 24872647 PMCID: PMC4033851 DOI: 10.4103/0972-5229.130569] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Several studies have shown that the number of B-lines was related to the amount of extravascular lung water (EVLW). In our study, we aimed to demonstrate the magnitude of the incremental B-lines in shock patients with positive net fluid balance and the association with gas exchange impairment. MATERIALS AND METHODS We performed trans-thoracic ultrasound at admission (T0) and at follow-up period (TFL) to demonstrate the change of B lines (ΔB-lines) after fluid therapy. We compared the total B-line score (TBS) at T0 and TFL and calculated the Pearson's correlation coefficient between the ΔB-lines and PaO2/FiO2 ratio. RESULTS A total of 20 patients were analyzed. All patients had septic shock. Net fluid balance was + 2228.05 ± 1982.15 ml. The TBS at T0 and TFL were 36.6 ± 23.73 and 63.80 ± 29.25 (P < 0.01). The ΔB-lines along anterior axillary line (AAL) correlated to the ΔTBS (r = 0.90, P < 0.01). The ΔB-lines along AAL had inverse correlation to PaO2/FiO2 ratio (r = -0.704, P < 0.05). The increase of B-lines ≥ 10 was related to the decrease of PaO2/FiO2 ratio. The inter-observer reliability between two ultrasound readers was high (r = 0.92, P < 0.01). DISCUSSION The number of B-lines increased in shock patients with positive net fluid balance and correlated to impaired oxygenation. These data supported the benefit of ultrasound for assessing the EVLW.
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Affiliation(s)
- Pongdhep Theerawit
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nutchanart Touman
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yuda Sutherasan
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sumalee Kiatboonsri
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Yasuuji M, Kusunoki S, Hamada H, Kawamoto M. Intermittent reinflation is safe to maintain oxygenation without alteration of extravascular lung water during one-lung ventilation. J Clin Anesth 2014; 26:177-83. [PMID: 24793701 DOI: 10.1016/j.jclinane.2013.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 10/09/2013] [Accepted: 10/11/2013] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To investigate whether a maneuver for repeated cycles of collapse and reexpansion of the operative lung, termed "intermittent reinflation" (IR), to counter hypoxemia during one-lung ventilation (OLV), results in a time-dependent alteration of extravascular lung water. DESIGN Prospective, randomized clinical study. SETTING Operating room and postsurgical intensive care unit of a university hospital. PATIENTS 36 ASA physical status 1 and 2 patients undergoing elective, video-assisted thoracic surgery for lung tumors. INTERVENTIONS Patients were randomly assigned to two groups. Group C consisted of 18 patients whose nondependent lung was kept collapsed during OLV, while Group IR included 18 patients with IR that consisted of 4 separate, 10-second manual inflations and 5-second openings within one minute at intervals of 20 minutes during OLV. MEASUREMENTS Perioperative parameters included transcutaneous oxygen saturation (SpO2), hemodynamic data, extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI) as determined by the single-indicator transpulmonary thermodilution technique, and partial pressure of arterial oxygen/inspired oxygen fraction (PaO2/FIO2) ratio. MAIN RESULTS Group IR had significantly higher SpO2 at 20 minutes after commencement of OLV (98.9% vs 96.3%, P = 0.029) and average SpO2 throughout OLV (98.7% vs 97.0%, P = 0.020). Hemodynamic data, EVLWI, PVPI, and PaO2/FIO2 ratio did not differ between the groups, and there were no differences between groups in postoperative morbidity or hospital stay. CONCLUSIONS Intermittent reinflation had a beneficial effect on oxygenation during OLV, without any significant effects on EVLW or postoperative outcomes.
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Affiliation(s)
- Masakazu Yasuuji
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima 734-8551, Japan.
| | - Shinji Kusunoki
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Hiroshi Hamada
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Masashi Kawamoto
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
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Haemodynamic monitoring in the intensive care unit: results from a web-based Swiss survey. BIOMED RESEARCH INTERNATIONAL 2014; 2014:129593. [PMID: 24860809 PMCID: PMC4016935 DOI: 10.1155/2014/129593] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/25/2014] [Indexed: 01/20/2023]
Abstract
Background. The aim of this survey was to describe, in a situation of growing availability of monitoring devices and parameters, the practices in haemodynamic monitoring at the bedside. Methods. We conducted a Web-based survey in Swiss adult ICUs (2009-2010). The questionnaire explored the kind of monitoring used and how the fluid management was addressed. Results. Our survey included 71% of Swiss ICUs. Echocardiography (95%), pulmonary artery catheter (PAC: 85%), and transpulmonary thermodilution (TPTD) (82%) were the most commonly used. TPTD and PAC were frequently both available, although TPTD was the preferred technique. Echocardiography was widely available (95%) but seems to be rarely performed by intensivists themselves. Guidelines for the management of fluid infusion were available in 45% of ICUs. For the prediction of fluid responsiveness, intensivists rely preferentially on dynamic indices or echocardiographic parameters, but static parameters, such as central venous pressure or pulmonary artery occlusion pressure, were still used. Conclusions. In most Swiss ICUs, multiple haemodynamic monitoring devices are available, although TPTD is most commonly used. Despite the usefulness of echocardiography and its large availability, it is not widely performed by Swiss intensivists themselves. Regarding fluid management, several parameters are used without a clear consensus for the optimal method.
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Abstract
OBJECTIVE Hypoxemia is a feared complication of acute liver failure, and high oxygen requirements will frequently lead to removal of patients from the transplant list. As data regarding the prevalence and outcome of acute respiratory distress syndrome in acute liver failure are scant and hypoxemia being a commonly encountered systemic complication, we analyzed radiological, gas exchange, and ventilator data in consecutive patients admitted with acute liver failure. PATIENTS Acute liver failure patients receiving mechanical ventilation admitted between January 2007 and February 2011 were included. INTERVENTIONS Patients were categorized according to the Berlin definition as: no acute respiratory distress syndrome, acute respiratory distress syndrome (PaO2/FIO2 < 300 mm Hg), and subdivisions of mild, moderate, and severe acute respiratory distress syndrome (200-300 mm Hg, 100-200 mm Hg, and < 100 mm Hg, respectively). Chest radiographs were independently assessed by two observers for the presence or absence of acute respiratory distress syndrome. Absence of left atrial pressure elevation was based on combined hemodynamic and echocardiographic assessment. MEASUREMENTS AND MAIN RESULTS Two hundred acute liver failure patients were admitted during the study period of whom 148, median age 39 years (16-74 yr), were included. Thirty-one (21%) had acute respiratory distress syndrome (17 mild acute respiratory distress syndrome [12%], 9 moderate acute respiratory distress syndrome [12%], and 5 severe acute respiratory distress syndrome) within the first 72 hours following admission. Acute respiratory distress syndrome patients required higher positive end-expiratory pressure (7 vs 6 vs 10 vs 15 cm H2O for no, mild, moderate, or severe acute respiratory distress syndrome, p = 0.014), had reduced respiratory system compliance (34 vs 29 vs 30 vs 23 L/cm H2O, p = 0.028), and an increased number of ventilator days (no acute respiratory distress syndrome, 10 d; mild acute respiratory distress syndrome acute lung injury, 12 d; moderate acute respiratory distress syndrome, 23 d; severe acute respiratory distress syndrome, 22 d; p = 0.097). Duration of liver intensive therapy unit stay (p = 0.175), survival (p = 0.877), inotrope requirements (p = 0.495), need for extracorporeal renal support (p = 0.565), and severity of organ failure scores were not affected. Extravascular lung water index had a moderate sensitivity of 65% and specificity of 77% for the prediction of acute respiratory distress syndrome. CONCLUSION The prevalence of lung injury is relatively low in acute liver failure, where 21% fulfilled acute respiratory distress syndrome criteria. Overall presence of acute respiratory distress syndrome appeared to have a limited impact on outcome.
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Vrettou CS, Zakynthinos SG, Malachias S, Mentzelopoulos SD. The effect of high-frequency oscillatory ventilation combined with tracheal gas insufflation on extravascular lung water in patients with acute respiratory distress syndrome: a randomized, crossover, physiologic study. J Crit Care 2014; 29:568-73. [PMID: 24814973 DOI: 10.1016/j.jcrc.2014.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/31/2014] [Accepted: 03/25/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE High-frequency oscillation combined with tracheal gas insufflation (HFO-TGI) improves oxygenation in patients with acute respiratory distress syndrome (ARDS). There are limited physiologic data regarding the effects of HFO-TGI on hemodynamics and pulmonary edema during ARDS. The aim of this study was to investigate the effect of HFO-TGI on extravascular lung water (EVLW). MATERIALS AND METHODS We conducted a prospective, randomized, crossover study. Consecutive eligible patients with ARDS received sessions of conventional mechanical ventilation with recruitment maneuvers (RMs), followed by HFO-TGI with RMs, or vice versa. Each ventilatory technique was administered for 8 hours. The order of administration was randomly assigned. Arterial/central venous blood gas analysis and measurement of hemodynamic parameters and EVLW were performed at baseline and after each 8-hour period using the single-indicator thermodilution technique. RESULTS Twelve patients received 32 sessions. Pao2/fraction of inspired oxygen and respiratory system compliance were higher (P<.001 for both), whereas extravascular lung water index to predicted body weight and oxygenation index were lower (P=.021 and .029, respectively) in HFO-TGI compared with conventional mechanical ventilation. There was a significant correlation between Pao2/fraction of inspired oxygen improvement and extravascular lung water index drop during HFO-TGI (Rs=-0.452, P=.009). CONCLUSIONS High-frequency oscillation combined with tracheal gas insufflation improves gas exchange and lung mechanics in ARDS and potentially attenuates EVLW accumulation.
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Affiliation(s)
- Charikleia S Vrettou
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece.
| | - Spyros G Zakynthinos
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Sotirios Malachias
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Critical Care Medicine and Pulmonary Services, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
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Chung FT, Lin SM, Lin HC, Yu CT, Hsieh MH, Fang YF, Liu CY, Kuo CH, Wang TY. Predictive value of extravascular lung water indexed to predicted body weight. World J Anesthesiol 2014; 3:124-128. [DOI: 10.5313/wja.v3.i1.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/04/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate extravascular lung water indexed to predicted body weight (EVLWIp) and actual body weight (EVLWIa) on outcome of patients with severe sepsis.
METHODS: Transpulmonary thermodilution was prospectively used to measure cardiovascular hemodynamics, EVLWIp and EVLWIa via an arterial catheter placed in each patient within 48 h of meeting the criteria for severe sepsis from a medical intensive care unit (ICU) at a university affiliated hospital. Survival was the single dependent variable. In order to examine and compare the predictive power of EVLWIp, EVLWIa and other clinically significant factors in predicting the in-hospital survival status of severe sepsis patients in the medical ICU, a receiver operating characteristic (ROC) curve method to analyze the significant variables and the area under the ROC curve (AUC) of the variables, P value and 95%CI were calculated.
RESULTS: In total, 33 patients were studied. In the ROC curve method analyses, EVLWIp (the AUC: 0.849; P = 0.001, 95%CI: 0.72-0.98) was as predictive for in-hospital survival rate as variables with EVLWIa (AUC, 0.829; P = 0.001, 95%CI: 0.68-0.98). The proportion of patients surviving with a low EVLW (EVLWI < 10 mL/kg) was better than that of patients with a higher EVLW, whether indexed by actual (HR = 0.2; P = 0.0002, 95%CI: 0.06-0.42) or predicted body weight (HR = 0.13; P < 0.0001, 95%CI: 0.05-0.35) during their hospital stay with the Kaplan-Meier method (76% vs 12.5%, respectively).
CONCLUSION: This investigation proposed that EVLWIp is as good a predictor as EVLWIa to predict in-hospital survival rate among severe sepsis patients in the medical ICU.
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Difference in pulmonary permeability between indirect and direct acute respiratory distress syndrome assessed by the transpulmonary thermodilution technique: a prospective, observational, multi-institutional study. J Intensive Care 2014; 2:24. [PMID: 25520836 PMCID: PMC4267584 DOI: 10.1186/2052-0492-2-24] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 03/06/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is characterized by the increased pulmonary permeability secondary to diffuse alveolar inflammation and injuries of several origins. Especially, the distinction between a direct (pulmonary injury) and an indirect (extrapulmonary injury) lung injury etiology is gaining more attention as a means of better comprehending the pathophysiology of ARDS. However, there are few reports regarding the quantitative methods distinguishing the degree of pulmonary permeability between ARDS patients due to pulmonary injury and extrapulmonary injury. METHODS A prospective, observational, multi-institutional study was performed in 23 intensive care units of academic tertiary referral hospitals throughout Japan. During a 2-year period, all consecutive ARDS-diagnosed adult patients requiring mechanical ventilation were collected in which three experts retrospectively determined the pathophysiological mechanisms leading to ARDS. Patients were classified into two groups: patients with ARDS triggered by extrapulmonary injury (ARDSexp) and those caused by pulmonary injury (ARDSp). The degree of pulmonary permeability using the transpulmonary thermodilution technique was obtained during the first three intensive care unit (ICU) days. RESULTS In total, 173 patients were assessed including 56 ARDSexp patients and 117 ARDSp patients. Although the Sequential Organ Failure Assessment (SOFA) score was significantly higher in the ARDSexp group than in the ARDSp group, measurements of the pulmonary vascular permeability index (PVPI) were significantly elevated in the ARDSp group on all days: at day 0 (2.9 ± 1.3 of ARDSexp vs. 3.3 ± 1.3 of ARDSp, p = .008), at day 1 (2.8 ± 1.5 of ARDSexp vs. 3.2 ± 1.2 of ARDSp, p = .01), at day 2 (2.4 ± 1.0 of ARDSexp vs. 2.9 ± 1.3 of ARDSp, p = .01). There were no significant differences in mortality at 28 days, mechanical ventilation days, and hospital length of stay between the two groups. CONCLUSIONS The results of this study suggest the existence of several differences in the increased degree of pulmonary permeability between patients with ARDSexp and ARDSp. TRIAL REGISTRATION This report is a sub-group analysis of the study registered with UMIN-CTR (IDUMIN000003627).
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Zhang F, Li C, Zhang JN, Guo HP, Wu DW. Comparison of quantitative computed tomography analysis and single-indicator thermodilution to measure pulmonary edema in patients with acute respiratory distress syndrome. Biomed Eng Online 2014; 13:30. [PMID: 24625023 PMCID: PMC4001110 DOI: 10.1186/1475-925x-13-30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 03/04/2014] [Indexed: 01/31/2023] Open
Abstract
Objective To compare quantitative computed tomography (CT) analysis and single-indicator thermodilution to measure pulmonary edema in patients with acute respiratory distress syndrome (ARDS). Method Ten patients with ARDS were included. All underwent spiral CT of the thorax for estimating gas content of lung (GVCT), tissue volume of lung (TVCT), tissue volume index (TVI), mean radiographic attenuation (CTmean) for the whole lung and gas-to-tissue ratio (g/t). Pulmonary thermal volume (PTV) and extravascular lung water index (ELWI) were determined by the PiCCO plus system. CT or single-indicator thermodilution variables were correlated with respiratory system compliance (Crs), PaO2/FiO2, and Acute Physiology And Chronic Health EvaluationII (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores. Results 1) TVCT and PTV were positively correlated (r =0.8878; P = 0.0006; equation of regression line: PTV = 1.0793 × TVCT + 179.8) as were TVI and ELWI (r =0.9459; P < 0.0001; equation of regression line: ELWI = 1.4506 × TVI-8.7792). The bias between TVCT and PTV as well as TVI and ELWI was -277 ± 217 and 0.62 ± 4.56, respectively. 2) ELWI and CT distribution of lung-tissue compartments were not correlated. 3) CT or single-indicator thermodilution variables were not correlated with Crs, PaO2/FiO2 or APACHE II or SOFA score. Conclusion Quantitative CT analysis and single-indicator thermodilution showed good agreement in measuring pulmonary edema.
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Affiliation(s)
| | | | | | | | - Da-wei Wu
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China.
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Parker JC. Acute lung injury and pulmonary vascular permeability: use of transgenic models. Compr Physiol 2013; 1:835-82. [PMID: 23737205 DOI: 10.1002/cphy.c100013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute lung injury is a general term that describes injurious conditions that can range from mild interstitial edema to massive inflammatory tissue destruction. This review will cover theoretical considerations and quantitative and semi-quantitative methods for assessing edema formation and increased vascular permeability during lung injury. Pulmonary edema can be quantitated directly using gravimetric methods, or indirectly by descriptive microscopy, quantitative morphometric microscopy, altered lung mechanics, high-resolution computed tomography, magnetic resonance imaging, positron emission tomography, or x-ray films. Lung vascular permeability to fluid can be evaluated by measuring the filtration coefficient (Kf) and permeability to solutes evaluated from their blood to lung clearances. Albumin clearances can then be used to calculate specific permeability-surface area products (PS) and reflection coefficients (σ). These methods as applied to a wide variety of transgenic mice subjected to acute lung injury by hyperoxic exposure, sepsis, ischemia-reperfusion, acid aspiration, oleic acid infusion, repeated lung lavage, and bleomycin are reviewed. These commonly used animal models simulate features of the acute respiratory distress syndrome, and the preparation of genetically modified mice and their use for defining specific pathways in these disease models are outlined. Although the initiating events differ widely, many of the subsequent inflammatory processes causing lung injury and increased vascular permeability are surprisingly similar for many etiologies.
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Affiliation(s)
- James C Parker
- Department of Physiology, University of South Alabama, Mobile, Alabama, USA.
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Abstract
OBJECTIVES Acute respiratory distress syndrome is characterized by diffuse alveolar damage and increased extravascular lung water levels. However, there is no threshold extravascular lung water level that can indicate diffuse alveolar damage in lungs. We aimed to determine the threshold extravascular lung water level that discriminates between normal lungs and lungs affected with diffuse alveolar damage. DESIGN A retrospective analysis of normal lungs and lungs affected with diffuse alveolar damage was performed. SETTING Normal lung cases were taken from published data. Lung cases with diffuse alveolar damage were taken from a nationwide autopsy database. All cases of autopsy followed hospital deaths in Japan from more than 800 hospitals between 2004 and 2009; complete autopsies with histopathologic examinations were performed by board-certified pathologists authorized by the Japanese Society of Pathology. PATIENTS Normal lungs: 534; lungs with diffuse alveolar damage: 1,688. INTERVENTIONS We compared the postmortem weights of both lungs between the two groups. These lung weights were converted to extravascular lung water values using a validated equation. Finally, the extravascular lung water value that indicated diffuse alveolar damage was estimated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS The extravascular lung water values of the lungs showing diffuse alveolar damage were approximately two-fold higher than those of normal lungs (normal group, 7.3±2.8 mL/kg vs diffuse alveolar damage group 13.7±4.5 mL/kg; p<0.001). An extravascular lung water level of 9.8 mL/kg allowed the diagnosis of diffuse alveolar damage to be established with a sensitivity of 81.3% and a specificity of 81.2% (area under the curve, 0.90; 95% CI, 0.88-0.91). An extravascular lung water level of 14.6 mL/kg represented a 99% positive predictive value. CONCLUSIONS This study may provide the first validated quantitative bedside diagnostic tool for diffuse alveolar damage. Extravascular lung water may allow the detection of diffuse alveolar damage and may support the clinical diagnosis of acute respiratory distress syndrome. The best extravascular lung water cut-off value to discriminate between normal lungs and lungs with diffuse alveolar damage is around 10 mL/kg.
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Abstract
PURPOSE OF REVIEW Fluid management is one of the most important measures shown to impact acute respiratory distress syndrome (ARDS) outcomes. This review summarizes the current strategies aimed at evaluating and modulating lung fluid balance. RECENT FINDINGS Multiple recent studies have shown that a conservative fluid management in ARDS patients had beneficial effects on morbidity and mortality. These findings were replicated also in different patient populations assumed to have potential deleterious effects from this approach. So far, only one retrospective study raised the possibility of impaired cognitive function in ARDS patients managed with a conservative fluid strategy. Thermodilution methods and serum biomarkers can be used to monitor lung fluid balance and guide therapy. Recent evidence has indicated significant detrimental effects associated with beta-2 agonists use in ARDS, despite a putative beneficial role in the resolution of alveolar edema seen in preliminary studies. SUMMARY Dynamic monitoring of lung fluid balance needs to be implemented to guide fluid therapy in ARDS patients. A conservative fluid strategy seems safe and yields overall good clinical outcomes, but its impact on cognitive function needs to be evaluated in further studies. The role of colloids and other pharmacological agents deserves further investigation.
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Kushimoto S, Endo T, Yamanouchi S, Sakamoto T, Ishikura H, Kitazawa Y, Taira Y, Okuchi K, Tagami T, Watanabe A, Yamaguchi J, Yoshikawa K, Sugita M, Kase Y, Kanemura T, Takahashi H, Kuroki Y, Izumino H, Rinka H, Seo R, Takatori M, Kaneko T, Nakamura T, Irahara T, Saito N. Relationship between extravascular lung water and severity categories of acute respiratory distress syndrome by the Berlin definition. Crit Care 2013; 17:R132. [PMID: 23844662 PMCID: PMC4056600 DOI: 10.1186/cc12811] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/06/2013] [Accepted: 06/20/2013] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The Berlin definition divides acute respiratory distress syndrome (ARDS) into three severity categories. The relationship between these categories and pulmonary microvascular permeability as well as extravascular lung water content, which is the hallmark of lung pathophysiology, remains to be elucidated. The aim of this study was to evaluate the relationship between extravascular lung water, pulmonary vascular permeability, and the severity categories as defined by the Berlin definition, and to confirm the associated predictive validity for severity. METHODS The extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) were measured using a transpulmonary thermodilution method for three consecutive days in 195 patients with an EVLWi of ≥10 mL/kg and who fulfilled the Berlin definition of ARDS. Collectively, these patients were seen at 23 ICUs. Using the Berlin definition, patients were classified into three categories: mild, moderate, and severe. RESULTS Compared to patients with mild ARDS, patients with moderate and severe ARDS had higher acute physiology and chronic health evaluation II and sequential organ failure assessment scores on the day of enrollment. Patients with severe ARDS had higher EVLWi (mild, 16.1; moderate, 17.2; severe, 19.1; P <0.05) and PVPI (2.7; 3.0; 3.2; P <0.05). When categories were defined by the minimum PaO2/FIO2 ratio observed during the study period, the 28-day mortality rate increased with severity categories: moderate, odds ratio: 3.125 relative to mild; and severe, odds ratio: 4.167 relative to mild. On independent evaluation of 495 measurements from 195 patients over three days, negative and moderate correlations were observed between EVLWi and the PaO2/FIO2 ratio (r = -0.355, P<0.001) as well as between PVPI and the PaO2/FIO2 ratio (r = -0.345, P <0.001). ARDS severity was associated with an increase in EVLWi with the categories (mild, 14.7; moderate, 16.2; severe, 20.0; P <0.001) in all data sets. The value of PVPI followed the same pattern (2.6; 2.7; 3.5; P <0.001). CONCLUSIONS Severity categories of ARDS described by the Berlin definition have good predictive validity and may be associated with increased extravascular lung water and pulmonary vascular permeability. TRIAL REGISTRATION UMIN-CTR ID UMIN000003627.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Tomoyuki Endo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Satoshi Yamanouchi
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Teruo Sakamoto
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka 830-0011, Japan
| | - Hiroyasu Ishikura
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, 8-19-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Yasuhide Kitazawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, 10-15 Fumizonocho, Moriguchi, Osaka 573-1191, Japan
| | - Yasuhiko Taira
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa 216-8511, Japan
| | - Kazuo Okuchi
- Department of Emergency and Critical Care Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8521, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Akihiro Watanabe
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Junko Yamaguchi
- Department of Emergency and Critical Care Medicine, Nihon University School of Medicine Itabashi Hospital, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazuhide Yoshikawa
- Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku Tokyo 177-8521, Japan
| | - Yoichi Kase
- Critical Care Medicine, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tochigi 105 8461, Japan
| | - Takashi Kanemura
- Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, 2-5-1, Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan
| | - Hiroyuki Takahashi
- Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa 230-8765, Japan
| | - Yuuichi Kuroki
- Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, 1-1-10. Sanjyo, Minami-ku, Nagoya, Aichi 457-8510, Japan
| | - Hiroo Izumino
- Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, 10-15, Fumizono-cho, Moriguchi, Osaka 570-8507, Japan
| | - Hiroshi Rinka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, 1-5-7 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ryutarou Seo
- Intensive Care Unit, Kobe City Medical Center General Hospital, 4-6, Minatojimanakamachi, Chuo-ku, Kobe, Hyogo 650-0046, Japan
| | - Makoto Takatori
- Department of Anesthesia and Intensive Care, Hiroshima City Hospital, 7-33 Motomachi Naka-ku, Hiroshima-shi, Hiroshima 730-8518, Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, 1-1-1, Minamikogushi, Ube-ku, Yamaguchi 755-8505, Japan
| | - Toshiaki Nakamura
- Intensive Care Unit, Nagasaki University Hospital, 1-14 Bunkyo-machi, Nagasaki-ku Nagasaki 852-8521, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Nobuyuki Saito
- Department of Emergency and Critical Care Medicine, Nippon Medical School Chiba Hokusou Hospital, 1715 Kamagari, Inzai-shi, Chiba 270-1694, Japan
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Abstract
BACKGROUND Extravascular lung water is a quantitative marker of the amount of fluid in the thoracic cavity besides the vasculature. Indexing to both predicted and actual body weight have been proposed to compare different individuals and provide a uniform range of normal. OBJECTIVE We explored extravascular lung water measured by single-indicator transpulmonary thermodilution in a large cohort of patients without cardiopulmonary instability, in order to evaluate current and alternative indexing methods. DESIGN Prospective, observational. SETTING Neurosurgical ICU in a tertiary referral academic teaching hospital. PATIENTS One hundred and one consecutive patients requiring elective brain tumor surgery and postoperative ICU surveillance. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Indexed to predicted body weight, females had a mean extravascular lung water of 9.1 (SD=3.1, range: 5-23) mL/kg and males of 8.0 (SD=2.0, range: 4-19) mL/kg (p<0.001). Values indexed to predicted body weight were inversely correlated with the patient's height (p<0.001). Indexed to the traditionally used actual body weight, data showed a significant relationship to weight (p<0.001) and gender (p<0.05). In contrast, indexing to body height presented a method without dependencies on height, weight, or gender, yielding a uniform 95% confidence interval of 218-430 mL/m. Extravascular lung water increased with positive perioperative fluid balance (p=0.04). CONCLUSIONS Using either predicted or actual body weight for indexing extravascular lung water does not lead to independence of height, weight, and gender of the patient. Specifying a fixed range of normal or a uniform upper threshold for all patients is misleading for either method, despite widespread use. Our data suggest that indexing extravascular lung water to height is superior to weight-based methods. As we are not aware of any abnormal hemodynamic profile for brain tumor patients, we propose our findings to be a close approximation to normal values.
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Chau EHL, Slinger P. Perioperative fluid management for pulmonary resection surgery and esophagectomy. Semin Cardiothorac Vasc Anesth 2013; 18:36-44. [PMID: 23719773 DOI: 10.1177/1089253213491014] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Perioperative fluid management is of significant importance during pulmonary resection surgery and esophagectomy. Excessive fluid administration has been consistently shown as a risk factor for lung injury after thoracic procedures. Probable causes of this serious complication include fluid overload, lung lymphatics and pulmonary endothelial damage. Along with new insights regarding the Starling equation and the absence of a third space, current evidence supports a restrictive fluid regimen for patients undergoing pulmonary resection surgery and esophagectomy. Multiple minimally invasive hemodyamic monitoring devices, including pulse pressure/stroke volume variation, esophageal Doppler, and extravascular lung water measurement, were evaluated for optimizing perioperative fluid therapy. Further research regarding the prevention, diagnosis, and treatment of acute lung injury after pulmonary resection and esophagectomy is required.
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Haas SA, Trepte CJC, Nitzschke R, Jürgens TP, Goepfert MS, Goetz AE, Reuter DA. An assessment of global end-diastolic volume and extravascular lung water index during one-lung ventilation: is transpulmonary thermodilution usable? Anesth Analg 2013; 117:83-90. [PMID: 23592603 DOI: 10.1213/ane.0b013e31828f2c39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The thermodilution curve assessed by transpulmonary thermodilution is the basis for calculation of global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI). Until now, it was unclear whether the method is affected by 1-lung ventilation. Therefore, aim of our study was to evaluate the impact of 1-lung ventilation on the thermodilution curve and assessment of GEDI and EVLWI. METHODS In 23 pigs, mean transit time, down slope time, and difference in blood temperature (ΔTb) were assessed by transpulmonary thermodilution. "Gold standard" cardiac output was measured by pulmonary artery flowprobe (PAFP) and used for GEDIPAFP and EVLWIPAFP calculations. Measurements were performed during normovolemia during double-lung ventilation (M1), 15 minutes after 1-lung ventilation (M2) and during hypovolemia (blood withdrawal 20 mL/kg) during double-lung ventilation (M3) and again 15 minutes after 1-lung ventilation (M4). RESULTS Configuration of the thermodilution curve was significantly affected by 1-lung ventilation demonstrated by an increase in ΔTb and a decrease in mean transit time and down slope time (all P < 0.04) during normovolemia and hypovolemia. GEDIPAFP was lower after 1-lung ventilation during normovolemia (M1: 459.9 ± 67.5 mL/m(2); M2: 397.0 ± 54.8 mL/m(2); P = 0.001) and hypovolemia (M3: 300.6 ± 40.9 mL/m(2); M4: 275.2 ± 37.6 mL/m(2); P = 0.03). EVLWIPAFP also decreased after 1-lung ventilation in normovolemia (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) and hypovolemia (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4]) mL/kg; P = 0.0009). CONCLUSION Configuration of the thermodilution curve and therefore assessment of GEDI and EVLWI are significantly affected by 1-lung ventilation.
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Affiliation(s)
- Sebastian A Haas
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
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Saugel B, Phillip V, Ernesti C, Messer M, Meidert AS, Schmid RM, Huber W. Impact of large-volume thoracentesis on transpulmonary thermodilution–derived extravascular lung water in medical intensive care unit patients. J Crit Care 2013; 28:196-201. [DOI: 10.1016/j.jcrc.2012.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 04/18/2012] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
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Extravascular lung water and the pulmonary vascular permeability index may improve the definition of ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:108. [PMID: 23347799 PMCID: PMC4057435 DOI: 10.1186/cc11918] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The recent Berlin definition has made some improvements in the older definition of acute respiratory distress syndrome (ARDS), although the concepts and components of the definition remained largely unchanged. In an effort to improve both predictive and face validity, the Berlin panel has examined a number of additional measures that may reflect increased pulmonary vascular permeability, including extravascular lung water. The panel concluded that although extravascular lung water has improved face validity and higher values are associated with mortality, it is infeasible to mandate on the basis of availability and the fact that it does not distinguish between hydrostatic and inflammatory pulmonary edema. However, the results of a multi-institutional study that appeared in the previous issue of Critical Care show that this latter reservation may not necessarily be true. By using extravascular lung water and the pulmonary vascular permeability index, both of which are derived from transpulmonary thermodilution, the authors could successfully differentiate between patients with ARDS and other patients in respiratory failure due to either cardiogenic edema or pleural effusion with atelectasis. This commentary discusses the merits and limitations of this study in view of the potential improvement that transpulmonary thermodilution may bring to the definition of ARDS.
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