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Cousin VL, Joye R, Wacker J, Beghetti M, Polito A. Use of CO 2-Derived Variables in Cardiac Intensive Care Unit: Pathophysiology and Clinical Implications. J Cardiovasc Dev Dis 2023; 10:jcdd10050208. [PMID: 37233175 DOI: 10.3390/jcdd10050208] [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: 03/14/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
Shock is a life-threatening condition, and its timely recognition is essential for adequate management. Pediatric patients with congenital heart disease admitted to a cardiac intensive care unit (CICU) after surgical corrections are particularly at risk of low cardiac output syndrome (LCOS) and shock. Blood lactate levels and venous oxygen saturation (ScVO2) are usually used as shock biomarkers to monitor the efficacy of resuscitation efforts, but they are plagued by some limitations. Carbon dioxide (CO2)-derived parameters, namely veno-arterial CO2 difference (ΔCCO2) and the VCO2/VO2 ratio, may represent a potentially valuable addition as sensitive biomarkers to assess tissue perfusion and cellular oxygenation and may represent a valuable addition in shock monitoring. These variables have been mostly studied in the adult population, with a strong association between ΔCCO2 or VCO2/VO2 ratio and mortality. In children, particularly in CICU, few studies looked at these parameters, while they reported promising results on the use of CO2-derived indices for patients' management after cardiac surgeries. This review focuses on the physiological and pathophysiological determinants of ΔCCO2 and VCO2/VO2 ratio while summarizing the actual state of knowledge on the use of CO2-derived indices as hemodynamical markers in CICU.
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Affiliation(s)
- Vladimir L Cousin
- Réanimation Pédiatrique, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Raphael Joye
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Julie Wacker
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Angelo Polito
- Réanimation Pédiatrique, Women, Child and Adolescent Department, Geneva University Hospital, 1205 Geneva, Switzerland
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Ufkes S, Zuercher M, Erdman L, Slorach C, Mertens L, Taylor KL. Automatic Prediction of Paediatric Cardiac Output From Echocardiograms Using Deep Learning Models. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:12-19. [PMID: 37970100 PMCID: PMC10642111 DOI: 10.1016/j.cjcpc.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2023]
Abstract
Background Cardiac output (CO) perturbations are common and cause significant morbidity and mortality. Accurate CO assessment is crucial for guiding treatment in anaesthesia and critical care, but measurement is difficult, even for experts. Artificial intelligence methods show promise as alternatives for accurate, rapid CO assessment. Methods We reviewed paediatric echocardiograms with normal CO and a dilated cardiomyopathy patient group with reduced CO. Experts measured the left ventricular outflow tract diameter, velocity time integral, CO, and cardiac index (CI). EchoNet-Dynamic is a deep learning model for estimation of ejection fraction in adults. We modified this model to predict the left ventricular outflow tract diameter and retrained it on paediatric data. We developed a novel deep learning approach for velocity time integral estimation. The combined models enable automatic prediction of CO. We evaluated the models against expert measurements. Primary outcomes were root-mean-squared error, mean absolute error, mean average percentage error, and coefficient of determination (R2). Results In a test set unused during training, CI was estimated with the root-mean-squared error of 0.389 L/min/m2, mean absolute error of 0.321 L/min/m2, mean average percentage error of 10.8%, and R2 of 0.755. The Bland-Altman analysis showed that the models estimated CI with a bias of +0.14 L/min/m2 and 95% limits of agreement -0.58 to 0.86 L/min/m2. Conclusions Our model estimated CO with strong correlation to ground truth and a bias of 0.17 L/min, better than many CO measurements in paediatrics. Model pretraining enabled accurate estimation despite a small dataset. Potential uses include supporting clinicians in real-time bedside calculation of CO, identification of low-CO states, and treatment responses.
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Affiliation(s)
- Steven Ufkes
- Division of Genetics and Genome Biology, Centre for Computational Medicine, The Hospital for Sick Children, Research Institute, Toronto, Ontario, Canada
| | - Mael Zuercher
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Anesthesia, Centre hospitalier universitaire Vaudois, Lausanne, Switzerland
| | - Lauren Erdman
- Division of Genetics and Genome Biology, Centre for Computational Medicine, The Hospital for Sick Children, Research Institute, Toronto, Ontario, Canada
| | - Cameron Slorach
- Department of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- Department of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine L. Taylor
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
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Schapka E, Gee J, Cyrus JW, Goldstein G, Greenfield K, Marinello M, Karam O. Lung Ultrasound versus Chest X-Ray for the Detection of Fluid Overload in Critically Ill Children: A Systematic Review. J Pediatr Intensive Care 2022; 11:177-182. [DOI: 10.1055/s-0041-1725123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/23/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractFluid overload is a common complication of critical illness, associated with increased morbidity and mortality. Pulmonary fluid status is difficult to evaluate clinically and many clinicians utilize chest X-ray (CXR) to identify fluid overload. Adult data have shown lung ultrasound (LUS) to be a more sensitive modality. Our objective was to determine the performance of LUS for detecting fluid overload, with comparison to CXR, in critically ill children. We conducted a systematic review using multiple electronic databases and included studies from inception to November 15, 2020. The sensitivity and specificity of each test were evaluated. Out of 1,209 studies screened, 4 met eligibility criteria. Overall, CXR is reported to have low sensitivity (44–58%) and moderate specificity (52–94%) to detect fluid overload, while LUS is reported to have high sensitivity (90–100%) and specificity (94–100%). Overall, the quality of evidence was moderate, and the gold standard was different in each study. Our systematic review suggests LUS is more sensitive and specific than CXR to identify pulmonary fluid overload in critically ill children. Considering the clinical burden of fluid overload and the relative ease of obtaining LUS, further evaluation of LUS to diagnose volume overload is warranted.
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Affiliation(s)
- Emily Schapka
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
| | - Jerica Gee
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
| | - John W. Cyrus
- Health Sciences Library, VCU Libraries, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Gregory Goldstein
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
| | - Kara Greenfield
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
| | - Mark Marinello
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, Virginia, United States
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Otte A, Schindler E, Neumann C. [Hemodynamic monitoring in pediatric anesthesia]. DIE ANAESTHESIOLOGIE 2022; 71:417-425. [PMID: 35925144 DOI: 10.1007/s00101-022-01125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Perioperative mortality and morbidity in childhood essentially depend on the quality of the anesthesia. The Safe Anesthesia for every Tot (SafeTots) initiative takes this into account and has defined normotension, normovolemia and normal heart rate as quality criteria in pediatric anesthesia. Appropriate monitoring of pediatric hemodynamics is necessary to fulfil these criteria. This article provides an overview of currently used methods and techniques for instrumental and non-instrumental cardiovascular monitoring in children. The current study situation, recommendations and guidelines on the application as well as practical aspects of the measurement methods are explained as far as possible. For a better understanding, procedures not routinely used in clinical practice are described in more detail.
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Affiliation(s)
- Andreas Otte
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Ehrenfried Schindler
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Claudia Neumann
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
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Early Restrictive Fluid Strategy Impairs the Diaphragm Force in Lambs with Acute Respiratory Distress Syndrome. Anesthesiology 2022; 136:749-762. [PMID: 35320344 DOI: 10.1097/aln.0000000000004162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of fluid management strategies in critical illness-associated diaphragm weakness are unknown. This study hypothesized that a liberal fluid strategy induces diaphragm muscle fiber edema, leading to reduction in diaphragmatic force generation in the early phase of experimental pediatric acute respiratory distress syndrome in lambs. METHODS Nineteen mechanically ventilated female lambs (2 to 6 weeks old) with experimental pediatric acute respiratory distress syndrome were randomized to either a strict restrictive fluid strategy with norepinephrine or a liberal fluid strategy. The fluid strategies were maintained throughout a 6-h period of mechanical ventilation. Transdiaphragmatic pressure was measured under different levels of positive end-expiratory pressure (between 5 and 20 cm H2O). Furthermore, diaphragmatic microcirculation, histology, inflammation, and oxidative stress were studied. RESULTS Transdiaphragmatic pressures decreased more in the restrictive group (-9.6 cm H2O [95% CI, -14.4 to -4.8]) compared to the liberal group (-0.8 cm H2O [95% CI, -5.8 to 4.3]) during the application of 5 cm H2O positive end-expiratory pressure (P = 0.016) and during the application of 10 cm H2O positive end-expiratory pressure (-10.3 cm H2O [95% CI, -15.2 to -5.4] vs. -2.8 cm H2O [95% CI, -8.0 to 2.3]; P = 0.041). In addition, diaphragmatic microvessel density was decreased in the restrictive group compared to the liberal group (34.0 crossings [25th to 75th percentile, 22.0 to 42.0] vs. 46.0 [25th to 75th percentile, 43.5 to 54.0]; P = 0.015). The application of positive end-expiratory pressure itself decreased the diaphragmatic force generation in a dose-related way; increasing positive end-expiratory pressure from 5 to 20 cm H2O reduced transdiaphragmatic pressures with 27.3% (17.3 cm H2O [95% CI, 14.0 to 20.5] at positive end-expiratory pressure 5 cm H2O vs. 12.6 cm H2O [95% CI, 9.2 to 15.9] at positive end-expiratory pressure 20 cm H2O; P < 0.0001). The diaphragmatic histology, markers for inflammation, and oxidative stress were similar between the groups. CONCLUSIONS Early fluid restriction decreases the force-generating capacity of the diaphragm and diaphragmatic microcirculation in the acute phase of pediatric acute respiratory distress syndrome. In addition, the application of positive end-expiratory pressure decreases the force-generating capacity of the diaphragm in a dose-related way. These observations provide new insights into the mechanisms of critical illness-associated diaphragm weakness. EDITOR’S PERSPECTIVE
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Safety aspects of the PiCCO thermodilution-cardiac output catheter during magnetic resonance imaging at 3 Tesla. J Clin Monit Comput 2021; 36:141-145. [PMID: 33398546 PMCID: PMC8894192 DOI: 10.1007/s10877-020-00630-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Thermodilution cardiac output monitoring, using a thermistor-tipped intravascular catheter, is used in critically ill patients to guide hemodynamic therapy. Often, these patients also need magnetic resonance imaging (MRI) for diagnostic or prognostic reasons. As thermodilution catheters contain metal, they are considered MRI-unsafe and advised to be removed prior to investigation. However, removal and replacement of the catheter carries risks of bleeding, perforation and infection. This research is an in vitro safety assessment of the PiCCO™ thermodilution catheter during 3 T Magnetic Resonance Imaging (3T-MRI). In a 3T-MRI environment, three different PiCCO™ catheter sizes were investigated in an agarose-gel, tissue mimicking phantom. Two temperature probes measured radiofrequency-induced heating; one at the catheter tip and one at a reference point. Magnetically induced catheter dislocation was assessed by visual observation as well as by analysis of the tomographic images. For all tested catheters, the highest measured temperature increase was 0.2 °C at the center of the bore and 0.3 °C under “worst-case” setting for the tested MRI pulse sequences. No magnetically induced catheter displacements were observed. Under the tested circumstances, no heating or dislocation of the PiCCO™ catheter was observed in a tissue mimicking phantom during 3T-MRI. Leaving the catheter in the critically ill patient during MRI investigation might pose a lower risk of complications than catheter removal and replacement.
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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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Critical Care Management: Sepsis and Disseminated and Local Infections. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123939 DOI: 10.1007/978-3-030-01322-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Local and systemic infections are a significant cause of morbidity and mortality among immunocompromised children, including but not limited to patients with hematologic and solid malignancies, congenital or acquired immunodeficiencies, or hematopoietic cell or solid organ transplantation patients. Progression to septic shock can be rapid and profound and thus requires specific diagnostic and treatment approaches. This chapter will discuss the diagnosis and the initial hemodynamic management strategies of septic shock in immunocompromised children, including strategies to improve oxygen delivery, reduce metabolic demand, and monitor hemodynamic response to resuscitation. This chapter also discusses strategies to reverse septic shock pathobiology, including the use of both empiric and targeted anti-infective strategies and pharmacologic and cell therapy-based immunomodulation. Specific consideration is also paid to the management of high-risk subpopulations and the care of septic shock patients with resolving injury.
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Jacquet-Lagrèze M, Tiberghien N, Evain JN, Hanna N, Courtil-Teyssedre S, Lilot M, Baudin F, Chardonnal L, Bompard D, Koffel C, Portefaix A, Javouhey E, Fellahi JL. Diagnostic accuracy of a calibrated abdominal compression to predict fluid responsiveness in children. Br J Anaesth 2018; 121:1323-1331. [PMID: 30442260 DOI: 10.1016/j.bja.2018.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/24/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Fluid administration to increase stroke volume index (SVi) is a cornerstone of haemodynamic resuscitation. We assessed the accuracy of SVi variation during a calibrated abdominal compression manoeuvre (ΔSVi-CAC) to predict fluid responsiveness in children. METHODS Patients younger than 8 yr with acute circulatory failure, regardless of their ventilation status, were selected. SVi, calculated as the average of five velocity-time integrals multiplied by the left ventricular outflow tract surface area, was recorded at four different steps: baseline, after an abdominal compression with a calibrated pressure of 25 mm Hg, after return to baseline, and then after a volume expansion (VE) of 10 ml kg-1 lactated Ringer solution over 10 min. Patients were classified as responders if SVi variation after volume expansion (ΔSVi-VE) increased by at least 15%. RESULTS The 39 children included had a median [inter-quartile range (IQR)] age of 9 [5-31] months. Twenty patients were fluid responders and 19 were non-responders. ΔSVi-CAC correlated with ΔSVi-VE (r=0.829; P<0.001). The area under the receiver operating characteristic curve (ROCAUC) was 0.94 [95% confidence interval (CI), 0.85-0.99]. The best threshold for ΔSVi-CAC was 11% with a specificity of 95% [95% CI, 84-100] and a sensitivity of 75% [95% CI, 55-95]. ROCAUC of respiratory variation of IVC diameter (ΔIVC) was 0.53 [95% CI, 0.32-0.72]. CONCLUSION ΔSVi-CAC during abdominal compression was a reliable method to predict fluid responsiveness in children with acute circulatory failure regardless of their ventilation status. CLINICAL TRIALS REGISTRATION CPP Lyon sud est II: n° ANSM 2015-A00388-41 Clinicaltrial.gov: NCT02505646.
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Affiliation(s)
- M Jacquet-Lagrèze
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France; Université Claude-Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France.
| | - N Tiberghien
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France
| | - J-N Evain
- Département de Réanimation Pédiatrique, Centre Hospitalier Femme Mère Enfant, Bron, France
| | - N Hanna
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France
| | - S Courtil-Teyssedre
- Département de Réanimation Pédiatrique, Centre Hospitalier Femme Mère Enfant, Bron, France
| | - M Lilot
- Département d'Anesthésie Pédiatrique, Centre Hospitalier Femme Mère Enfant, Bron, France; Université Claude-Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France; Centre Lyonnais d'Enseignement par Simulation en Santé, SAMSEI, Lyon, France; Health Services and Performance Research Laboratory, Université Claude Bernard Lyon 1, Lyon, France
| | - F Baudin
- Département de Réanimation Pédiatrique, Centre Hospitalier Femme Mère Enfant, Bron, France; Université Claude-Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France
| | - L Chardonnal
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France
| | - D Bompard
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France
| | - C Koffel
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France
| | - A Portefaix
- EPICIME-CIC 1407 de Lyon, Inserm, Hospices Civils de Lyon, Bron, France
| | - E Javouhey
- Département de Réanimation Pédiatrique, Centre Hospitalier Femme Mère Enfant, Bron, France; Université Claude-Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France
| | - J-L Fellahi
- Département d'Anesthésie Réanimation, Centre Hospitalier Louis Pradel, Bron, France; Université Claude-Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France
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Propranolol Reduces Cardiac Index But does not Adversely Affect Peripheral Perfusion in Severely Burned Children. Shock 2018; 46:486-491. [PMID: 27380530 DOI: 10.1097/shk.0000000000000671] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to quantify the effect of propranolol on hemodynamic parameters assessed using the PiCCO system in burned children. METHODS We analyzed hemodynamic data from patients who were randomized to receive either propranolol (4 mg/kg/day) or placebo (control), which was initiated as a prospective randomized controlled trial. Endpoints were cardiac index (CI), percent predicted heart rate (%HR), mean arterial pressure (MAP), percent predicted stroke volume (%SV), rate pressure product (RPP), cardiac work (CW), systemic vascular resistance index (SVRI), extravascular lung water index (EVLWI), arterial blood gases, events of lactic acidosis, and mortality. Mixed multiple linear regressions were applied, and a 95% level of confidence was assumed. RESULTS One hundred twenty-one burned children (control: n = 62, propranolol: n = 59) were analyzed. Groups were comparable in demographics, EVLWI, SVRI, %SV, arterial blood gases, Denver 2 postinjury organ failure score, incidence of lactic acidosis, or mortality. Percent predicted HR, MAP, CI, CW, and RPP were significantly reduced in the propranolol-treated group (P <0.01). CONCLUSIONS Propranolol significantly reduces cardiogenic stress by reducing CI and MAP in children with severe burn injury. However, peripheral oxygen delivery was not reduced and events of lactic acidosis as well as organ dysfunction was not higher in propranolol treated patients.
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Transpulmonary Thermodilution Versus Transthoracic Echocardiography for Cardiac Output Measurements in Severely Burned Children. Shock 2018; 46:249-53. [PMID: 27058051 DOI: 10.1097/shk.0000000000000627] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Severe burns trigger a hyperdynamic state, necessitating accurate measurement of cardiac output (CO) for cardiovascular observation and guiding fluid resuscitation. However, it is unknown whether, in burned children, the increasingly popular transthoracic echocardiography (TTE) method of CO measurement is as accurate as the widely used transpulmonary thermodilution (TPTD) method. PATIENTS AND METHODS We retrospectively compared near-simultaneously performed CO measurements in severely burned children using TPTD with the Pulse index Continuous Cardiac Output (PiCCO) system or TTE. Outcomes were compared using t tests, multiple linear regression, and a Bland-Altman plot. RESULTS Fifty-four children (9 ± 5 years) with 68 ± 18% total body surface area burns were studied. An analysis of 105 data pairs revealed that PiCCO yielded higher CO measurements than TTE (190 ± 39% vs. 150 ± 50% predicted values; P < 0.01). PiCCO- and TTE-derived CO measurements correlated moderately well (R = 0.54, P < 0.01). A Bland-Altman plot showed a mean bias of 1.53 L/min with a 95% prediction interval of 4.31 L/min. CONCLUSIONS TTE-derived estimates of CO may underestimate severity of the hyperdynamic state in severely burned children. We propose using the PiCCO system for objective cardiovascular monitoring and to guide goal-directed fluid resuscitation in this population.
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Exploring the best predictors of fluid responsiveness in patients with septic shock. Am J Emerg Med 2017; 35:1258-1261. [DOI: 10.1016/j.ajem.2017.03.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/15/2017] [Accepted: 03/21/2017] [Indexed: 12/21/2022] Open
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Hemodynamic coherence in critically ill pediatric patients. Best Pract Res Clin Anaesthesiol 2016; 30:499-510. [PMID: 27931653 DOI: 10.1016/j.bpa.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
Abstract
Differences in physiology and pathophysiology make the treatment of developing, critically ill children particularly challenging as compared to that of adults. Significant differences in the cardiovascular system of neonates and children in size, weight, body proportions, and metabolism should be considered. Hemodynamic monitoring is crucial for early warning of pending deterioration and to guide therapy. Current monitoring is limited to the macrocirculation, but an adequately functioning macrocirculation does not guarantee a well-functioning microcirculation. Research in children revealed loss of hemodynamic coherence, i.e., microcirculatory alterations despite normal systemic hemodynamics. Implementing the framework of hemodynamic coherence in microcirculatory monitoring in children can aid physicians in titrating therapy on both macrocirculatory and microcirculatory effects to assure optimal oxygen delivery. Monitoring the microcirculation at the bedside requires further technical development. Although more research is necessary to validate the concept of hemodynamic coherence in children, the possibilities of applying this concept in children seem promising.
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Abstract
OBJECTIVES In this review, we discuss hemodynamic monitoring modalities, including their application, the interpretation of data, limitations, and impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS One of the tenets of critical care medicine is to ensure adequate tissue oxygenation. This assessment must be timely and accurate to optimize outcomes. The clinical assessment of cardiac function, cardiac output, and tissue oxygenation based on the physical examination and standard hemodynamic variables, although an indispensable part of this exercise, has significant limitations. The use of adjunctive hemodynamic monitoring modalities provides a much more objective, accurate, and timely assessment of the patient's hemodynamic profile and is invaluable for assessing the patient's clinical status, clinical trajectory, and response to interventions.
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Urbano J, López J, González R, Fernández SN, Solana MJ, Toledo B, Carrillo Á, López-Herce J. Comparison between pressure-recording analytical method (PRAM) and femoral arterial thermodilution method (FATD) cardiac output monitoring in an infant animal model of cardiac arrest. Intensive Care Med Exp 2016; 4:13. [PMID: 27256288 PMCID: PMC4891310 DOI: 10.1186/s40635-016-0087-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/26/2016] [Indexed: 02/06/2023] Open
Abstract
Background The pressure-recording analytical method is a new semi-invasive method for cardiac output measurement (PRAM). There are no studies comparing this technique with femoral artery thermodilution (FATD) in an infant animal model. Methods A prospective study was performed using 25 immature Maryland pigs weighing 9.5 kg. Fifty-eight simultaneous measurements of cardiac index (CI) were made by FATD and PRAM at baseline and after return of spontaneous circulation. Differences, correlation, and concordance between both methods were analyzed. The ability of PRAM to track changes in CI was explored with a polar plot. Results Mean CI measurements were 4.5 L/min/m2 (95 % CI, 4.2–4.8 L/min/m2; coefficient of variation, 27 %) by FATD and 4.0 L/min/m2 (95 % CI, 3.6–4.3 L/min/m2; coefficient for variation, 37 %) by PRAM (difference, 0.5 L/min/m2; 95 % CI for the difference, 0.1–1.0 L/min/m2; p = 0.003; n = 58). No correlation between both methods was observed (r = 0.170, p = 0.20). Limits of agreement were −2.9 to 4.0 L/min/m2 (−69.9 to 84.9 %). Percentage error was 80.6 %. Only 26.1 % of data points lied within an absolute deviation of ±30° from the polar axis. Conclusions No correlation nor concordance between both methods was observed. Limits of agreement and percentage of error were high and clinically not acceptable. No concurrence between both methods in CI changes was observed. PRAM is not a useful method for measurement of the CI in this pediatric model of cardiac arrest.
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Affiliation(s)
- Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Jorge López
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Sarah N Fernández
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Blanca Toledo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Ángel Carrillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain. .,Universidad Complutense, Madrid, Spain. .,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain.
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16
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Grindheim G, Eidet J, Bentsen G. Transpulmonary thermodilution (PiCCO) measurements in children without cardiopulmonary dysfunction: large interindividual variation and conflicting reference values. Paediatr Anaesth 2016; 26:418-24. [PMID: 26857433 DOI: 10.1111/pan.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The PiCCO system, based on transpulmonary thermodilution, is one of the few tools available for continuous hemodynamic monitoring in children. However, published data for some of the derived variables reveal indexed values that seem questionable. AIMS The aim of this study was to collect data from hemodynamically normal children and compare these to existing reference values. Furthermore, we sought to explore if indexing some of the variables differently could improve the clinical application of the obtained values. METHODS This is a prospective observational study in a tertiary university hospital including 31 children without cardiopulmonary disease scheduled for major neurosurgery. Measurements were performed after induction of general anesthesia. RESULTS Median age was 8 months. PiCCO-derived median Cardiac Index (CI) was 3.8 l · min(-1) · m(-2) (range 2.6-6.6), reference range 3.0-5.0, median Global End-Diastolic Volume Index (GEDVI) was 366 ml · m(-2) (range 269-685), reference range 680-800, whereas median Extravascular Lung Water Index (EVLWI) was 12 ml · kg(-1) (range 7-31), reference range 3-7. All measured variables had a high interindividual variation, especially in children weighing less than 15 kg. CONCLUSIONS Values obtained by the PiCCO system in children have a wide range, and should therefore be interpreted with caution. Current reference values published for GEDVI and EVLWI are not applicable in children; the former is too high and the latter too low, and should not guide clinical practice. Indexing by other physiological indices may reduce this problem. Using current variables, we find GEDVI 280-590 ml · m(-2) and ELWI 7-27 ml · kg(-1) to be typical ranges for children.
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Affiliation(s)
- Guro Grindheim
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Jo Eidet
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Gunnar Bentsen
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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17
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Linden K, Ladage D, Dewald O, Gatzweiler E, Pieper A, Seehase M, Duerr GD, Breuer J, Herberg U. Comparison of stroke volumes assessed by three-dimensional echocardiography and transpulmonary thermodilution in a pediatric animal model. J Clin Monit Comput 2016; 31:353-360. [PMID: 26886899 DOI: 10.1007/s10877-016-9843-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 02/14/2016] [Indexed: 02/02/2023]
Abstract
To compare stroke volumes (SV) in small hearts assessed by real-time three-dimensional echocardiography (3DE) with SV measured by transpulmonary thermodilution (TPTD) and continuous pulse contour analysis (PC) under various hemodynamic conditions. In thirteen anesthetized piglets (range 3.6-7.1 kg) SV were measured by 3DE, TPTD and PC at baseline and during phenylephrine and esmolol administration. 3DE and TPTD measurements were done successively while SV calculated by PC was documented at the time of 3DE. 3DE and TPTD showed a good correlation (r2 = 0.74) and a bias of -1.3 ml (limits of agreement -4.1 to 1.5 ml). While TPTD measured higher SV than 3DE, both methods tracked SV changes with a concordance rate of 91 %. PC and 3DE showed a lower correlation coefficient of r2 = 0.57 and a bias of -2.1 ml (limits of agreement -5.9 to 1.8 ml). Inter- and intra-observer variability of SV measured by 3DE was good with a mean bias <5 %. SV3DE showed a small variance and tracked acute small changes in SV in acceptable concordance with TPTD. PC measured SV with a higher variance and mean difference compared to 3DE. In an experimental setting 3DE has the possibility to offer non-invasive assessments of ventricular volumes volume changes. To determine whether 3DE could be used for SV assessment in a clinical routine our results need confirmation in a clinical setting.
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Affiliation(s)
- Katharina Linden
- Department of Pediatric Cardiology, Pediatric Heart Center, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany.
| | - Dennis Ladage
- Department of Internal Medicine III, Heart Center, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Oliver Dewald
- Department of Cardiac Surgery, Pediatric Heart Center, University Clinical Center Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Eva Gatzweiler
- Department of Pediatric Cardiology, Pediatric Heart Center, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany
| | - Andrea Pieper
- House of Experimental Therapy, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Matthias Seehase
- Department of Pediatric Cardiology, Pediatric Heart Center, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, Pediatric Heart Center, University Clinical Center Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, Pediatric Heart Center, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, Pediatric Heart Center, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany
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Gil-Anton J, Redondo S, Garcia Urabayen D, Nieto Faza M, Sanz I, Pilar J. Combined Cerebral and Renal Near-Infrared Spectroscopy After Congenital Heart Surgery. Pediatr Cardiol 2015; 36:1173-8. [PMID: 25764508 DOI: 10.1007/s00246-015-1139-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/04/2015] [Indexed: 12/27/2022]
Abstract
The maintenance of an adequate oxygen supply to tissues after congenital heart surgery is essential for good outcomes. The objective of this study was to assess the usefulness of near-infrared spectroscopy (NIRS) for estimating central venous oxygen saturation (ScvO2) using both cerebral and renal measurements, explore its relation with cardiac output measurements and check its ability to detect low cardiac output. A prospective observational pilot study was conducted in patients weighing <10 kg undergoing cardiopulmonary bypass surgery. Spectroscopy probes were placed on the forehead and renal area, and serial cardiac output measurements were obtained by femoral transpulmonary thermodilution over the first 24 h after surgery. In the 15 patients studied, ScvO2 was correlated with cerebral (r = 0.58), renal (r = 0.60) and combined (r = 0.71) measurements. Likewise, the systolic index was correlated with the NIRS signals: cerebral (r = 0.60), renal (r = 0.50) and combined (r = 0.66). Statistically significant differences were found in the NIRS measures registered in the 29 low cardiac output events detected by thermodilution: cerebral: 62 % (59-65) versus 69 % (63-76); renal: 83 % (70-89) versus 89 % (83-95); and combined 64 % (60-69) versus 72 % (67-76). In our series, combined cerebral and renal monitoring was correlated with central venous oxygen saturation and cardiac output; low cardiac output detection associated a different spectroscopy pattern.
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Affiliation(s)
- Javier Gil-Anton
- Pediatric Intensive Care Unit, Cruces University Hospital, Bizkaia, Spain,
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19
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Monitoring of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S86-101. [PMID: 26035368 DOI: 10.1097/pcc.0000000000000436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement. CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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20
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Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S73-85. [PMID: 26035367 DOI: 10.1097/pcc.0000000000000435] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies. CONCLUSIONS The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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21
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Improved sepsis bundles in the treatment of septic shock: a prospective clinical study. Am J Emerg Med 2015; 33:1045-9. [PMID: 25959848 DOI: 10.1016/j.ajem.2015.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/26/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis bundles can decrease mortality in patients with severe sepsis or septic shock. However, current methods of measuring pressure, such as central venous pressure, are inadequate. This study investigated the effect of improved sepsis bundles informed by pulse-indicated continuous cardiac output. METHODS We compared the outcome of treatment with sepsis bundles informed by either conventional pressure measurements or pulse-indicated continuous cardiac output. Patients in 2 groups received fluid resuscitation, standard antibiotics, and oxygen therapy. RESULTS A total of 105 patients with septic shock were randomly divided into 2 groups: the conventional sepsis bundle group (n = 52) or the improved sepsis bundle group (ISBG, n =53). The ISBG significantly reduced the mean Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment scores. Significantly fewer ISBG-treated patients received vasoactive drugs compared to conventional sepsis bundle group-treated patients. In addition, patients in the ISBG exhibited a significantly increased arterial blood lactate clearance rate and required less total fluid resuscitation and a shorter duration of mechanical ventilation and stay in the intensive care unit. CONCLUSIONS Pulse-indicated continuous cardiac output-directed sepsis bundles can reduce the severity of septic shock, provide more accurate fluid resuscitation, and reduce the duration of mechanical ventilation and stay in the intensive care unit.
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Laight NS, Levin AI. Transcardiopulmonary Thermodilution-Calibrated Arterial Waveform Analysis: A Primer for Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2015; 29:1051-64. [PMID: 26279223 DOI: 10.1053/j.jvca.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola S Laight
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew I Levin
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa.
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23
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Garisto C, Favia I, Ricci Z, Romagnoli S, Haiberger R, Polito A, Cogo P. Pressure recording analytical method and bioreactance for stroke volume index monitoring during pediatric cardiac surgery. Paediatr Anaesth 2015; 25:143-9. [PMID: 24491036 DOI: 10.1111/pan.12360] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and tracks cardiac output changes in pediatric cardiac surgery patients. OBJECTIVE To evaluate the difference between stroke volume index (SVI) measured by pressure recording analytical method (PRAM) and bioreactance and their ability to track changes after a therapeutic intervention. METHODS A single-center prospective observational cohort study in children undergoing cardiac surgery with cardiopulmonary bypass (CPB) was conducted. Twenty children below 20 kg with median (interquartile range) weight of 5.3 kg (4.1-7.8) and age of 6 months (3-20) were enrolled. Data were collected after anesthesia induction, at the end of CPB, before fluid administration and after fluid administration. Overall, median-IQR PRAM SVI values (23 ml·m(-2), 19-27) were significantly higher than bioreactance SVI (15 ml·m(-2), 12-25, P = 0.0001). Correlation (r(2) ) between the two methods was 0.15 (P = 0.0003). The mean difference between the measurements (bias) was 5.7 ml·m(-2) with a standard deviation of 9.6 (95% limits of agreement ranged from -13 to 24 ml·m(-2)). Percentage error was 91.7%. Baseline SVI appeared to be similar, but PRAM SVI was systematically greater than bioreactance thereafter, with the highest gap after the fluid loading phase: 13 (12-18) ml·m(-2) vs. 23 (19-25) ml·m(-2), respectively, P = 0.0013. A multivariable regression model showed that a significant independent inverse correlation with patients' body weight predicted the CI difference between the two methods after fluid challenge (β coefficient -0.12, P = 0.013). CONCLUSIONS Pressure recording analytical method and bioreactance provided similar SVI estimation at stable hemodynamic conditions, while bioreactance SVI values appeared significantly lower than PRAM at the end of CPB and after fluid replacement.
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Affiliation(s)
- Cristiana Garisto
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Urbano J, López J, González R, Solana MJ, Fernández SN, Bellón JM, López-Herce J. Measurement of cardiac output in children by pressure-recording analytical method. Pediatr Cardiol 2015; 36:358-64. [PMID: 25179459 DOI: 10.1007/s00246-014-1014-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 08/22/2014] [Indexed: 12/13/2022]
Abstract
We evaluated two pressure-recording analytical method (PRAM) software versions (v.1 and v.2) to measure cardiac index (CI) in hemodynamically stable critically ill children and investigate factors that influence PRAM values. The working hypothesis was that PRAM CI measurements would stay within normal limits in hemodynamically stable patients. Ninety-five CI PRAM measurements were analyzed in 47 patients aged 1-168 months. Mean CI was 4.1 ± 1.4 L/min/m(2) (range 2.0-7.0). CI was outside limits defined as normal (3-5 L/min/m(2)) in 53.7% of measurements (47.8% with software v.1 and 69.2% with software v.2, p = 0.062). Moreover, 14.7% of measurements were below 2.5 L/min/m(2), and 13.6% were above 6 L/min/m(2). CI was significantly lower in patients with a clearly visible dicrotic notch than in those without (3.7 vs. 4.6 L/min/m(2), p = 0.004) and in children with a radial arterial catheter (3.5 L/min/m(2)) than in those with a brachial (4.4 L/min/m(2), p = 0.021) or femoral catheter (4.7 L/min/m(2), p = 0.005). By contrast, CI was significantly higher in children under 12 months (4.2 vs. 3.6 L/min/m(2), p = 0.034) and weighing under 10 kg (4.2 vs. 3.6 L/min/m(2), p = 0.026). No significant differences were observed between cardiac surgery patients and the rest of children. A high percentage of CI measurements registered by PRAM were outside normal limits in hemodynamically stable, critically ill children. CI measured by PRAM may be influenced by the age, weight, location of catheter, and presence of a dicrotic notch.
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Affiliation(s)
- Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del, Hospital General Universitario Gregorio Marañón de Madrid, Madrid, Spain
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Abstract
OBJECTIVES To define near-normal values of extravascular lung water indexed to body weight in children. DESIGN Prospective multicenter observational study. SETTING Medical/surgical PICUs of 5 multinational hospitals. PATIENTS Fifty-eight children with a median age of 4 years (range 1 month to 17 year) with heterogeneous PICU admission diagnoses were included. Extravascular lung water measurements from these children were collected after resolution of their illness. Obtained values were indexed to actual body weight and height and subsequently related to age. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extravascular lung water indexed to body weight correlated with age (r2 = 0.7) and could be categorized in three-age groups consisting of significantly different median extravascular lung water indexed to body weight values (5th-95th percentile): less than 1 year, 9-29 mL/kg; 1-5 years, 7-25 mL/kg; and 5-17 years, 5-13 mL/kg. Extravascular lung water indexed to height did not correlate to age and resulted in an age-independent near-normal value of less than 315 mL/m. CONCLUSIONS Younger children have higher values of extravascular lung water indexed to actual body weight. Age categorized near-normal values of extravascular lung water indexed to body weight are presented for possible clinical use. Furthermore, we suggest to index extravascular lung water to height, which seems to be age independent.
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Hemodynamic volumetry using transpulmonary ultrasound dilution (TPUD) technology in a neonatal animal model. J Clin Monit Comput 2014; 29:643-52. [PMID: 25500953 DOI: 10.1007/s10877-014-9647-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/08/2014] [Indexed: 10/24/2022]
Abstract
To analyze changes in cardiac output and hemodynamic volumes using transpulmonary ultrasound dilution (TPUD) in a neonatal animal model under different hemodynamic conditions. 7 lambs (3.5-8.3 kg) under general anesthesia received arterial and central venous catheters. A Gore-Tex(®) shunt was surgically inserted between the descending aorta and the left pulmonary artery to mimic a patent ductus arteriosus. After shunt opening and closure, induced hemorrhagic hypotension (by repetitive blood withdrawals) and repetitive volume challenges, the following parameters were assessed using TPUD: cardiac output, active circulating volume index (ACVI), central blood volume index (CBVI) and total end-diastolic volume index (TEDVI). 27 measurement sessions were analyzed. After shunt opening, there was a significant increase in TEDVI and a significant decrease in cardiac output with minimal change in CBVI and ACVI. With shunt closure, these results reversed. After progressive hemorrhage, cardiac output and all volumes decreased significantly, except for ACVI. Following repetitive volume resuscitation, cardiac output increased and all hemodynamic volumes increased significantly. Correlations between changes in COufp and changes in hemodynamic volumes (ACVI 0.83; CBVI 0.84 and TEDVI 0.78 respectively) were (slightly) better than between changes in COufp and changes in heart rate (0.44) and central venous pressure (0.7). Changes in hemodynamic volumes using TPUD were as expected under different conditions. Hemodynamic volumetry using TPUD might be a promising technique that has the potential to improve the assessment and interpretation of the hemodynamic status in critically ill newborns and children.
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Cardiac index monitoring by femoral arterial thermodilution after cardiac surgery in children. J Crit Care 2014; 29:1132.e1-4. [DOI: 10.1016/j.jcrc.2014.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/05/2014] [Accepted: 06/03/2014] [Indexed: 02/07/2023]
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Trending ability and limitations of transpulmonary thermodilution and pulse contour cardiac output measurement in cats as a model for pediatric patients. J Clin Monit Comput 2014; 29:377-83. [DOI: 10.1007/s10877-014-9615-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022]
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30
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Validation of extravascular lung water measurement by transpulmonary thermodilution in a pediatric animal model. Pediatr Crit Care Med 2014; 15:e226-33. [PMID: 24717901 DOI: 10.1097/pcc.0000000000000104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The measurement of extravascular lung water using the transpulmonary thermodilution technique enables the bedside quantification of the amount of pulmonary edema. Children have higher indexed to body weight values of extravascular lung water compared with adults. Transpulmonary thermodilution measurements of extravascular lung water in children have not yet been validated. The purpose of this study was to validate the extravascular lung water measurements with the transpulmonary thermodilution method over a wide range of lung water values in a pediatric animal model. DESIGN Experimental animal intervention study. SETTING Animal laboratory at the Radboud University Nijmegen, The Netherlands. SUBJECTS Eleven lambs. INTERVENTION Pulmonary edema was induced using a surfactant washout model. MEASUREMENTS AND MAIN RESULTS Between the lavages, extravascular lung water index was estimated using transpulmonary single and double indicator dilution. Two additional lambs were used to estimate extravascular lung water index in lungs without pulmonary edema. The final extravascular lung water index results were compared with the extravascular lung water index estimations by postmortem gravimetry (EVLWIG). The results were analyzed using both correlation and Bland-Altman statistics. Extravascular lung water index by transpulmonary thermodilution (EVLWITPTD) correlated significantly with either EVLWIG (r = 0.88) or with extravascular lung water index by transpulmonary double indicator dilution (EVLWITPDD) (r = 0.98). The mean bias with EVLWIG was 12.2 mL/kg (limits of agreement ± 10.9 mL/kg) and with EVLWITPDD 2.4 mL/kg (limits of agreement ± 3.8 mL/kg). The percentage errors were 41% and 14%, respectively. The bias became more positive when the mean of EVLWITPTD and EVLWIG increased (r = 0.72; p = 0.003). CONCLUSIONS EVLWITPTD was significantly correlated to the postmortem gravimetric gold standard, although a significant overestimation was demonstrated with increasing pulmonary edema.
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Abstract
Reexpansion pulmonary edema (RPE) is an increased permeability pulmonary edema that usually occurs in the reexpanded lung after several days of lung collapse. This condition is recognized to occur more frequently in patients under the age of 40 years, but there has been no detailed analysis of reported pediatric cases of RPE to date. For this review, PubMed literature searches were performed using the following terms: 're(-)expansion pulmonary (o)edema' AND ('child' OR 'children' OR 'infant' OR 'boy' OR 'girl' OR 'adolescent'). The 22 pediatric cases of RPE identified were included in this review. RPE was reported in almost the entire pediatric age range, and as in adult cases, the severity ranged from subclinical to lethal. No specific treatment for RPE was identified, and treatment was administered according to the clinical features of each patient. Of the 22 reported cases, 10 occurred during the perioperative period, but were not related to any specific surgical procedures or anesthetic techniques, or to the duration of lung collapse. Pediatric anesthesiologists should be aware that pediatric RPE can occur after reexpansion of any collapsed lung and that some invasive therapies can be useful in severe cases.
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Affiliation(s)
- Shinichiro Kira
- Division of Anesthesia, Medical Department, Beppu Developmental Medicine & Rehabilitation Center, Beppu, Japan
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Nusmeier A, Vrancken S, de Boode W, van der Hoeven J, Lemson J. Transpulmonary thermodilution cardiac output measurement is not affected by severe pulmonary oedema: a newborn animal study. Br J Anaesth 2013; 111:286-92. [DOI: 10.1093/bja/aet021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Busse L, Davison DL, Junker C, Chawla LS. Hemodynamic monitoring in the critical care environment. Adv Chronic Kidney Dis 2013; 20:21-9. [PMID: 23265593 DOI: 10.1053/j.ackd.2012.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 10/18/2012] [Accepted: 10/19/2012] [Indexed: 12/24/2022]
Abstract
Hemodynamic monitoring is essential to the care of the critically ill patient. In the hemodynamically unstable patient where volume status is not only difficult to determine, but excess fluid administration can lead to adverse consequences, utilizing markers that guide resuscitation can greatly affect outcomes. Several markers and devices have been developed to aid the clinician in assessing volume status with the ultimate goal of optimizing tissue oxygenation and organ perfusion. Early static measures of volume status, including pulmonary artery occlusion pressure and central venous pressure, have largely been replaced by newer dynamic measures that rely on real-time measurements of physiological parameters to calculate volume responsiveness. Technological advances have lead to the creation of invasive and noninvasive devices that guide the physician through the resuscitative process. In this manuscript, we review the physiologic rationale behind hemodynamic monitoring, define the markers of volume status and volume responsiveness, and explore the various devices and technologies available for the bedside clinician.
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Kang WS, Lee J, Shin H, Kim SH, Kim TY, Seo D, Yoon TG. Noninvasive Cardiac Output Monitoring in Paediatric Cardiac Surgery: Correlation between Change in Thoracic Fluid Content and Change in Patient Body Weight. J Int Med Res 2012; 40:2295-304. [DOI: 10.1177/030006051204000627] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Change in thoracic fluid content (TFC) derived via a bioreactance technique with a noninvasive cardiac output monitoring device (NICOM) reportedly shows a good correlation with the amount of fluid removed. The present study prospectively evaluated the utility and clinical application of TFC in the intraoperative fluid management of paediatric patients with congenital heart disease, undergoing cardiac surgery with bioreactance-based noninvasive monitoring. Methods: Haemodynamic parameters, patient body weight and parameters derived from the NICOM device (including cardiac output, cardiac index, TFC, percentage change in TFC compared with baseline [TFCd0%] and stroke volume variation) were recorded after anaesthesia induction but before surgical incision, and just before departure from the operating room to the intensive care unit. Results: In the 80 paediatric patients included in this study, linear regression analyses demonstrated good correlations between body weight gain and TFCd0%, between body weight gain % and TFCd0%, and between intra -operative fluid balance and TFCd0%. Conclusion: TFCd0% may be a useful indicator for intraoperative fluid management in paediatric patients with congenital heart disease, undergoing cardiac surgery.
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Affiliation(s)
- W-S Kang
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jh Lee
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hj Shin
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - S-H Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - T-Y Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Dm Seo
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - T-G Yoon
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, Republic of Korea
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Vrancken S, de Boode W, Hopman J, Looijen-Salamon M, Liem K, van Heijst A. Influence of lung injury on cardiac output measurement using transpulmonary ultrasound dilution: a validation study in neonatal lambs. Br J Anaesth 2012; 109:870-8. [DOI: 10.1093/bja/aes297] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Saxena R, Durward A, Puppala NK, Murdoch IA, Tibby SM. Pressure recording analytical method for measuring cardiac output in critically ill children: a validation study. Br J Anaesth 2012. [PMID: 23183320 DOI: 10.1093/bja/aes420] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pressure recording analytical method (PRAM) is a novel, arterial pulse contour-based method for measuring cardiac output (CO). Validation studies of PRAM in children are few, and have not assessed both absolute accuracy and ability to track changes in CO across a broad case mix. We aimed to compare CO as measured by PRAM with that using a transpulmonary dilution method in a cohort of critically ill children. METHODS Forty-eight, mechanically ventilated children with a median (inter-quartile) weight of 10.7 (5.5-15) kg with arterial and central venous catheters in situ were studied. CO was measured simultaneously using PRAM and the comparator method, transpulmonary ultrasound dilution (UD). Measurements were repeated before and after therapeutic interventions that were intended to augment CO (e.g. fluid bolus). RESULTS In total, 210 paired measurements were compared. The mean (sd) CO was 1.9 (1.2) litre min(-1) with UD when compared with 1.92 (0.5) litre min(-1) using PRAM. The mean bias was 0.02 litre min(-1) with wide limits of agreement: ± 2.21 litre min(-1), giving a percentage error of 116%. The concordance between PRAM and UD for measuring changes in CO was also poor, with only 37% of measurements falling within the pre-defined polar plot limits of ±30°. CONCLUSIONS There is an unacceptably poor agreement between UD and PRAM. We do not recommend the use of PRAM for measuring CO in critically ill children with the current algorithm.
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Affiliation(s)
- R Saxena
- Paediatric Intensive Care Unit, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
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Abstract
Advanced haemodynamic monitoring remains a cornerstone in the management of the critically ill. While rates of pulmonary artery catheter use have been declining, there has been an increase in the number of alternatives for monitoring cardiac output as well as greater understanding of the methods and criteria with which to compare devices. The PiCCO (Pulse index Continuous Cardiac Output) device is one such alternative, integrating a wide array of both static and dynamic haemodynamic data through a combination of trans-cardiopulmonary thermodilution and pulse contour analysis. The requirement for intra-arterial and central venous catheterisation limits the use of PiCCO to those with evolving critical illness or at high risk of complex and severe haemodynamic derangement. While the accuracy of trans-cardiopulmonary thermodilution as a measure of cardiac output is well established, several other PiCCO measurements require further validation within the context of their intended clinical use. As with all advanced haemodynamic monitoring systems, efficacy in improving patient-centred outcomes has yet to be conclusively demonstrated. The challenge with PiCCO is in improving the understanding of the many variables that can be measured and integrating those that are clinically relevant and adequately validated with appropriate therapeutic interventions.
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Affiliation(s)
- E. Litton*
- Intensive Care Specialist, Royal Perth Hospital and Clinical Senior Lecturer, School of Medicine and Pharmacology, University of Western Australia
| | - M. Morgan
- School of Medicine, Cardiff University and Anaesthetic and Intensive Care Doctor, University Hospital of Wales, Cardiff, UK
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Boehne M, Schmidt F, Witt L, Köditz H, Sasse M, Sümpelmann R, Bertram H, Wessel A, Osthaus WA. Comparison of transpulmonary thermodilution and ultrasound dilution technique: novel insights into volumetric parameters from an animal model. Pediatr Cardiol 2012; 33:625-32. [PMID: 22349665 DOI: 10.1007/s00246-012-0192-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 11/22/2011] [Indexed: 11/29/2022]
Abstract
Especially in critically ill children with cardiac diseases, fluid management and monitoring of cardiovascular function are essential. Ultrasound dilution technique (UDT) was recently introduced to measure cardiac output (CO) and volumetric parameters, such as intrathoracic and end-diastolic blood volume. We compared UDT with the well-established transpulmonary thermodilution (TPTD) method (PiCCO) for determining CO measurements and derived volumes in a juvenile animal model. Experiments were performed in 18 ventilated, anesthetized piglets during normovolemia and after isovolemic hemodilution. At baseline and 20 min after each step of isovolemic hemodilution, 3 independent measurements of CO and volumetric parameters were conducted with TPTD and UDT, consecutively, under hemodynamically stable conditions. We observed comparable results for CO measurements with both methods (mean 1.98 l/min; range 1.12-2.87) with a percentage error of 17.3% (r = 0.92, mean bias = 0.28 l/min). Global end-diastolic volume (GEDV) and intrathoracic blood volume (ITBV) by TPTD were almost two times greater than analogous volumes [central blood volume (CBV); total end-diastolic volume (TEDV)] quantified by UDT (CBV = 0.58 × ITBV + 27.1 ml; TEDV = 0.48 × GEDV + 23.1 ml). CO measurements by UDT were found to be equivalent and hence interchangeable with TPTD. Discrepancies in volumetric parameters could either be due to the underlying algorithm or different types of indicators (diffusible vs. nondiffusible). Compared with the anatomically defined heart volume, TPTD seems to overestimate end-diastolic volumes. Future studies will be necessary to assign these results to critically ill children and to validate volumetric parameters with reference techniques.
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Affiliation(s)
- Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
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Schmutzhard E, Pfausler B. Complications of the management of status epilepticus in the intensive care unit. Epilepsia 2011; 52 Suppl 8:39-41. [PMID: 21967359 DOI: 10.1111/j.1528-1167.2011.03233.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Barbiturates and propofol are widely used to control status epilepticus. This review aims to discuss all possible adverse effects incurred by the administration of GABA-mediated anesthetic agents. Further on unconventional therapies such as ketamine, lidocaine, or anesthetic agents are discussed both with respect to efficacy and complications. The aim of this review is to raise awareness of complications incurred by therapeutic approaches to patients with status epilepticus in the intensive care unit.
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Affiliation(s)
- Erich Schmutzhard
- Department of Neurology, Medical University Hospital Innsbruck, Anichstrasse 35, Innsbruck, Austria.
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Hemodynamic monitoring by pulse contour analysis in critically ill children with congenital heart disease. Pediatr Crit Care Med 2011; 12:608-9; author reply 609-10. [PMID: 21897172 DOI: 10.1097/pcc.0b013e318219182b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Steil GM, Eckstein OS, Caplow J, Agus MSD, Walsh BK, Wong J. Non-invasive cardiac output and oxygen delivery measurement in an infant with critical anemia. J Clin Monit Comput 2011; 25:113-9. [PMID: 21691835 DOI: 10.1007/s10877-011-9287-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 06/11/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the combination of a non-invasive blood oxygen content (CaO(2)) monitor and a non-invasive cardiac output (CO) monitor to continuously measure oxygen delivery (DO(2); DO(2) = CaO(2) × CO). METHODS DO(2) was assessed during blood transfusions in an infant with acute hemolytic anemia following admission (~48 h). CaO(2) was measured by Pulse Co-Oximetry, which also provides estimates of hemoglobin (Hgb) concentration and percent oxygen saturation. CO was measured by Electrical Velocimetry, which also provides an estimate of stroke volume (SV). Lactate levels, an indirect measure of adequate DO(2), were assessed during the initial 8 h following admission. RESULTS Incremental blood transfusions during the first 36 h increased Hgb from 2.7 to 9.5 g/dL during which time heart rate (HR) normalized from 156 to 115 beats/min. Lactate levels decreased from 20 to 0.8 mmol/L in the first 7 h. Non-invasive Hgb and CaO(2) measurements were well correlated with invasive Hgb and CaO(2) measures (r (2) = 0.88; P = 0.019; r (2) = 0.86; P = 0.0074, respectively). CO decreased from 2.47 ± 0.06 to 1.28 ± 0.02 L/min and SV decreased from 15.9 ± 0.4 to 11.1 ± 0.2 mL/beat. Mean arterial blood pressure was stable throughout the admission with systemic vascular resistance increasing from 407.6 ± 15.2 to 887.7 ± 30.1 dynes-s/cm(5). DO(2) was estimated to increase from 120.2 ± 18.9 to 182.4 ± 5.6 mL O(2)/min. CONCLUSIONS Non-invasive continuous CO and CaO(2) monitors are shown in this single case to provide continuous DO(2) measurement. The ability to assess DO(2) may improve hemodynamic monitoring during goal directed therapies.
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Affiliation(s)
- Garry M Steil
- Department of Medicine: Medicine Critical Care Program, Children's Hospital Boston, 330 Longwood Avenue 11 South, Boston, MA 02115, USA
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Keller G, Desebbe O, Henaine R, Lehot JJ. Transpulmonary thermodilution in a pediatric patient with an intracardiac left-to-right shunt. J Clin Monit Comput 2011; 25:105-8. [PMID: 21656261 DOI: 10.1007/s10877-011-9281-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 05/04/2011] [Indexed: 02/06/2023]
Abstract
Monitoring of cardiac output (CO) in the perioperative period and in seriously ill pediatric patients is of major importance for medical management. Hemodynamic monitoring, using transpulmonary thermodilution (TPTD) via a single thermal indicator injection, allows for measurements of CO, volumetric variables and extravascular lung water (EVLW). We describe and explain the influence of a left-to-right shunt on TPTD curve characteristics and EVLW measurements in a young child undergoing a surgical atrial septal defect repair. We suggest that these specific changes in the TPTD curve and the overestimation of EVLW detected by current device, in absence of gas exchange abnormalities, could be indicators of existing circulatory shunts in pediatric patients.
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Affiliation(s)
- Geoffray Keller
- Hospices Civils de Lyon, Groupement Hospitalier Est, Department of Anesthesiology and Intensive Care, Louis Pradel Hospital and Claude Bernard Lyon 1 University, Lyon, France.
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