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Hon S, Martin-Flores M, Koehler P, Gleed R, Campoy L. Evaluation of transpulmonary ultrasound dilution cardiac output in piglets: accuracy, precision and trending ability with room temperature injectate. Vet Anaesth Analg 2023; 50:163-169. [PMID: 36641330 DOI: 10.1016/j.vaa.2022.11.008] [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: 01/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Transpulmonary ultrasound dilution (TPUD) is a minimally invasive technique to measure cardiac output (CO) using a 1 mL kg-1 isotonic 37 °C saline injectate indicator. The objective was to evaluate the performance of TPUD using a room temperature saline injectate. STUDY DESIGN Prospective experimental trial. ANIMALS A total of seven anesthetized male Yorkshire piglets. METHODS Piglets aged 1 month and weighing 7.7-9.0 kg were anesthetized with detomidine-ketamine-hydromorphone-isoflurane and a pulmonary artery flow probe (PAFP) placed via a median sternotomy. The thoracic cavity remained open during measurement of CO by PAFP and TPUD. The TPUD indicators of 1 mL kg-1 0.9% saline at 37 °C and 20 °C were compared during infusions of phenylephrine and dobutamine, blood withdrawal and replacement. Bias, limits of agreement (LoAs) and percentage error (PE) between each iteration of PAFP and TPUD were measured with Bland-Altman plots. Trending ability via concordance, angular bias and radial LoA were compared. RESULTS Bland-Altman plots showed negligible bias with varying LoAs. PEs of 22% and 38% were found for 37 °C and 20 °C saline injectates, respectively. In the four-quadrant plots, the concordance rate was 94% and 100% for measurements obtained with 37 °C and 20 °C saline injectates, respectively. Angular bias for both were < ±5 °, with radial LoA < ±7 °. CONCLUSIONS TPUD was accurate when using 1 mL kg-1 of isotonic saline at 37 °C in a range of CO within 0.2-0.8 L minute-1, and it reliably tracked positive and negative changes in CO. Room temperature (20 °C) indicator was less accurate but equally able to track direction of changes in CO. CLINICAL RELEVANCE The use of room temperature injectates allows an easy, readily available clinical application of TPUD CO monitoring while preserving the trending ability of the monitor.
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Affiliation(s)
- Stephanie Hon
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Perry Koehler
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Robin Gleed
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Sigurdsson TS, Lindberg L. Indexing haemodynamic variables in young children. Acta Anaesthesiol Scand 2021; 65:195-202. [PMID: 33015826 PMCID: PMC7820964 DOI: 10.1111/aas.13720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/13/2020] [Accepted: 09/26/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Haemodynamic studies in children are rare and most studies have included few subjects in the youngest age group. Haemodynamic variables need to be indexed to establish a reference of normality that is valid in all populations. The traditional way to index haemodynamic variables with body surface area (BSA) is complicated in young children due to its non-linear relationship with body weight (BW). We examined several haemodynamic variables in children by indexing them with BSA and BW. METHODS A single-centre, observational cohort study comparing non-indexed and indexed haemodynamic variables in children undergoing heart surgery (divided into three weight groups: 1-5 kg, >5-10 kg and >10-15 kg). RESULTS A total of 68 children were included in this study, mean age 11.1 months ± 11.1 month (range 0 to 43 months). All haemodynamic variables, cardiac output (CO), stroke volume (SV), total end-diastolic volume (TEDV), central blood volume (CBV) and active circulation volume (ACV), increased with weight without indexing (P < .05). Indexing variables with BW produced a more linear relationship for all haemodynamic variables between weight groups than BSA. The mean BSA-indexed haemodynamic values were CIBSA 3.5 ± 1.1 L/min/m2 and SVIBSA 27.3 ± 8.9 ml/min/m2 . The mean BW-indexed haemodynamic values were CIBW 180 ± 50 ml/min/kg and SVIBW 1.34 ± 0.38 ml/kg. Blood volume variables indexed with BW were TEDVBW 12.0 ± 2.8 ml/kg, CBVBW 21.3 ± 6.6 ml/kg and ACVBW 70.3 ± 15.2 ml/kg. CONCLUSIONS Indexing haemodynamic variables with BW produces a more appropriate body size-independent scale in young children than BSA. SUMMARY STATEMENT In this study, we studied indexing of haemodynamic variables and estimation of blood volumes in young children undergoing corrective heart surgery using an indicator dilution technology.
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Affiliation(s)
- Theodor S. Sigurdsson
- Department of Paediatric Anaesthesiology and Intensive Care MedicineLund Children´s HospitalSkåne University HospitalLundSweden
- Department of Anaesthesiology and Intensive Care MedicineLandspitalinn University HospitalReykjavikIceland
| | - Lars Lindberg
- Department of Paediatric Anaesthesiology and Intensive Care MedicineLund Children´s HospitalSkåne University HospitalLundSweden
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Fries RC, Clark-Price SC, Kadotani S, Stack JP, Schaeffer DJ, Lascola KM. Quantitative assessment of left ventricular volume and function by transthoracic and transesophageal echocardiography, ultrasound velocity dilution, and gated magnetic resonance imaging in healthy foals. Am J Vet Res 2020; 81:930-939. [PMID: 33251841 DOI: 10.2460/ajvr.81.12.930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare measurements of left ventricular volume and function derived from 2-D transthoracic echocardiography (2DE), transesophageal echocardiography (TEE), and the ultrasound velocity dilution cardiac output method (UDCO) with those derived from cardiac MRI (cMRI) in healthy neonatal foals. ANIMALS 6 healthy 1-week-old Standardbred foals. PROCEDURES Foals were anesthetized and underwent 2DE, TEE, and cMRI; UDCO was performed simultaneously with 2DE. Images acquired by 2DE included the right parasternal 4-chamber (R4CH), left apical 4- and 2-chamber (biplane), and right parasternal short-axis M-mode (M-mode) views. The longitudinal 4-chamber view was obtained by TEE. Measurements assessed included left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV), ejection fraction, stroke volume (LVSV), cardiac output (CO), and cardiac index (CI). Bland-Altman analyses were used to compare measurements derived from biplane, R4CH, and M-mode images and UDCO with cMRI-derived measurements. Repeatability of measurements calculated by 3 independent reviewers was assessed by the intraclass correlation coefficient. RESULTS Compared with cMRI, all 2DE and TEE modalities underestimated LVEDV and LVESV and overestimated ejection fraction, CO, and CI. The LVSV was underestimated by the biplane, R4CH, and TEE modalities and overestimated by UDCO and M-mode methods. However, the R4CH-derived LVSV, CO, and CI were clinically comparable to cMRI-derived measures. Repeatability was good to excellent for measures derived from the biplane, R4CH, M-mode, UDCO, and cMRI methods and poor for TEE-derived measures. CONCLUSIONS AND CLINICAL RELEVANCE All assessed modalities yielded clinically acceptable measurements of LVEDV, LVESV, and function, but those measurements should not be used interchangeably when monitoring patient progress.
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Singh Y, Villaescusa JU, da Cruz EM, Tibby SM, Bottari G, Saxena R, Guillén M, Herce JL, Di Nardo M, Cecchetti C, Brierley J, de Boode W, Lemson J. Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:620. [PMID: 33092621 PMCID: PMC7579971 DOI: 10.1186/s13054-020-03326-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. METHODS Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature-a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. RESULTS Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached "strong agreement," 20 "weak agreement," and 2 had "no agreement." Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. CONCLUSIONS These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Javier Urbano Villaescusa
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Eduardo M da Cruz
- Department of Pediatrics, Children's Hospital Colorado, Section of Cardiac Intensive Care, The Heart Institute, Pittsburgh, USA
| | - Shane M Tibby
- Department of Pediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Gabriella Bottari
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Rohit Saxena
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Marga Guillén
- Department of Pediatric Intensive Care, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jesus Lopez Herce
- Department of Pediatric Intensive Care, Gregorio Marañón Hospital University Hospital, Madrid, Spain
| | - Matteo Di Nardo
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Intensive Care, Ospedale Pediatrico Bambino Gesù-IRCC, Rome, Italy
| | - Joe Brierley
- Department of Pediatric and Cardiac Intensive Care, Great Ormond Street Hospital for Children and UCL Institute for Child Health, London, UK
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Abstract
Clinical assessment of cardiac output by interpretation of indirect parameters has proven to be inaccurate, irrespective of the level of experience of the clinician. Objective cardiac output monitoring is feasible in newborn infants in intensive care. The most promising methods include transthoracic echocardiography, transcutaneous Doppler, electrical biosensing technologies, transpulmonary ultrasound dilution, and arterial pulse contour analysis. Simultaneous assessment of blood pressure and cardiac output enables the identification of the earliest stage of shock. Comprehensive hemodynamic monitoring is pivotal for an individualized pathophysiology-based hemodynamic management.
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Affiliation(s)
- Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
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Sigurdsson TS, Lindberg L. Six commonly used empirical body surface area formulas disagreed in young children undergoing corrective heart surgery. Acta Paediatr 2020; 109:1838-1846. [PMID: 32010999 DOI: 10.1111/apa.15208] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/10/2020] [Accepted: 01/30/2020] [Indexed: 11/30/2022]
Abstract
AIM Formulas for empirical body surface area (BSA), which is used to estimate body size and standardise physiological parameters, may disagree in children. We compared six commonly used BSA formulas-Du Bois, Boyd, Costeff, Haycock, Meban and Mosteller-in a surgical cohort. METHODS This retrospective single-centre cohort study comprised 68 children who had corrective heart surgery at Skåne University Children's Hospital, Lund, Sweden, from February 2010 to March 2017. RESULTS The children (51% female) underwent surgery at a mean weight of 7.0 kilograms (range 2.7-14.1 kg) and a mean age 11 months (range 0-43 months). All the BSA formulas showed good correlation with mean BSA, but there were considerable variations between them. Mosteller's formula was exactly the same as the mean BSA (bias 0.000). The Du Bois and Boyd formulas had the largest mean BSA deviations (bias -0.012 and 0.015). Costeff's formula showed good agreement with mean BSA, Haycock's formula showed minimal overestimation and Meban's formula demonstrated a systemic error in older children. CONCLUSION Commonly used BSA formulas did not agree in young children undergoing heart surgery, but they were all close to the overall mean of the six formulas, with the Mosteller formula producing the same value.
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Affiliation(s)
- Theodor Skuli Sigurdsson
- Department of Paediatric Anaesthesiology and Intensive Care Medicine Children's Hospital Skåne University Hospital of Lund Lund Sweden
- Department of Anaesthesiology and Intensive Care Medicine Landspítalinn National University Hospital of Iceland Reykjavik Iceland
| | - Lars Lindberg
- Department of Paediatric Anaesthesiology and Intensive Care Medicine Children's Hospital Skåne University Hospital of Lund Lund Sweden
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Extracorporeal Arteriovenous Ultrasound Measurement of Cardiac Output in Small Children. Anesthesiology 2020; 130:712-718. [PMID: 30907763 DOI: 10.1097/aln.0000000000002582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Technology for cardiac output (CO) and blood volume measurements has been developed based on blood dilution with a small bolus of physiologic body temperature saline, which, after transcardiopulmonary mixing, is detected with ultrasound sensors attached to an extracorporeal arteriovenous loop using existing central venous and peripheral arterial catheters. This study aims to compare the precision and agreement of this technology to measure cardiac output with a reference method, a perivascular flow probe placed around the aorta, in young children. The null hypothesis is that the methods are equivalent in precision, and there is no bias in the cardiac output measurements. METHODS Forty-three children scheduled for cardiac surgery were included in this prospective single-center comparison study. After corrective cardiac surgery, five consecutive repeated cardiac output measurements were performed simultaneously by both methods. RESULTS A total of 215 cardiac output measurements were compared in 43 children. The mean age of the children was 354 days (range, 30 to 1,303 days), and the mean weight was 7.1 kg (range, 2.7 to 13.6 kg). The precision assessed as two times the coefficient of error was 3.6% for the ultrasound method and 5.0% for the flow probe. Bias (mean COultrasound 1.28 l/min - mean COflow probe 1.20 l/min) was 0.08 l/min, limits of agreement was ±0.32 l/min, and the percentage error was 26.6%. CONCLUSIONS The technology to measure cardiac output with ultrasound detection of blood dilution after a bolus injection of saline yields comparable precision as cardiac output measurements by a periaortic flow probe. The difference in accuracy in the measured cardiac output between the methods can be explained by the coronary blood flow, which is excluded in the cardiac output measurements by the periaortic flow probe.
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8
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Sigurdsson TS, Lindberg L. Estimation of intracardiac shunts in young children with a novel indicator dilution technology. Sci Rep 2020; 10:1337. [PMID: 31992787 PMCID: PMC6987168 DOI: 10.1038/s41598-020-58347-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 01/14/2020] [Indexed: 11/20/2022] Open
Abstract
Clinical evaluation of intracardiac shunts in children is not straightforward. Echocardiography can only diagnose the presence of a shunt but does not estimate the shunt ratio. This can be a critical factor that influences treatment options. In this single-center, prospective, observational, method-comparison study, we validate the ability of a novel monitoring device COstatus to estimate the intracardiac shunt ratio (Qp/Qs) of pulmonary (Qp) to systemic (Qs) blood flow in young children before and after corrective cardiac surgery. The indicator dilution technology COstatus monitor was compared to two other more invasive reference techniques, perivascular ultrasonic flow probes (placed around the pulmonary truncus and ascending aorta) and the oximetric shunt equation (using arterial and venous blood gases). Our study revealed that the COstatus monitor detected intracardiac shunts with high sensitivity and specificity but there was some underestimation of the shunt ratios compared to the reference techniques.
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Affiliation(s)
- Theodor Skuli Sigurdsson
- Department of Pediatric Anesthesia and Intensive Care, Children´s Hospital, University Hospital of Lund, Lund, Sweden. .,Department of Anesthesia and Intensive Care, Landspítalinn, University Hospital of Iceland, Reykjavík, Iceland.
| | - Lars Lindberg
- Department of Pediatric Anesthesia and Intensive Care, Children´s Hospital, University Hospital of Lund, Lund, Sweden
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9
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Sigurdsson TS, Lindberg L. Indirect Calorimetry Overestimates Oxygen Consumption in Young Children: Caution is Advised Using Direct Fick Method as a Reference Method in Cardiac Output Comparison Studies. Pediatr Cardiol 2020; 41:149-154. [PMID: 31741015 PMCID: PMC6987070 DOI: 10.1007/s00246-019-02238-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022]
Abstract
Direct Fick method is considered a standard reference method for estimation of cardiac output. It relies on indirect calorimetry to measure oxygen consumption. This is important as only a minor measurement error in oxygen consumption can result in false estimation of cardiac output. A number of studies have shown that indirect calorimetry overestimates oxygen consumption in adults. The aim of this prospective single center observational method comparison study was to compare the determination of oxygen consumption by indirect calorimetry and reverse Fick method in pediatric patients. Forty-two children mean age 352 days (range 30 to 1303 days) and mean weight 7.1 kg (range 2.7-13.6 kg) undergoing corrective cardiac surgery were included in the study. The mean (standard deviation) oxygen consumption by reverse Fick method was 43.5 (16.2) ml/min and by indirect calorimetry 49.9 (18.8) ml/min (p < 0.001). Indirect calorimetry overestimated the reverse Fick oxygen consumption by 14.7%. Bias between methods was 6.5 (11.3) ml/min, limits of agreement (LOA) - 15.7 and 28.7 ml/min and percentage error of 47.7%. A significant bias and large percentage error indicates that the methods are not interchangeable. Indirect calorimetry and the direct Fick method should be used with caution as a reference method in cardiac output comparison studies in young children.
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Affiliation(s)
- Theodor S Sigurdsson
- Department of Pediatric Anesthesia and Intensive Care, Children's Hospital, Skåne University Hospital, Lund, Sweden.
- Department of Anesthesia and Intensive Care, Landspítalinn University Hospital, Reykjavík, Iceland.
| | - Lars Lindberg
- Department of Pediatric Anesthesia and Intensive Care, Children's Hospital, Skåne University Hospital, Lund, Sweden
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10
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Cardiac output measurements via echocardiography versus thermodilution: A systematic review and meta-analysis. PLoS One 2019; 14:e0222105. [PMID: 31581196 PMCID: PMC6776392 DOI: 10.1371/journal.pone.0222105] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/21/2019] [Indexed: 12/03/2022] Open
Abstract
Echocardiography, as a noninvasive hemodynamic evaluation technique, is frequently used in critically ill patients. Different opinions exist regarding whether it can be interchanged with traditional invasive means, such as the pulmonary artery catheter thermodilution (TD) technique. This systematic review aimed to analyze the consistency and interchangeability of cardiac output measurements by ultrasound (US) and TD. Five electronic databases were searched for studies including clinical trials conducted up to June 2019 in which patients’ cardiac output was measured by ultrasound techniques (echocardiography) and TD. The methodological quality of the included studies was evaluated by two independent reviewers who used the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), which was tailored according to our systematic review in Review Manager 5.3. A total of 68 studies with 1996 patients were identified as eligible. Meta-analysis and subgroup analysis were used to compare the cardiac output (CO) measured using the different types of echocardiography and different sites of Doppler use with TD. No significant differences were found between US and TD (random effects model: mean difference [MD], -0.14; 95% confidence interval, -0.30 to 0.02; P = 0.08). No significant differences were observed in the subgroup analyses using different types of echocardiography and different sites except for ascending aorta (AA) (random effects model: mean difference [MD], -0.37; 95% confidence interval, -0.74 to -0.01; P = 0.05) of Doppler use. The median of bias and limits of agreement were -0.12 and ±0.94 L/min, respectively; the median of correlation coefficient was 0.827 (range, 0.140–0.998). Although the difference in CO between echocardiography by different types or sites and TD was not entirely consistent, the overall effect of meta-analysis showed that no significant differences were observed between US and TD. The techniques may be interchangeable under certain conditions.
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11
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Skowno JJ. Hemodynamic monitoring in children with heart disease: Overview of newer technologies. Paediatr Anaesth 2019; 29:467-474. [PMID: 30667124 DOI: 10.1111/pan.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/26/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Justin J Skowno
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
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12
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Martin-Flores M, Sakai DM, Honkavaara J, Campoy L, Portela DA, Gleed RD. Hemodynamic effects of MK-467 following intravenous administration to isoflurane-anesthetized cats concurrently receiving dexmedetomidine. Am J Vet Res 2018; 79:711-717. [DOI: 10.2460/ajvr.79.7.711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Martin-Flores M, Sakai DM, Honkavaara J, Campoy L. Hemodynamic effects of low-dose atipamezole in isoflurane-anesthetized cats receiving an infusion of dexmedetomidine. J Feline Med Surg 2018; 20:571-577. [PMID: 28766985 PMCID: PMC11104072 DOI: 10.1177/1098612x17722265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objectives The objective of this study was to evaluate the cardiovascular effects of low-dose atipamezole administered intravenously to isoflurane-anesthetized cats receiving dexmedetomidine. We hypothesized that atipamezole would increase heart rate (HR) and reduce arterial blood pressure in isoflurane-anesthetized cats receiving dexmedetomidine. Methods Six healthy adult domestic shorthair cats were anesthetized with isoflurane and instrumented for direct arterial pressures and cardiac output (CO) measurements. The cats received a target-controlled infusion of dexmedetomidine (target plasma concentration 10 ng/ml) for 30 mins before administration of atipamezole. Two sequential doses of atipamezole (15 and 30 μg/kg IV) were administered at least 20 mins apart, during dexmedetomidine administration. The effects of dexmedetomidine and each dose of atipamezole on HR, mean arterial blood pressure (MAP), CO and systemic vascular resistance (SVR) were documented. Results Dexmedetomidine reduced the HR by 22%, increased MAP by 78% (both P ⩽0.01), decreased CO by 48% and increased SVR by 58% (both P ⩽0.0003). Administration of atipamezole 15 and 30 μg/kg intravenously increased HR by 8% ( P = 0.006) and 4% ( P = 0.1), respectively. MAP decreased by 39% and 47%, respectively (both P ⩽0.004). Atipamezole 30 μg/kg returned CO and SVR to baseline values. Conclusions and relevance Low doses of atipamezole (15 and 30 μg/kg) administered intravenously to anesthetized cats decreased arterial blood pressure with only marginal increases in HR. Atipamezole 30 μg/kg restored CO and SVR to baseline values before dexmedetomidine administration.
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Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Daniel M Sakai
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Juhana Honkavaara
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Finland
| | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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MacEwen C, Sutherland S, Daly J, Pugh C, Tarassenko L. Validation of Modelflow Estimates of Cardiac Output in Hemodialysis Patients. Ther Apher Dial 2018; 22:337-344. [DOI: 10.1111/1744-9987.12650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 09/10/2017] [Accepted: 10/17/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Clare MacEwen
- Oxford Kidney Unit; Oxford University Hospitals NHS Trust; Oxford UK
- Department of Engineering Science; Institute of Biomedical Engineering, Oxford University; Oxford UK
| | - Sheera Sutherland
- Oxford Kidney Unit; Oxford University Hospitals NHS Trust; Oxford UK
| | - Jonathan Daly
- Department of Engineering Science; Institute of Biomedical Engineering, Oxford University; Oxford UK
| | - Christopher Pugh
- Oxford Kidney Unit; Oxford University Hospitals NHS Trust; Oxford UK
- Nuffield Department of Medicine; Oxford University; Oxford UK
| | - Lionel Tarassenko
- Department of Engineering Science; Institute of Biomedical Engineering, Oxford University; Oxford UK
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15
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Vrancken SL, van Heijst AF, de Boode WP. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring. Front Pediatr 2018; 6:87. [PMID: 29675404 PMCID: PMC5895966 DOI: 10.3389/fped.2018.00087] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.
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Affiliation(s)
- Sabine L Vrancken
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arno F van Heijst
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem P de Boode
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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16
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Perioperative Cardiac Output Monitoring Utilizing Non-pulse Contour Methods. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Feasibility and Accuracy of Cardiac Right-to-Left-Shunt Detection in Children by New Transpulmonary Ultrasound Dilution Method. Pediatr Cardiol 2017; 38:135-148. [PMID: 27826705 DOI: 10.1007/s00246-016-1494-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
Transpulmonary ultrasound dilution (TPUD) method, a novel indicator dilution (ID) technique for cardiac output measurement, detects and quantifies shunts, both in children and adults. However, its accuracy and reproducibility in cardiac right-to-left-shunt (RLS) detection have not been investigated. In a prospective observational study, we assessed the validity of TPUD algorithm for RLS detection in children with congenital heart disease (CHD) and proven RLS in comparison with controls without shunts between February 2010 and October 2011. As TPUD algorithm was unknown, we tested ID curve morphology, appearance time (AT) and central blood volume index (CBVI) as diagnostic criteria. TPUD identified RLS correctly in all 16 RLS subjects [median age (range): 18 months (1 month-15 years 6 months)] and excluded RLS in all 26 controls [74 months (8 months to 17 years 4 months)]. AT was significantly shorter in RLS (P < 0.05). Applying only AT (93.8 % sensitivity, 92.3 % specificity), RLS can be detected by shortening of ≥1.69 s of normally expected AT. RLS ID curves were subdivided into four morphological categories: (I) hump-on-upslope (n = 5); (II) double-hump (n = 3); (III) pseudonormal (n = 3); (IV) abnormal width (n = 5). No correlation was found between specific type of CHD and RLS categories. CBVI measurements were significantly smaller in RLS categories I-III than in controls (P < 0.05). TPUD appears to be a valid method for cardiac RLS detection. Shortened AT and low CBVI are reliable parameters for RLS identification. RLS categories have specific implications for cardiac output, blood volume and RLS fraction measurements. TPUD is valuable to monitor shunt direction and magnitude to optimise haemodynamic and respiratory therapy.
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Vrancken SL, van Heijst AF, Hopman JC, Liem KD, van der Hoeven JG, de Boode WP. Detection and quantification of left-to-right shunting using transpulmonary ultrasound dilution (TPUD): a validation study in neonatal lambs. J Perinat Med 2016; 44:925-932. [PMID: 27159914 DOI: 10.1515/jpm-2015-0310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 03/31/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We investigated the accuracy of left-to-right shunt detection using transpulmonary ultrasound dilution (TPUD) and compared the agreement between pulmonary over systemic blood flow (Qp/Qs) ratio measured by TPUD [Qp/Qs(tpud)] and ultrasonic flow probes [Qp/Qs(ufp)]. METHODS Seven newborn lambs under general anesthesia were connected to the TPUD monitor (COstatus™) after insertion of arterial and central venous catheters. A Gore-Tex® shunt, inserted between the descending aorta and left pulmonary artery, was intermittently opened and closed while cardiac output was varied by blood withdrawals. Flow probes were placed around the main pulmonary artery (Qufp) and the descending aorta proximal (Qpre) and distal (Qpost) to the shunt insertion. Qp/Qs(ufp) was calculated as (Qufp+Qpre-Qpost)/Qufp. RESULTS Seventy-two paired measurement sessions were analyzed. Shunts were detected by TPUD with a positive predictive value of 86%, a negative predictive value of 100%, a sensitivity of 100% and a specificity of 83%. The Bland-Altman analysis comparing Qp/Qs(tpud) and Qp/Qs(ufp) showed an overall mean bias (SD) of 0.1 (0.3), limits of agreement (LOA) of ±0.6 and a percentage error of 34.8%. CONCLUSIONS The qualitative diagnostic accuracy of TPUD for shunt detection is high. Modification of the algorithm seems required as shunt quantification by TPUD is accurate, but not yet very precise.
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Favia I, Rizza A, Garisto C, Haiberger R, Di Chiara L, Romagnoli S, Ricci Z. Cardiac index assessment by the pressure recording analytical method in infants after paediatric cardiac surgery: a pilot retrospective study. Interact Cardiovasc Thorac Surg 2016; 23:919-923. [DOI: 10.1093/icvts/ivw251] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/14/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022] Open
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20
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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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Suehiro K, Joosten A, Murphy LSL, Desebbe O, Alexander B, Kim SH, Cannesson M. Accuracy and precision of minimally-invasive cardiac output monitoring in children: a systematic review and meta-analysis. J Clin Monit Comput 2015; 30:603-20. [PMID: 26315477 DOI: 10.1007/s10877-015-9757-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 08/19/2015] [Indexed: 12/14/2022]
Abstract
Several minimally-invasive technologies are available for cardiac output (CO) measurement in children, but the accuracy and precision of these devices have not yet been evaluated in a systematic review and meta-analysis. We conducted a comprehensive search of the medical literature in PubMed, Cochrane Library of Clinical Trials, Scopus, and Web of Science from its inception to June 2014 assessing the accuracy and precision of all minimally-invasive CO monitoring systems used in children when compared with CO monitoring reference methods. Pooled mean bias, standard deviation, and mean percentage error of included studies were calculated using a random-effects model. The inter-study heterogeneity was also assessed using an I(2) statistic. A total of 20 studies (624 patients) were included. The overall random-effects pooled bias, and mean percentage error were 0.13 ± 0.44 l min(-1) and 29.1 %, respectively. Significant inter-study heterogeneity was detected (P < 0.0001, I(2) = 98.3 %). In the sub-analysis regarding the device, electrical cardiometry showed the smallest bias (-0.03 l min(-1)) and lowest percentage error (23.6 %). Significant residual heterogeneity remained after conducting sensitivity and subgroup analyses based on the various study characteristics. By meta-regression analysis, we found no independent effects of study characteristics on weighted mean difference between reference and tested methods. Although the pooled bias was small, the mean pooled percentage error was in the gray zone of clinical applicability. In the sub-group analysis, electrical cardiometry was the device that provided the most accurate measurement. However, a high heterogeneity between studies was found, likely due to a wide range of study characteristics.
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Affiliation(s)
- Koichi Suehiro
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA. .,Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abenoku, Osaka City, Osaka, 545-8586, Japan.
| | - Alexandre Joosten
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA.,Department of Anesthesiology and Critical Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium
| | - Linda Suk-Ling Murphy
- Ayala Science Library Reference Department, University of California, Irvine, Irvine, CA, USA
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA.,EA 4169 INSERM US 7 CNRS UMS 3453, University Lyon 1, Lyon, France
| | - Brenton Alexander
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA
| | - Sang-Hyun Kim
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA.,Department of Anesthesiology and Pain Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, CA, USA
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Cisternas AF, Martin-Flores M, Gleed RD. Continuous minimally invasive cardiac output monitoring with the COstatus in a neonatal swine model: recalibration is necessary during vasoconstriction and vasodilation. Paediatr Anaesth 2015; 25:852-859. [PMID: 25959048 DOI: 10.1111/pan.12679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND The COstatus monitor measures cardiac output via the transpulmonary ultrasound dilution method (COTPUD ) after injection of normal saline, and can calculate continuous cardiac output (CCO) from the arterial pressure waveform. The relationship between arterial waveform and COTPUD however, might be degraded during vasoconstriction/vasodilation. OBJECTIVES To examine if recalibration of arterial waveform-derived CCO is required during mild vasoconstriction/vasodilation. METHODS In 10 anesthetized piglets (6.6-10.1 kg), two COstatus monitors calculated the CCO from the same femoral arterial waveform before and during infusions of phenylephrine (PE; 1 or 3 mg·kg(-1) ·min(-1) ) and sodium nitroprusside (SNP; 1 or 5 mg·kg(-1) ·min(-1) ), administered in random order. One monitor was recalibrated (CCORecal ) after each intervention, while the other monitor was not (CCONon-Recal ). Recalibration was performed with COTPUD with 1 ml·kg(-1) normal saline as indicator. The effects of each infusion on hemodynamic parameters were compared with baseline using paired t-tests. The bias, limits of agreement (LOA), and percentage error between simultaneous measurements (CCORecal and CCONon-Recal ) were examined with Bland-Altman plots. RESULTS Infusion of PE significantly increased COTPUD , heart rate (HR), and arterial pressures but not systemic vascular resistance (SVR). Infusion of SNP decreased arterial pressures without affecting COTPUD , HR, and SVR. There was no bias between CCORecal and CCONon-Recal at the baseline, but a small bias was observed during PE and SNP infusions. The LOA increased approximately 10 fold during vasoconstriction and vasodilation. The percentage error increased from ≤ 5% to 32% and 27% during PE and SNP infusions, respectively. CONCLUSION Continuous cardiac output (CO) measured with the COstatus monitor requires recalibration during vasoconstriction and vasodilation, even if changes in COTPUD or SVR are not substantial.
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Affiliation(s)
- Alvaro F Cisternas
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Robin D Gleed
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Saxena R, Krivitski N, Peacock K, Durward A, Simpson JM, Tibby SM. Accuracy of the transpulmonary ultrasound dilution method for detection of small anatomic shunts. J Clin Monit Comput 2014; 29:407-14. [PMID: 25240251 DOI: 10.1007/s10877-014-9618-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 09/12/2014] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to investigate the qualitative and quantitative accuracy of transpulmonary ultrasound dilution (UD) (COstatus™, Transonic Systems) for the detection of small anatomic shunts. It was a prospective, observational study in a multi-disciplinary pediatric intensive care unit. Seventy-three critically ill children (67 post cardiac surgery), with a median (IQR) age of 10 (3-50.3) months and a median (IQR) weight of 8 (3.43-13) kg were enrolled. Ultrasound dilution (UD) measurements were performed on patients within 1 h of undergoing two-dimensional echocardiography, which was used as the comparator technique. Shunt was diagnosed by characteristic changes on the UD curve shape, and was considered "test-positive" only if two or more measurements suggested the presence of the shunt. The UD technology also provided an estimate of pulmonary to systemic blood flow ratio (Qp:Qs). 12/73 (16.4 %) patients had a shunt identified by both UD and echocardiography. The overall accuracy (95 % CI) was 86.1 % (75.6-96.6 %), with a sensitivity of 85.7 % (57.2-98.2 %) and specificity of 86.4 % (75.0-94.0 %). The estimated Qp:Qs ranged from 0.7 to 1.4, which was consistent qualitatively with the echocardiographic findings on color flow doppler. Shunt was detected by UD alone in eight children; six of these had clinical conditions known to compromise dilution curve analysis (valve regurgitation, asymmetric pulmonary blood flow). Shunt was detected by echocardiography alone in two children; in both cases the shunt was tiny. UD is an accurate method for the detection of small anatomical shunts, both qualitatively and quantitatively.
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Affiliation(s)
- R Saxena
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK,
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