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Chudow MB, Condeni MS, Dhar S, Heavner MS, Nei AM, Bissell BD. Current Practice Review in the Management of Acute Respiratory Distress Syndrome. J Pharm Pract 2023; 36:1454-1471. [PMID: 35728076 DOI: 10.1177/08971900221108713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) presents as an acute inflammatory lung injury characterized by refractory hypoxemia and non-cardiac pulmonary edema. An estimated 10% of patients in the intensive care unit and 25% of those who are mechanically ventilated are diagnosed with ARDS. Increased awareness is warranted as mortality rates remain high and delays in diagnosing ARDS are common. The COVID-19 pandemic highlights the importance of understanding ARDS management. Treatment of ARDS can be challenging due to the complexity of the disease state and conflicting existing evidence. Therefore, it is imperative that pharmacists understand both pharmacologic and non-pharmacologic treatment strategies to optimize patient care. This narrative review provides a critical evaluation of current literature describing management practices for ARDS. A review of treatment modalities and supportive care strategies will be presented.
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Affiliation(s)
- Melissa B Chudow
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Melanie S Condeni
- MUSC College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Sanjay Dhar
- Pulmonary Critical Care Ultrasound and Research, Pulmonary and Critical Care Fellowship Program, Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, Lexington, KY, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Andrea M Nei
- Mayo Clinic College of Medicine & Science, Critical Care Pharmacist, Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I. Intensive Care Med 2019; 45:190-200. [PMID: 30706120 DOI: 10.1007/s00134-019-05527-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/09/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE Clinical examination is often the first step to diagnose shock and estimate cardiac index. In the Simple Intensive Care Studies-I, we assessed the association and diagnostic performance of clinical signs for estimation of cardiac index in critically ill patients. METHODS In this prospective, single-centre cohort study, we included all acutely ill patients admitted to the ICU and expected to stay > 24 h. We conducted a protocolised clinical examination of 19 clinical signs followed by critical care ultrasonography for cardiac index measurement. Clinical signs were associated with cardiac index and a low cardiac index (< 2.2 L min-1 m2) in multivariable analyses. Diagnostic test accuracies were also assessed. RESULTS We included 1075 patients, of whom 783 (73%) had a validated cardiac index measurement. In multivariable regression, respiratory rate, heart rate and rhythm, systolic and diastolic blood pressure, central-to-peripheral temperature difference, and capillary refill time were statistically independently associated with cardiac index, with an overall R2 of 0.30 (98.5% CI 0.25-0.35). A low cardiac index was observed in 280 (36%) patients. Sensitivities and positive and negative predictive values were below 90% for all signs. Specificities above 90% were observed only for 110/280 patients, who had atrial fibrillation, systolic blood pressures < 90 mmHg, altered consciousness, capillary refill times > 4.5 s, or skin mottling over the knee. CONCLUSIONS Seven out of 19 clinical examination findings were independently associated with cardiac index. For estimation of cardiac index, clinical examination was found to be insufficient in multivariable analyses and in diagnostic accuracy tests. Additional measurements such as critical care ultrasonography remain necessary.
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Early Liberal Fluid Therapy for Sepsis Patients Is Not Harmful: Hydrophobia Is Unwarranted but Drink Responsibly. Crit Care Med 2018; 44:2263-2269. [PMID: 27749314 PMCID: PMC5113226 DOI: 10.1097/ccm.0000000000002145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
PURPOSE OF REVIEW In the acute setting of circulatory shock, physicians largely depend on clinical examination and basic laboratory values. The daily use of clinical examination for diagnostic purposes contrasts sharp with the limited number of studies. We aim to provide an overview of the diagnostic accuracy of clinical examination in estimating circulatory shock reflected by an inadequate cardiac output (CO). RECENT FINDINGS Recent studies showed poor correlations between CO and mottling, capillary refill time or central-to-peripheral temperature gradients in univariable analyses. The accuracy of physicians to perform an educated guess of CO based on clinical examination lies around 50% and the accuracy for recognizing a low CO is similar. Studies that used predefined clinical profiles composed of several clinical examination signs show more reliable estimations of CO with accuracies ranging from 81 up to 100%. SUMMARY Single variables obtained by clinical examination should not be used when estimating CO. Physician's educated guesses of CO based on unstructured clinical examination are like the 'flip of a coin'. Structured clinical examination based on combined clinical signs shows the best accuracy. Future studies should focus on using a combination of signs in an unselected population, eventually to educate physicians in estimating CO by using predefined clinical profiles.
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Abstract
PURPOSE OF REVIEW The purpose of the review is to identify the recently validated minimally invasive or noninvasive monitoring devices used to both monitor and guide resuscitation in the critically ill patients. RECENT FINDINGS Recent advances in noninvasive measures of blood pressure, blood flow, and vascular tone have been validated and complement existing minimally invasive and invasive monitoring techniques. These monitoring approaches should be used within the context of a focused physical examination and static vital sign analysis. When available, measurement of urinary output is often included. All studies show that minimally invasive and noninvasive measure of arterial pressure and cardiac output are possible and often remain as accurate as invasive measures. The noninvasive techniques degrade in severe circulatory failure and the use of vasopressor therapy. Importantly, these output parameters form the treatment goals for many goal-directed therapies protocols. SUMMARY When coupled with a focused physical examination and functional hemodynamic monitoring analyses, these measures become even more specific at defining volume responsiveness and vasomotor tone and can be used to drive resuscitation strategies.
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Monnet X, Teboul JL. Cardiac output monitoring: throw it out… or keep it? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:35. [PMID: 29422074 PMCID: PMC5806252 DOI: 10.1186/s13054-018-1957-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/16/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, EA4533, Le Kremlin-Bicêtre, F-94270, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, EA4533, Le Kremlin-Bicêtre, F-94270, France
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Abstract
PURPOSE OF REVIEW Rapid restoration of tissue perfusion and oxygenation are the main goals in the resuscitation of a patient with circulatory collapse. This review will focus on providing an evidence based framework of the technological and conceptual advances in the evaluation and management of the patient with cardiovascular collapse. RECENT FINDINGS The initial approach to the patient in cardiovascular collapse continues to be based on the Ventilate-Infuse-Pump rule. Point of care ultrasound is the preferred modality for the initial evaluation of undifferentiated shock, providing information to narrow the differential diagnosis, to assess fluid responsiveness and to evaluate the response to therapy. After the initial phase of resuscitative fluid administration, which focuses on re-establishing a mean arterial pressure to 65 mmHg, the use of dynamic parameters to assess preload responsiveness such as the passive leg raise test, stroke volume variation, pulse pressure variation and collapsibility of the inferior vena cava in mechanically ventilated patients is recommended. SUMMARY The crashing patient remains a clinical challenge. Using an integrated approach with bedside ultrasound, dynamic parameters for the evaluation of fluid responsiveness and surrogates of evaluation of tissue perfusion have made the assessment of the patient in shock faster, safer and more physiologic.
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Affiliation(s)
- Hitesh Gidwani
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hernando Gómez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Oxygen extraction and perfusion markers in severe sepsis and septic shock: diagnostic, therapeutic and outcome implications. Curr Opin Crit Care 2016; 21:381-7. [PMID: 26348417 DOI: 10.1097/mcc.0000000000000241] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this study is to review the recent literature examining the clinical utility of markers of systemic oxygen extraction and perfusion in the diagnosis, treatment and prognosis of severe sepsis and septic shock. RECENT FINDINGS When sepsis is accompanied by conditions in which systemic oxygen delivery does not meet tissue oxygen demands, tissue hypoperfusion begins. Tissue hypoperfusion leads to oxygen debt, cellular injury, organ dysfunction and death. Tissue hypoperfusion can be characterized using markers of tissue perfusion (central venous oxygen saturation and lactate), which reflect the interaction between systemic oxygen delivery and demands. For the last two decades, studies and quality initiatives incorporating the early detection and interruption of tissue hypoperfusion have been shown to improve mortality and altered sepsis care. Three recent trials, while confirming an all-time improvement in sepsis mortality, challenged the concept that rapid normalization of markers of perfusion confers outcome benefit. By defining and comparing haemodynamic phenotypes using markers of tissue perfusion, we may better understand which patients are more likely to benefit from early goal-directed haemodynamic optimization. SUMMARY The phenotypic haemodynamic characterization of patients using perfusion markers has diagnostic, therapeutic and outcome implications in severe sepsis and septic shock. However, irrespective of haemodynamic phenotype, the outcome reflects the quality of care provided at the point of presentation. Utilizing these principles may allow more objective interpretation of resuscitation trials and translate these findings into current practice.
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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Goyal N, Taylor AR, Rivers EP. Relationship between Central and Peripheral Venous Oxygen Saturation and Lactate Levels: A Prospective Study. J Emerg Med 2016; 50:809-17. [DOI: 10.1016/j.jemermed.2016.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 01/09/2016] [Accepted: 03/26/2016] [Indexed: 11/28/2022]
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Brissaud O, Botte A, Cambonie G, Dauger S, de Saint Blanquat L, Durand P, Gournay V, Guillet E, Laux D, Leclerc F, Mauriat P, Boulain T, Kuteifan K. Experts' recommendations for the management of cardiogenic shock in children. Ann Intensive Care 2016; 6:14. [PMID: 26879087 PMCID: PMC4754230 DOI: 10.1186/s13613-016-0111-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/26/2016] [Indexed: 12/13/2022] Open
Abstract
Cardiogenic shock which corresponds to an acute state of circulatory failure due to impairment of myocardial contractility is a very rare disease in children, even more than in adults. To date, no international recommendations regarding its management in critically ill children are available. An experts’ recommendations in adult population have recently been made (Levy et al. Ann Intensive Care 5(1):52, 2015; Levy et al. Ann Intensive Care 5(1):26, 2015). We present herein recommendations for the management of cardiogenic shock in children, developed with the grading of recommendations’ assessment, development, and evaluation system by an expert group of the Groupe Francophone de Réanimation et Urgences Pédiatriques (French Group for Pediatric Intensive Care and Emergencies). The recommendations cover four major fields of application such as: recognition of early signs of shock and the patient pathway, management principles and therapeutic goals, monitoring hemodynamic and biological variables, and circulatory support (indications, techniques, organization, and transfer criteria). Major principle care for children with cardiogenic shock is primarily based on clinical and echocardiographic assessment. There are few drugs reported as effective in childhood in the medical literature. The use of circulatory support should be facilitated in terms of organization and reflected in the centers that support these children. Children with cardiogenic shock are vulnerable and should be followed regularly by intensivist cardiologists and pediatricians. The experts emphasize the multidisciplinary nature of management of children with cardiogenic shock and the importance of effective communication between emergency medical assistance teams (SAMU), mobile pediatric emergency units (SMUR), pediatric emergency departments, pediatric cardiology and cardiac surgery departments, and pediatric intensive care units.
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Affiliation(s)
- Olivier Brissaud
- Unité de Réanimation Pédiatrique et Néonatale, Hôpital des Enfants, CHU Pellegrin Enfants, Place Amélie Raba Léon, 33000, Bordeaux, France.
| | - Astrid Botte
- Unité de Réanimation Pédiatrique, Faculté de Médecine, Université de Lille Nord de France, Hôpital Jeanne de Flandre CHU de Lille, 54, Avenue Eugène Avinée, 59037, Lille Cedex, France
| | - Gilles Cambonie
- Département de Pédiatrie Néonatale et Réanimations, Pôle Hospitalo-Universitaire Femme-Mère-Enfant, Hôpital Arnaud-de-Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, 371, Avenue du Doyen-Gaston-Giraud, 34295, Montpellier Cedex 5, France
| | - Stéphane Dauger
- Réanimation et Surveillance Continue Pédiatriques, Pôle de Pédiatrie Médicale, Hôpital Robert-Debré, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot-Paris 7, Sorbonne Paris Cité, 48, Boulevard Sérurier, 75019, Paris, France
| | - Laure de Saint Blanquat
- Service de Réanimation, CHU Necker-Enfants-Malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France
| | - Philippe Durand
- Réanimation Pédiatrique, AP-HP, CHU Kremlin Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Véronique Gournay
- Service de Cardiologie Pédiatrique, CHU de Nantes, 44093, Nantes Cedex, France
| | - Elodie Guillet
- Unité de Réanimation Pédiatrique et Néonatale, Hôpital des Enfants, CHU Pellegrin Enfants, Place Amélie Raba Léon, 33000, Bordeaux, France
| | - Daniela Laux
- Pôle des Cardiopathies Congénitales, Centre Chirurgical Marie Lannelongue, 133, Avenue de la Résistance, 92350, Le Plessis-Robinson, France
| | - Francis Leclerc
- Unité de Réanimation Pédiatrique, Faculté de Médecine, Université de Lille Nord de France, Hôpital Jeanne de Flandre CHU de Lille, 54, Avenue Eugène Avinée, 59037, Lille Cedex, France
| | - Philippe Mauriat
- Service de Cardiologie Pédiatrique et Congénitale, Hôpital Haut-Lévèque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac Cedex, France
| | - Thierry Boulain
- Service de Réanimation Polyvalente, Hôpital de La Source, Centre Hospitalier Régional Orléans, 45067, Orléans, France
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, Hôpital Émile-Muller, 68070, Mulhouse, France
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Campos I, Chan L, Zhang H, Deziel S, Vaughn C, Meyring-Wösten A, Kotanko P. Intradialytic Hypoxemia in Chronic Hemodialysis Patients. Blood Purif 2016; 41:177-87. [PMID: 26765143 DOI: 10.1159/000441271] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
When kidney failure occurs, patients are at risk for fluid overload states, which can cause pulmonary edema, pleural effusions, and upper airway obstruction. Kidney disease is also associated with impaired respiratory function, as in central sleep apnea or chronic obstructive pulmonary disease. Hence, respiratory and renal diseases are frequently coexisting. Hypoxemia is the terminal pathway of a multitude of respiratory pathologies. The measurement of oxygen saturation (SO2) is a basic and commonly used tool in clinical practice. Both arterial oxygen saturation (SaO2) and central venous oxygen saturation (ScvO2) can be easily obtained in hemodialysis (HD) patients, SaO2 from an arteriovenous access and ScvO2 from a central catheter. Here, we give a brief overview of the anatomy and physiology of the respiratory system, and the different technologies that are currently available to measure oxygen status in dialysis patients. We then focus on literature regarding intradialytic SaO2 and ScvO2. Lastly, we present clinical vignettes of intradialytic drops in SaO2 and ScvO2 in association with different symptoms and clinical scenarios with an emphasis on the pathophysiology of these cases. Given the fact that in the general population hypoxemia is associated with adverse outcomes, including increased mortality, cardiac arrhythmias and cardiovascular events, we posit that intradialytic SO2 may serve as a potential marker to identify HD patients at increased risk for morbidity and mortality.
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Kutter APN, Bettschart-Wolfensberger R, Romagnoli N, Bektas RN. Evaluation of agreement and trending ability between transpulmonary thermodilution and calibrated pulse contour and pulse power cardiac output monitoring methods against pulmonary artery thermodilution in anesthetized dogs. J Vet Emerg Crit Care (San Antonio) 2016; 26:531-40. [PMID: 26754858 DOI: 10.1111/vec.12439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 12/21/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess agreement and trending ability of transpulmonary thermodilution (TPTD), calibrated pulse contour (PiCCO), and pulse power (PulseCO) methods compared to pulmonary artery thermodilution (PATD) for determination of cardiac output (CO) in anesthetized dogs. DESIGN Experimental, prospective study. SETTING University teaching hospital. ANIMALS Six adult Beagle dogs. INTERVENTIONS Dogs were anesthetized with sevoflurane and instrumented with pulmonary and femoral artery thermodilution catheters. CO was measured at baseline and at 5, 15, 30, 45, 60, 120, 180, and 240 minutes after IV administration of ketamine or s-ketamine. Baseline PATD and TPTD calibrated PulseCO and PiCCO, respectively. Agreement and trending ability was analyzed with Bland-Altman, concordance, and polar plot methodology. MEASUREMENTS AND MAIN RESULTS Median (range) CO values of 2.27 (0.98-3.4) L/min were measured with PATD, and 2.8 (1.9-4.04) L/min with TPTD, which resulted in a mean bias (± standard deviation) of -0.66 (± 0.36) L/min. Concordance rate was 91% and radial limits of agreement (RLOA) were ±35°. PATD against PiCCO resulted in a mean bias of -0.71 (± 0.62) L/min and PATD against PulseCO in a mean bias of 0.13 (± 0.46) L/min. The continuous techniques resulted in concordance rates of 77% for PATD-PiCCO and 74% for PATD-PulseCO and RLOA of ±57° and ±60°, respectively. CONCLUSIONS Intermittent TPTD showed marginal trending ability, while continuous pulse contour and pulse power methods showed poor trending ability over a 4-hour period. The poor performance and possible side effects of the methods tested in this study suggest that they should not be recommended for use in critical patients.
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Affiliation(s)
- Annette P N Kutter
- Section of Anesthesiology, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Noemi Romagnoli
- Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Rima N Bektas
- Section of Anesthesiology, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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Perel A, Saugel B, Teboul JL, Malbrain MLNG, Belda FJ, Fernández-Mondéjar E, Kirov M, Wendon J, Lussmann R, Maggiorini M. The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study. J Clin Monit Comput 2015; 30:511-8. [DOI: 10.1007/s10877-015-9811-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/26/2015] [Indexed: 11/28/2022]
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Grissom CK, Hirshberg EL, Dickerson JB, Brown SM, Lanspa MJ, Liu KD, Schoenfeld D, Tidswell M, Hite RD, Rock P, Miller RR, Morris AH. Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*. Crit Care Med 2015; 43:288-95. [PMID: 25599463 PMCID: PMC4675623 DOI: 10.1097/ccm.0000000000000715] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols. DESIGN Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock. SETTING ICUs of Acute Respiratory Distress Syndrome Network participating hospitals. PATIENTS Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite. INTERVENTIONS Fluid management by protocol. MEASUREMENTS AND MAIN RESULTS Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite). CONCLUSIONS FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.
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Affiliation(s)
- Colin K Grissom
- 1Division of Critical Care Medicine, Intermountain Medical Center, Murray, UT. 2Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT. 3Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT. 4College of Pharmacy, University of Utah, Salt Lake City, UT. 5Division of Nephrology, University of California San Francisco, San Francisco, CA. 6Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA. 7Biostatistics Center, Massachusetts General Hospital, Boston, MA. 8Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA. 9Respiratory Institute, Cleveland Clinic, Cleveland, OH. 10Department of Anesthesiology, University of Maryland, Baltimore, MD
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Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients. Intensive Care Med 2014; 41:452-9. [PMID: 25516087 DOI: 10.1007/s00134-014-3600-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Skin mottling is frequent and can be associated with an increased mortality rate in ICU patients with septic shock. Its overall incidence in ICU and its impact on outcome is unknown. We aimed to assess the incidence of skin mottling over the knee among all critically ill patients admitted in ICU and its role on their outcome. METHODS An observational study over a 1-year period in a 15-bed medical ICU of a teaching hospital. Skin mottling over the knee was prospectively and qualitatively assessed by trained nurses. RESULTS Incidence of skin mottling was 29% (230 of 791 patients) in overall, and 49% (32 of 65 patients) in the subset of patients admitted for septic shock. Skin mottling was present on the day on admission in 65% of patients and persisted more than 6 h in 59% of cases. In-ICU mortality was 8% in patients without mottling, 30% in patients with short skin mottling and 40% in patients with persistent skin mottling (p < 0.01 between all groups). In the overall population, skin mottling over the knee was associated with in-ICU mortality independently from SAPS II (aOR 3.29 [95% CI, 2.08-5.19], p < 0.0001). Among patients with skin mottling over the knee, persistence of skin mottling remained associated with increased in-ICU mortality independently of organ dysfunctions at the mottling onset (OR 2.77 [95% CI, 1.34-5.72], p = 0.004). CONCLUSIONS Skin mottling is frequent in the general population of patients admitted in ICU. Occurrence and persistence of skin mottling are independently associated with in-ICU mortality.
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19
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Hartog C, Bloos F. Venous oxygen saturation. Best Pract Res Clin Anaesthesiol 2014; 28:419-28. [DOI: 10.1016/j.bpa.2014.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/12/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023]
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Abstract
OBJECTIVE Portable ultrasound is now used routinely in many ICUs for various clinical applications. Echocardiography performed by noncardiologists, both transesophageal and transthoracic, has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on focused critical care echocardiography for the management of critically ill patients. METHOD Source data were obtained from a PubMed search of the medical literature, including the PubMed "related articles" search methodology. SUMMARY AND CONCLUSIONS Although studies demonstrating improved clinical outcomes for critically ill patients managed by focused critical care echocardiography are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, noncardiologists can learn focused critical care echocardiography and adequately interpret the information obtained. Noncardiologists can also successfully incorporate focused critical care echocardiography into advanced cardiopulmonary life support. Formal training and proctoring are important for safe application of focused critical care echocardiography in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of focused critical care echocardiography.
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Fares WH, Carson SS. The relationship between positive end-expiratory pressure and cardiac index in patients with acute respiratory distress syndrome. J Crit Care 2013; 28:992-7. [PMID: 23993772 DOI: 10.1016/j.jcrc.2013.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/20/2013] [Accepted: 06/25/2013] [Indexed: 01/21/2023]
Abstract
PURPOSE The purpose of the study is to evaluate the association between positive end-expiratory pressure (PEEP) and cardiac index in patients with acute respiratory distress syndrome (ARDS). METHODS This is a secondary cross-sectional analysis of the multicenter randomized controlled Fluid and Catheter Treatment Trial enrolling adult patients within 48 hours of ARDS onset. Patients randomized to the pulmonary artery catheter arm, who had PEEP and cardiac index measurements performed within a short period of each other during the first 3 days of the FACTT study enrollment, were included in this study. Because FACTT had a 2 × 2 factorial design, half of the patients were in a "liberal fluids" study arm, and the other half were in a "conservative fluids" study arm. RESULTS The final study population (833 measurements or observations, in 367 patients) was comparable with the original overall FACTT study population. The mean PEEP level used was 8.2 ± 3.4 cm H2O, and the mean cardiac index was 4.2 ± 1.2 L/min per square meter. There was no association between PEEP and cardiac index in patients with ARDS, even when adjusted for Acute Physiology and Chronic Health Evaluation score, age, fluid study arm in FACTT, and sepsis. CONCLUSION In patients with ARDS who are managed with liberal or conservative fluid management protocols, PEEP is not associated with lower cardiac index.
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Affiliation(s)
- Wassim H Fares
- Yale University, School of Medicine, Department of Internal Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, New Haven, CT 06510.
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Lactate and venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio, but not central venous oxygen saturation, predict increase in oxygen consumption in fluid responders. Crit Care Med 2013; 41:1412-20. [PMID: 23442986 DOI: 10.1097/ccm.0b013e318275cece] [Citation(s) in RCA: 172] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES During circulatory failure, the ultimate goal of treatments that increase cardiac output is to reduce tissue hypoxia. This can only occur if oxygen consumption depends on oxygen delivery. We compared the ability of central venous oxygen saturation and markers of anaerobic metabolism to predict whether a fluid-induced increase in oxygen delivery results in an increase in oxygen consumption. DESIGN Prospective study. SETTING ICU. PATIENTS Fifty-one patients with an acute circulatory failure (78% of septic origin). MEASUREMENTS Before and after a volume expansion (500 mL of saline), we measured cardiac index, o2- and Co2-derived variables and lactate. MAIN RESULTS Volume expansion increased cardiac index ≥ 15% in 49% of patients ("volume-responders"). Oxygen delivery significantly increased in these 25 patients (+32% ± 16%, p < 0.0001). An increase in oxygen consumption ≥ 15% concomitantly occurred in 56% of these 25 volume-responders (+38% ± 28%). Compared with the volume-responders in whom oxygen consumption did not increase, the volume-responders in whom oxygen consumption increased ≥ 15% were characterized by a higher lactate (2.3 ± 1.1 mmol/L vs. 5.5 ± 4.0 mmol/L, respectively) and a higher ratio of the veno-arterial carbon dioxide tension difference (P(v - a)Co2) over the arteriovenous oxygen content difference (C(a - v)o2). A fluid-induced increase in oxygen consumption greater than or equal to 15% was not predicted by baseline central venous oxygen saturation but by high baseline lactate and (P(v - a)Co2/C(a - v)o2 ratio (areas under the receiving operating characteristics curves: 0.68 ± 0.11, 0.94 ± 0.05, and 0.91 ± 0.06). In volume-nonresponders, volume expansion did not significantly change cardiac index, but the oxygen delivery decreased due to a hemodilution-induced decrease in hematocrit. CONCLUSIONS In volume-responders, unlike markers of anaerobic metabolism, central venous oxygen saturation did not allow the prediction of whether a fluid-induced increase in oxygen delivery would result in an increase in oxygen consumption. This suggests that along with indicators of volume-responsiveness, the indicators of anaerobic metabolism should be considered instead of central venous oxygen saturation for starting hemodynamic resuscitation.
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Gil Cano A, Monge García M, Baigorri González F. Evidencia de la utilidad de la monitorización hemodinámica en el paciente crítico. Med Intensiva 2012; 36:650-5. [DOI: 10.1016/j.medin.2012.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 06/23/2012] [Indexed: 12/11/2022]
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Abstract
The use of pulmonary artery catheters has diminished, so that other technologies are emerging. Central venous oxygen saturation measurement (ScvO₂) as a surrogate for mixed venous oxygen saturation measurement (SvO₂) is simple and clinically accessible. To maximize the clinical utility of ScvO₂ (or SvO₂) measurement, it is useful to review what the measurement means in a physiologic context,how the measurement is made, important limitations, and how this measurement may be helpful in common clinical scenarios. Compared with cardiac output measurement, SvO₂ is more directly related to tissue oxygenation. Furthermore,when tissue oxygenation is a clinical concern, SvO₂ is less prone to error compared with cardiac output, where small measurement errors may lead to larger errors in interpreting adequacy of oxygen delivery. ScvO₂ should be measured from the tip of a central venous catheter placed close to, or within, the right atrium to reduce measurement error. Correct clinical interpretation of SvO₂, or its properly measured ScvO₂ surrogate, can be used to (1) estimate cardiac output using the Fick equation, (2) better understand whether a patient's oxygen delivery is adequate to meet their oxygen demands, (3) help guide clinical practice, particularly when resuscitating patients using validated early goal directed therapy treatment protocols, (4) understand and treat arterial hypoxemia, and (5) rapidly estimate shunt fraction (venous admixture).
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Affiliation(s)
- Keith R Walley
- Critical Care Research Laboratories, Heart and Lung Institute at St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
BACKGROUND After its introduction in 1970, the use of the pulmonary artery catheter became a central part of the management of critically ill patients in adult and pediatric intensive care units. However, because it was introduced as a class II device, efficacy for its safety and clinical benefit did not exist during the early years of use. This review describes the pulmonary artery catheter and reviews the literature supporting its use. METHODOLOGY A search of MEDLINE, PubMed, and the Cochrane Database was made to find literature about pulmonary artery catheter use. Literature for both adult and pediatric patients was reviewed. Guidelines published by the Society for Critical Care Medicine and the American Heart Association were reviewed, including further review of references cited. RESULTS AND CONCLUSIONS The evidence supporting the use of the pulmonary artery catheter is mostly limited to level IV (nonrandomized, historical controls, and expert opinion) and level V (case series, uncontrolled studies, and expert opinion). A higher level of evidence supports the use of the pulmonary artery catheter in selected pediatric patients, especially those with pulmonary arterial hypertension and shock refractory to standard fluid resuscitation and vasoactive agents. There are no data to suggest that use of the pulmonary artery catheter increases mortality in children.
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Matthay MA, Idell S. Update on acute lung injury and critical care medicine 2009. Am J Respir Crit Care Med 2010; 181:1027-32. [PMID: 20460547 PMCID: PMC3269230 DOI: 10.1164/rccm.201001-0074up] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 02/12/2010] [Indexed: 01/23/2023] Open
Affiliation(s)
- Michael A Matthay
- Department of Medicine, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0624, USA.
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Pulmonary artery catheter redux: physical findings in acute respiratory distress syndrome/acute lung injury. Crit Care Med 2009; 37:2846-8. [PMID: 19865011 DOI: 10.1097/ccm.0b013e3181b3a06a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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