Transpulmonary Thermodilution Versus Transthoracic Echocardiography for Cardiac Output Measurements in Severely Burned Children

[Hemodynamic monitoring in pediatric anesthesia]

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.

Effect of Pulse Indicator Continuous Cardiac Output Monitoring on Septic Shock Patients: A Meta-Analysis

Background

Septic shock (SS) is the most common severe syndrome in the Intensive Care Unit (ICU). Enhancing the monitoring of hemodynamic indexes in SS patients carries huge clinical implications for reducing patient mortality. Recently, pulse indicator continuous cardiac output (PICCO) has been widely used in clinical practice, but its advantages than central venous pressure (CVP) in guiding the treatment of SS patients remains to be refined. Therefore, this study is aimed at assessing the clinical effects of PICCO in the treatment of patients with SS.

Methods

The authors systematically searched several databases (PubMed, EMBASE, Cochrane Library, and China National Knowledge) between January 2001 and February 2021. When searching for relevant articles, the authors combined the following phrases describing the monitoring group (“pulse indicator continuous cardiac output,” “central venous pressure”) with the disease of interest as well as management (“SS,” “sepsis”). The outcomes were independently assessed by two reviewers who scored the articles for methodological quality using the Cochrane Collaboration's “risk of bias” tool. Forest plots, as well as sensitivity and bias analyses, were carried out for the included articles. The primary outcome measures were length of ICU stay, duration of mechanical ventilation, 28-day mortality, and fluid resuscitation volume.

Results

Ten studies comprising 350 cases monitored with PICCO and 373 cases monitored with traditional CVP were eventually identified. PICCO-monitored patients were observed to be significantly associated with shorter ICU stay than CVP-monitored patients (MD: −3.04, 95% CI: −4.74 to −1.34, P = 0.0005), shorter time of mechanical ventilation (MD: −1.84, 95% CI: −2.80 to −0.87, P = 0.0002), and lower 28-day mortality (RR: 0.67, 95% CI: 0.48 to 0.94, P = 0.02). The two groups showed no significant difference in subgroup analysis for fluid resuscitation volumes (P > 0.05).

Conclusion

PICCO monitoring technique can significantly improve the prognosis of SS patients, shorten the time of mechanical ventilation and ICU stay, and reduce the 28-day mortality, which has positive guiding significance for patients with SS. Given the limitations of the quantity and quality of included studies, further research is warranted to verify the conclusions.

Cardiac Dysfunction in Severely Burned Patients: Current Understanding of Etiology, Pathophysiology, and Treatment

Patients who experience severe burn injuries face a massive inflammatory response resulting in hemodynamic and cardiovascular complications. Even after immediate and appropriate resuscitation, removal of burn eschar and covering of open areas, burn patients remain at high risk for serious morbidity and mortality. As a result of the massive fluid shifts following the initial injury, along with large volume fluid resuscitation, the cardiovascular system is critically affected. Further, increased inflammation, catecholamine surge, and hypermetabolic syndrome impact cardiac dysfunction, which worsens outcomes of burn patients. This review aimed to summarize the current knowledge about the effect of burns on the cardiovascular system.A comprehensive search of the PubMed and Embase databases and manual review of articles involving effects of burns on the cardiovascular system was conducted.Many burn units use multimodal monitors (e.g., transpulmonary thermodilution) to assess hemodynamics and optimize cardiovascular function. Echocardiography is often used for additional evaluations of hemodynamically unstable patients to assess systolic and diastolic function. Due to its noninvasive character, echocardiography can be repeated easily, which allows us to follow patients longitudinally.The use of anabolic and anticatabolic agents has been shown to be beneficial for short- and long-term outcomes of burn survivors. Administration of propranolol (non-selective β-receptor antagonist) or oxandrolone (synthetic testosterone) for up to 12 months post-burn counteracts hypermetabolism during hospital stay and improves cardiac function.A comprehensive understanding of how burns lead to cardiac dysfunction and new therapeutic options could contribute to better outcomes in this patient population.

Noninvasive Cardiac Output Monitoring Using Electrical Cardiometry and Outcomes in Critically Ill Children

Cardiac output (CO) measurement is an important element of hemodynamic assessment in critically ill children and existing methods are difficult and/or inaccurate. There is insufficient literature regarding CO as measured by noninvasive electrical cardiometry (EC) as a predictor of outcomes in critically ill children. We conducted a retrospective chart review in children <21 years, admitted to our pediatric intensive care unit (PICU) between July 2018 and November 2018 with acute respiratory failure and/or shock and who were monitored with EC (ICON monitor). We collected demographic information, data on CO measurements with EC and with transthoracic echocardiography (TTE), and data on ventilator days, PICU and hospital days, inotrope score, and mortality. We analyzed the data using Chi-square and multiple linear regression analysis. Among 327 recordings of CO as measured by EC in 61 critically ill children, the initial, nadir, and median CO (L/min; median [interquartile range (IQR)]) were 3.4 (1.15, 5.6), 2.39 (0.63, 4.4), and 2.74 (1.03, 5.2), respectively. Low CO as measured with EC did not correlate well with TTE (p = 0.9). Both nadir and mean CO predicted ventilator days (p = 0.05 and 0.01, respectively), and nadir CO was correlated with peak inotrope score (correlation coefficient of –0.3). In our cohort of critically ill children with respiratory failure and/or shock, CO measured with EC did not correlate with TTE. Both nadir and median CO measured with EC predicted outcomes in critically ill children.

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)

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.

Comparison of cardiac output and cardiac index values measured by critical care echocardiography with the values measured by pulse index continuous cardiac output (PiCCO) in the pediatric intensive care unit:a preliminary study

Background

Planning optimal fluid and inotrope-vasopressor-inodilator therapy is essential in critically ill children. Pulse index Contour Cardiac Output (PiCCO) monitoring is an invasive, hemodynamic monitor that provides parameter measurements such as cardiac output (CO), cardiac index (CI). Use of ultrasonography and critical care echocardiography by the pediatric intensivists has increased in recent years. In the hands of an experienced pediatric intensivist, critical echocardiography can accurately measure both CO and CI. Our objective in this study is to compare the CO and CI values measured by pediatric intensivist using critical care echocardiography to the values measured by PiCCO monitor in critically ill pediatric patients.

Methods

A prospective observational study from a tertiary university hospital PICU. A total of 15 patients who required advanced hemodynamic monitoring and applied PiCCO monitoring were included the study. The diagnosis of patients were septic shock, cardiogenic shock, acute respiratory distress syndrome, pulmonary edema. Forty nine echocardiographic measurements were performed and from 15 patients. All echocardiographic measurements were performed by a pediatric intensive care fellow experienced in cardiac ultrasound. The distance of left ventricle outflow tract (LVOT) in the parasternal long axis and LVOT-Velocity Time Integral (LVOT-VTI) measurement was performed in the apical five chamber image. Cardiac output_echocardiography (CO_echo) and CI_echocardiography (CI_echo) were calculated using these two measurements. PiCCO (PiCCO, Pulsion Medical Systems, Munich, Germany) monitoring was performed. Cardiac output (CO_picco) and CI (CI_picco) were simultaneously measured by PiCCO monitor and echocardiography. We performed a correlation analysis with this 49 echocardiographic measurements and PiCCO measurements.

Results

We detected a strong positive correlation between CO_echo and CO_picco measurements (p < 0.001, r = 0.985) and a strong positive correlation between CI_echo and CI_picco measurements (p < 0.001, r = 0.943).

Conclusions

Our study results suggest that critical care echocardiography measurement of CO and CI performed by an experienced pediatric intensivist are comparable to PiCCO measurements. The critical care echocardiography measurement can be used to guide fluid and vasoactive-inotropic management of critically ill pediatric patients.

Volume Resuscitation in Patients With High-Voltage Electrical Injuries

Volume resuscitation of patients with high-voltage electrical injuries (>1000 V) is a more complex challenge than standard burn resuscitation. High voltages penetrate deep tissues. These deep injuries are not accounted for in resuscitation formulae dependent on percentage of cutaneous burn. Myonecrosis occurring from direct electrical injury and secondary compartment syndromes can result in rhabdomyolysis, compromising renal function and urine output. Urine output is the primary end point, with a goal of 1 mL/kg/h for adult patients with high-voltage electrical injuries. As such, secondary resuscitation end points of laboratory values, such as lactate, base deficit, hemoglobin, and creatinine, as well as hemodynamic monitoring, such as mean arterial pressure and thermodilution techniques, can become crucial in guiding optimum administration of resuscitation fluids. Mannitol and bicarbonates are available but have limited support in the literature. High-voltage electrical injury patients often develop acute kidney injury requiring dialysis and have increased risks of chronic kidney disease and mortality. Continuous venovenous hemofiltration is a well-supported adjunct to clear the myoglobin load that hemodialysis cannot from circulation.

Propranolol Reduces Cardiac Index But does not Adversely Affect Peripheral Perfusion in Severely Burned Children

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.

The P50 Research Center in Perioperative Sciences: How the investment by the National Institute of General Medical Sciences in team science has reduced postburn mortality

Since the inception of the P50 Research Center in Injury and Peri-operative Sciences (RCIPS) funding mechanism, the National Institute of General Medical Sciences has supported a team approach to science. Many advances in critical care, particularly burns, have been driven by RCIPS teams. In fact, burns that were fatal in the early 1970s, prior to the inception of the P50 RCIPS program, are now routinely survived as a result of the P50-funded research. The advances in clinical care that led to the reduction in postburn death were made by optimizing resuscitation, incorporating early excision and grafting, bolstering acute care including support for inhalation injury, modulating the hypermetabolic response, augmenting the immune response, incorporating aerobic exercise, and developing antiscarring strategies. The work of the Burn RCIPS programs advanced our understanding of the pathophysiologic response to burn injury. As a result, the effects of a large burn on all organ systems have been studied, leading to the discovery of persistent dysfunction, elucidation of the underlying molecular mechanisms, and identification of potential therapeutic targets. Survival and subsequent patient satisfaction with quality of life have increased. In this review article, we describe the contributions of the Galveston P50 RCIPS that have changed postburn care and have considerably reduced postburn mortality.