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Højlund J, Cihoric M, Foss NB. Vasoconstriction with phenylephrine increases cardiac output in preload dependent patients. J Clin Monit Comput 2024:10.1007/s10877-024-01186-7. [PMID: 38907106 DOI: 10.1007/s10877-024-01186-7] [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: 04/16/2024] [Accepted: 06/02/2024] [Indexed: 06/23/2024]
Abstract
General Anaesthesia (GA) is accompanied by a marked decrease in sympathetic outflow and thus loss of vasomotor control of cardiac preload. The use of vasoconstriction during GA has mainly focused on maintaining blood pressure. Phenylephrine (PE) is a pure α1-agonist without inotropic effects widely used to correct intraoperative hypotension. The potential of PE for augmenting cardiac stroke volume (SV) and -output (CO) by venous recruitment is controversial and no human studies have explored the effects of PE in preload dependent circulation using indicator dilution technique. We hypothesized that PE-infusion in patients with cardiac stroke volume limited by reduced preload would restore preload and thus augment SV and CO. 20 patients undergoing GA for gastrointestinal surgery were monitored with arterial catheter and LiDCO unity monitor. Upon stable haemodynamics after induction patients were placed in head-up tilt (HUT). All patients became preload responsive as verified by a stroke volume variation (SVV) of > 12%. PE-infusion was then started at 15-20mikrg/min and adjusted until preload was restored (SVV < 12%). Li-dilution cardiac output (CO) was initially measured after induction (baseline), again with HUT in the preload responsive phase, and finally when preload was restored with infusion of PE.At baseline SVV was 10 ± 3% (mean ± st.dev.), CI was 2,6 ± 0,4 L/min*m2, and SVI 43 ± 7mL/m2. With HUT SVV was 19 ± 4%, CI was 2,2 ± 0,4 L/min*m2, SVI 35 ± 7mL/m2. During PE-infusion SVV was reduced to 6 ± 3%, CI increased to 2,6 ± 0,5 L/min*m2, and SVI increased to 49 ± 11mL/m2. All differences p < 0,001. In conclusion: Infusion of phenylephrine during preload dependency increased venous return abolishing preload dependency as evaluated by SVV and increased cardiac stroke volume and -output as measured by indicator-dilution technique. (ClinicalTrials.gov NCT05193097).
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Affiliation(s)
- Jakob Højlund
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark.
| | - Mirjana Cihoric
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Capital Region, Denmark
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2
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Takei Y, Kumagai M, Suzuki M, Mori S, Sato Y, Tamii T, Tamii A, Saito A, Ogata Y, Kaiho Y, Toyama H, Ejima Y, Yamauchi M. Accuracy of Cardiac Output Measured by Fourth-Generation Flotrac and Lidcorapid, and Their Characteristics Regarding Systemic Vascular Resistance in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00187-8. [PMID: 37076386 DOI: 10.1053/j.jvca.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/24/2023] [Accepted: 03/11/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVES The clinical use of less-invasive devices that calculate the cardiac output from arterial pressure waveform is increasing. The authors aimed to evaluate the accuracy and characteristics of the systemic vascular resistance index (SVRI) of the cardiac index measured by 2 less-invasive devices, fourth-generation FloTrac (CIFT) and LiDCOrapid (CILR), compared with the intermittent thermodilution technique, using a pulmonary artery catheter (CITD). DESIGN This was a prospective observational study. SETTING This study was conducted at a single university hospital. PARTICIPANTS Twenty-nine adult patients undergoing elective cardiac surgery. INTERVENTIONS Elective cardiac surgery was used as an intervention. MEASUREMENTS AND MAIN RESULTS Hemodynamic parameters, CIFT, CILR, and CITD, were measured after the induction of general anesthesia, at the start of cardiopulmonary bypass, after completion of weaning from cardiopulmonary bypass, 30 minutes after weaning, and at sternal closure (135 measurements in total). The CIFT and CILR had moderate correlations with CITD (r = 0.62 and 0.58, respectively). Compared with CITD, CIFT, and CILR had a bias of -0.73 and -0.61 L/min/m2, limit of agreement of -2.14-to-0.68 L/min/m2 and -2.42-to-1.20 L/min/m2, and percentage error of 39.9% and 51.2%, respectively. Subgroup analysis for evaluating SVRI characteristics showed that the percentage errors of CIFT and CILR were 33.9% and 54.5% in low SVRI (<1,200 dyne×s/cm5/m), 37.6% and 47.9% in moderate SVRI (1,200-1,800 dyne×s/cm5/m), 49.3% and 50.6% in high SVRI (>1,800 dyne·s/cm5/m2), respectively. CONCLUSIONS The accuracy of CIFT or CILR was not clinically acceptable for cardiac surgery. Fourth-generation FloTrac was unreliable in high SVRI. LiDCOrapid was inaccurate across a broad range of SVRI, and minimally affected by SVRI.
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Affiliation(s)
- Yusuke Takei
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Michio Kumagai
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Manami Suzuki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sakura Mori
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuna Sato
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toru Tamii
- Department of Anesthesiology, Osaki Citizen Hospital, Osaki, Japan
| | - Akane Tamii
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Ako Saito
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Yuko Ogata
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Toyama
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yutaka Ejima
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Ylikauma LA, Tuovila MJ, Ohtonen PP, Erkinaro TM, Vakkala MA, Takala HT, Liisanantti JH, Kaakinen TI. Reliability of bioreactance and pulse power analysis in measuring cardiac index during cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). BMC Anesthesiol 2023; 23:38. [PMID: 36721097 PMCID: PMC9887811 DOI: 10.1186/s12871-023-01988-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/16/2023] [Indexed: 02/02/2023] Open
Abstract
PURPOSE Various malignancies with peritoneal carcinomatosis are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The hemodynamic instability resulting from fluid balance alterations during the procedure necessitates reliable hemodynamic monitoring. The aim of the study was to compare the accuracy, precision and trending ability of two less invasive hemodynamic monitors, bioreactance-based Starling SV and pulse power device LiDCOrapid with bolus thermodilution technique with pulmonary artery catheter in the setting of cytoreductive surgery with HIPEC. METHODS Thirty-one patients scheduled for cytoreductive surgery were recruited. Twenty-three of them proceeded to HIPEC and were included to the study. Altogether 439 and 430 intraoperative bolus thermodilution injections were compared to simultaneous cardiac index readings obtained with Starling SV and LiDCOrapid, respectively. Bland-Altman method, four-quadrant plots and error grids were used to assess the agreement of the devices. RESULTS Comparing Starling SV with bolus thermodilution, the bias was acceptable (0.13 l min- 1 m- 2, 95% CI 0.05 to 0.20), but the limits of agreement were wide (- 1.55 to 1.71 l min- 1 m- 2) and the percentage error was high (60.0%). Comparing LiDCOrapid with bolus thermodilution, the bias was acceptable (- 0.26 l min- 1 m- 2, 95% CI - 0.34 to - 0.18), but the limits of agreement were wide (- 1.99 to 1.39 l min- 1 m- 2) and the percentage error was high (57.1%). Trending ability was inadequate with both devices. CONCLUSION Starling SV and LiDCOrapid were not interchangeable with bolus thermodilution technique limiting their usefulness in the setting of cytoreductive surgery with HIPEC.
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Affiliation(s)
- Laura Anneli Ylikauma
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Mari Johanna Tuovila
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Pasi Petteri Ohtonen
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland ,grid.412326.00000 0004 4685 4917Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Tiina Maria Erkinaro
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Merja Annika Vakkala
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Heikki Timo Takala
- grid.412326.00000 0004 4685 4917Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Janne Henrik Liisanantti
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
| | - Timo Ilari Kaakinen
- grid.412326.00000 0004 4685 4917Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PL 21, 90029 OYS Oulu, Finland
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Bertaina M, Galluzzo A, Morici N, Sacco A, Oliva F, Valente S, D’Ascenzo F, Frea S, Sbarra P, Petitti E, Brach Prever S, Boccuzzi G, Zanini P, Attisani M, Rametta F, De Ferrari GM, Noussan P, Iannaccone M. Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal? Card Fail Rev 2022; 8:e15. [PMID: 35541286 PMCID: PMC9069264 DOI: 10.15420/cfr.2021.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.
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Affiliation(s)
- Maurizio Bertaina
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; IRCCS S Maria Nascente – Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Alice Sacco
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Serafina Valente
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Sbarra
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Elisabetta Petitti
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Silvia Brach Prever
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Boccuzzi
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Paola Zanini
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Matteo Attisani
- Department of Cardiac Surgery, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Patrizia Noussan
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
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Ylikauma LA, Lanning KM, Erkinaro TM, Ohtonen PP, Vakkala MA, Liisanantti JH, Juvonen TS, Kaakinen TI. Reliability of Bioreactance and Pulse-Power Analysis in Measuring Cardiac Index in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2021; 36:2446-2453. [PMID: 35027295 DOI: 10.1053/j.jvca.2021.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Less-invasive and continuous cardiac output monitors recently have been developed to monitor patient hemodynamics. The aim of this study was to compare the accuracy, precision, and trending ability of noninvasive bioreactance-based Starling SV and miniinvasive pulse-power device LiDCOrapid to bolus thermodilution technique with a pulmonary artery catheter (TDCO) when measuring cardiac index in the setting of cardiac surgery with cardiopulmonary bypass (CPB). DESIGN A prospective method-comparison study. SETTING Oulu University Hospital, Finland. PARTICIPANTS Twenty patients undergoing cardiac surgery with CPB. INTERVENTIONS Cardiac index measurements were obtained simultaneously with TDCO intraoperatively and postoperatively, resulting in 498 measurements with Starling SV and 444 with LiDCOrapid. MEASUREMENTS AND MAIN RESULTS The authors used the Bland-Altman method to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. The agreement between TDCO and Starling SV was qualified with a bias of 0.43 L/min/m2 (95% confidence interval [CI], 0.37-0.50), wide limits of agreement (LOA, -1.07 to 1.94 L/min/m2), and a percentage error (PE) of 66.3%. The agreement between TDCO and LiDCOrapid was qualified, with a bias of 0.22 L/min/m2 (95% CI 0.16-0.27), wide LOA (-0.93 to 1.43), and a PE of 53.2%. With both devices, trending ability was insufficient. CONCLUSION The reliability of bioreactance-based Starling SV and pulse-power analyzer LiDCOrapid was not interchangeable with TDCO, thus limiting their usefulness in cardiac surgery with CPB.
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Affiliation(s)
- Laura Anneli Ylikauma
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Katriina Marjatta Lanning
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tiina Maria Erkinaro
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pasi Petteri Ohtonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - Merja Annika Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Janne Henrik Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tatu Sakari Juvonen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Timo Ilari Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Ylikauma LA, Ohtonen PP, Erkinaro TM, Vakkala MA, Liisanantti JH, Satta JU, Juvonen TS, Kaakinen TI. Bioreactance and fourth-generation pulse contour methods in monitoring cardiac index during off-pump coronary artery bypass surgery. J Clin Monit Comput 2021; 36:879-888. [PMID: 34037919 PMCID: PMC8150147 DOI: 10.1007/s10877-021-00721-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
The pulmonary artery catheter (PAC) is considered the gold standard for cardiac index monitoring. Recently new and less invasive methods to assess cardiac performance have been developed. The aim of our study was to assess the reliability of a non-invasive monitor utilizing bioreactance (Starling SV) and a non-calibrated mini-invasive pulse contour device (FloTrac/EV1000, fourth-generation software) compared to bolus thermodilution technique with PAC (TDCO) during off-pump coronary artery bypass surgery (OPCAB). In this prospective study, 579 simultaneous intra- and postoperative cardiac index measurements obtained with Starling SV, FloTrac/EV1000 and TDCO were compared in 20 patients undergoing OPCAB. The agreement of data was investigated by Bland-Altman plots, while trending ability was assessed by four-quadrant plots with error grids. In comparison with TDCO, Starling SV was associated with a bias of 0.13 L min-1 m-2 (95% confidence interval, 95% CI, 0.07 to 0.18), wide limits of agreement (LOA, - 1.23 to 1.51 L min-1 m-2), a percentage error (PE) of 60.7%, and poor trending ability. In comparison with TDCO, FloTrac was associated with a bias of 0.01 L min-1 m-2 (95% CI - 0.05 to 0.06), wide LOA (- 1.27 to 1.29 L min-1 m-2), a PE of 56.8% and poor trending ability. Both Starling SV and fourth-generation FloTrac showed acceptable mean bias but imprecision due to wide LOA and high PE, and poor trending ability. These findings indicate limited reliability in monitoring cardiac index in patients undergoing OPCAB.
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Affiliation(s)
- Laura Anneli Ylikauma
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Pasi Petteri Ohtonen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.,Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - Tiina Maria Erkinaro
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Annika Vakkala
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Janne Henrik Liisanantti
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jari Uolevi Satta
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tatu Sakari Juvonen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland.,Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Timo Ilari Kaakinen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu University Hospital and University of Oulu, Oulu, Finland
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Rozental O, Thalappillil R, White RS, Tam CW. To Swan or Not to Swan: Indications, Alternatives, and Future Directions. J Cardiothorac Vasc Anesth 2020; 35:600-615. [PMID: 32859489 DOI: 10.1053/j.jvca.2020.07.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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8
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McGregor D, Sharma S, Gupta S, Ahmed S, Harris T. Emergency department non-invasive cardiac output study (EDNICO): an accuracy study. Scand J Trauma Resusc Emerg Med 2020; 28:8. [PMID: 32005274 PMCID: PMC6995135 DOI: 10.1186/s13049-020-0704-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/19/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assess here the accuracy of five non-invasive methods in detecting fluid responsiveness in the ED: (1) common carotid artery blood flow, (2) suprasternal aortic Doppler, (3) bioreactance, (4) plethysmography with digital vascular unloading method, and (5) inferior vena cava collapsibility index. Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients. METHODS This is a prospective observational study of non-invasive methods for assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Sensitivity and specificity of each method in determining the fluid responsiveness status of participants is determined in comparison to the reference standard. RESULTS Thirty-three patient data sets were included for analysis. The specificity and sensitivity to detect fluid responders was 46.2 and 45% for common carotid artery blood flow (CCABF), 61.5 and 63.2% for suprasternal artery Doppler (SSAD), 46.2 and 50% for bioreactance, 50 and 41.2% for plethysmography vascular unloading technique (PVUT), and 63.6 and 47.4% for inferior vena cava collapsibility index (IVCCI), respectively. Analysis of agreement with Cohen's Kappa - 0.08 for CCABF, 0.24 for SSAD, - 0.04 for bioreactance, - 0.08 for PVUT, and 0.1 for IVCCI. CONCLUSION In this study, non-invasive methods were not found to reliably identify fluid responders. Non-invasive methods of identifying fluid responders are likely to play a key role in improving patient outcome in the ED in fluid depleted states such as sepsis. These results have implications for future studies assessing the accuracy of such methods.
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Affiliation(s)
- David McGregor
- Queen Mary University London and Barts Health NHS Trust, London, UK.
| | - Shrey Sharma
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - Saksham Gupta
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - Shanaz Ahmed
- Emergency Department Research Group, Royal London Hospital, London, UK
| | - Tim Harris
- Queen Mary University London and Barts Health NHS Trust, London, UK
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9
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Grensemann J. Cardiac Output Monitoring by Pulse Contour Analysis, the Technical Basics of Less-Invasive Techniques. Front Med (Lausanne) 2018; 5:64. [PMID: 29560351 PMCID: PMC5845549 DOI: 10.3389/fmed.2018.00064] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/20/2018] [Indexed: 12/20/2022] Open
Abstract
Routine use of cardiac output (CO) monitoring became available with the introduction of the pulmonary artery catheter into clinical practice. Since then, several systems have been developed that allow for a less-invasive CO monitoring. The so-called “non-calibrated pulse contour systems” (PCS) estimate CO based on pulse contour analysis of the arterial waveform, as determined by means of an arterial catheter without additional calibration. The transformation of the arterial waveform signal as a pressure measurement to a CO as a volume per time parameter requires a concise knowledge of the dynamic characteristics of the arterial vasculature. These characteristics cannot be measured non-invasively and must be estimated. Of the four commercially available systems, three use internal databases or nomograms based on patients’ demographic parameters and one uses a complex calculation to derive the necessary parameters from small oscillations of the arterial waveform that change with altered arterial dynamic characteristics. The operator must ensure that the arterial waveform is neither over- nor under-dampened. A fast-flush test of the catheter–transducer system allows for the evaluation of the dynamic response characteristics of the system and its dampening characteristics. Limitations to PCS must be acknowledged, i.e., in intra-aortic balloon-pump therapy or in states of low- or high-systemic vascular resistance where the accuracy is limited. Nevertheless, it has been shown that a perioperative algorithm-based use of PCS may reduce complications. When considering the method of operation and the limitations, the PCS are a helpful component in the armamentarium of the critical care physician.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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10
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Gibbs NM. Can the timing of perioperative fluids affect hospital length of stay? Anaesth Intensive Care 2017; 45:536-538. [PMID: 28911281 DOI: 10.1177/0310057x1704500502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Huygh J, Peeters Y, Bernards J, Malbrain MLNG. Hemodynamic monitoring in the critically ill: an overview of current cardiac output monitoring methods. F1000Res 2016; 5. [PMID: 28003877 PMCID: PMC5166586 DOI: 10.12688/f1000research.8991.1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2016] [Indexed: 01/12/2023] Open
Abstract
Critically ill patients are often hemodynamically unstable (or at risk of becoming unstable) owing to hypovolemia, cardiac dysfunction, or alterations of vasomotor function, leading to organ dysfunction, deterioration into multi-organ failure, and eventually death. With hemodynamic monitoring, we aim to guide our medical management so as to prevent or treat organ failure and improve the outcomes of our patients. Therapeutic measures may include fluid resuscitation, vasopressors, or inotropic agents. Both resuscitation and de-resuscitation phases can be guided using hemodynamic monitoring. This monitoring itself includes several different techniques, each with its own advantages and disadvantages, and may range from invasive to less- and even non-invasive techniques, calibrated or non-calibrated. This article will discuss the indications and basics of monitoring, further elaborating on the different techniques of monitoring.
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Affiliation(s)
- Johan Huygh
- ZNA Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerpen, Belgium
| | - Yannick Peeters
- ZNA Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerpen, Belgium
| | - Jelle Bernards
- ZNA Stuivenberg, Lange Beeldekensstraat 267, B-2060 Antwerpen, Belgium
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Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 31:291-308. [PMID: 27671216 DOI: 10.1053/j.jvca.2016.05.029] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Evgeny V Fominskiy
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Cardiac Surgery, Research Institute of Circulation Pathology, Novosibirsk, Russia
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Phan TD, Kluger R, Wan C. Minimally Invasive Cardiac Output Monitoring: Agreement of Oesophageal Doppler, LiDCOrapid™ and Vigileo FloTrac™ Monitors in Non-Cardiac Surgery. Anaesth Intensive Care 2016; 44:382-90. [DOI: 10.1177/0310057x1604400313] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is lack of data about the agreement of minimally invasive cardiac output monitors, which make it impossible to determine if they are interchangeable or differ objectively in tracking physiological trends. We studied three commonly used devices: the oesophageal Doppler and two arterial pressure–based devices, the Vigileo FloTrac™ and LiDCOrapid™. The aim of this study was to compare the agreement of these three monitors in adult patients undergoing elective non-cardiac surgery. Measurements were taken at baseline and after predefined clinical interventions of fluid, metaraminol or ephedrine bolus. From 24 patients, 131 events, averaging 5.2 events per patient, were analysed. The cardiac index of LiDCOrapid versus FloTrac had a mean bias of −6.0% (limits of agreement from −51% to 39%) and concordance of over 80% to the three clinical interventions. The cardiac index of Doppler versus LiDCOrapid and Doppler versus FloTrac, had an increasing negative bias at higher mean cardiac outputs and there was significantly poorer concordance to all interventions. Of the preload-responsive parameters, Doppler stroke volume index, Doppler systolic flow time and FloTrac stroke volume variation were fair at predicting fluid responsiveness while other parameters were poor. While there is reasonable agreement between the two arterial pressure–derived cardiac output devices (LiDCOrapid and Vigileo FloTrac), these two devices differ significantly to the oesophageal Doppler technology in response to common clinical intraoperative interventions, representing a limitation to how interchangeable these technologies are in measuring cardiac output.
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Affiliation(s)
- T. D. Phan
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria
| | - R. Kluger
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria
| | - C. Wan
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Victoria
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Canfrán S, Cediel R, Sández I, Caro-Vadillo A, Gómez de Segura IA. Evaluation of an oesophageal Doppler device for monitoring cardiac output in anaesthetised healthy normotensive dogs. J Small Anim Pract 2015; 56:450-5. [DOI: 10.1111/jsap.12362] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/02/2015] [Accepted: 03/09/2015] [Indexed: 12/26/2022]
Affiliation(s)
- S. Canfrán
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - R. Cediel
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - I. Sández
- Itinerant Anaesthesiology Service; Sinergia Veterinaria Madrid Spain
| | - A. Caro-Vadillo
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
| | - I. A. Gómez de Segura
- Department of Animal Medicine and Surgery, Veterinary Faculty; Complutense University of Madrid; Madrid 28040 Spain
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Hamzaoui O, Monnet X, Teboul JL. Evolving concepts of hemodynamic monitoring for critically ill patients. Indian J Crit Care Med 2015; 19:220-6. [PMID: 25878430 PMCID: PMC4397629 DOI: 10.4103/0972-5229.154556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The last decades have been characterized by a continuous evolution of hemodynamic monitoring techniques from intermittent toward continuous and real-time measurements and from an invasive towards a less invasive approach. The latter approach uses ultrasounds and pulse contour analysis techniques that have been developed over the last 15 years. During the same period, the concept of prediction of fluid responsiveness has also been developed and dynamic indices such as pulse pressure variation, stroke volume variation, and the real-time response of cardiac output to passive leg raising or to end-expiration occlusion, can be easily obtained and displayed with the minimally invasive techniques. In this article, we review the main hemodynamic monitoring devices currently available with their respective advantages and drawbacks. We also present the current viewpoint on how to choose a hemodynamic monitoring device in the most severely ill patients and especially in patients with circulatory shock.
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Affiliation(s)
- Olfa Hamzaoui
- Intensive Care Unit, Antoine Beclere Hospital, Clamart, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
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Affiliation(s)
- Nathan H Waldron
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Timothy E Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Tong J Gan
- Department of Anesthesiology, Duke University, Durham, North Carolina.
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Suehiro K, Tanaka K, Matsuura T, Funao T, Yamada T, Mori T, Nishikawa K. The Vigileo-FloTracTM System: Arterial Waveform Analysis for Measuring Cardiac Output and Predicting Fluid Responsiveness: A Clinical Review. J Cardiothorac Vasc Anesth 2014; 28:1361-74. [DOI: 10.1053/j.jvca.2014.02.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Indexed: 02/03/2023]
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Huang L, Critchley LAH. An assessment of two Doppler-Based Monitors to Track Cardiac Output Changes in Anaesthetised Patients Undergoing Major Surgery. Anaesth Intensive Care 2014; 42:631-9. [PMID: 25233178 DOI: 10.1177/0310057x1404200514] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally-invasive cardiac output (CO) monitoring to follow changes in CO would be helpful in anaesthesia practice. Two Doppler systems marketed for this purpose include the CardioQ (Deltex Medical Group, Chichester, United Kingdom), which uses an oesophageal probe, and the USCOM (USCOM Ltd., Sydney, NSW, Australia), which uses a hand-held probe. The aim of the study was to assess the ability of these two methods to track CO during major surgery and to determine their relationship. Twenty patients, age 58 (26 to 81) years, (m/f) 15/5, requiring abdominal surgery were studied. The surgical procedures lasted between 128 and 408 minutes and a total of 285 data pairs (8 to 22 per case) were collected. Time plots showed good tracking ability across a wide range of CO in most patients. Correlation between the two devices was excellent in 14 patients (R2 >0.85), good in another four (R2 >0.64) and poor in two. Regression line data supported the hypothesis that CardioQ under-reads at low CO and over-reads at high CO in respect to the USCOM. However, the precision between the two CO readings was poor with wide limits of agreement and a percentage error of ± 37%. These findings indicate that these devices individually track changes in CO in many patients but cannot be relied upon to provide the same values.
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Affiliation(s)
- L. Huang
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China and Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - L. A. H. Critchley
- Department of Anaesthesia and Surgical Intensive Care, Peking University First Hospital, Beijing, China
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Waldron NH, Miller TE, Thacker JK, Manchester AK, White WD, Nardiello J, Elgasim MA, Moon RE, Gan TJ. A prospective comparison of a noninvasive cardiac output monitor versus esophageal Doppler monitor for goal-directed fluid therapy in colorectal surgery patients. Anesth Analg 2014; 118:966-75. [PMID: 24681660 DOI: 10.1213/ane.0000000000000182] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient's stroke volume was optimized using 250-mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were -0.96 to +1.95 days (P = 0.5016). CONCLUSIONS The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.
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Affiliation(s)
- Nathan H Waldron
- From the Departments of *Anesthesiology and †Surgery, Duke University, Durham, North Carolina
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Geisen M, Spray D, Nicholas Fletcher S. Echocardiography-Based Hemodynamic Management in the Cardiac Surgical Intensive Care Unit. J Cardiothorac Vasc Anesth 2014; 28:733-44. [DOI: 10.1053/j.jvca.2013.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Indexed: 11/11/2022]
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Desebbe O, Henaine R, Keller G, Koffel C, Garcia H, Rosamel P, Obadia JF, Bastien O, Lehot JJ, Haftek M, Critchley LA. Ability of the Third-Generation FloTrac/Vigileo Software to Track Changes in Cardiac Output in Cardiac Surgery Patients: A Polar Plot Approach. J Cardiothorac Vasc Anesth 2013; 27:1122-7. [DOI: 10.1053/j.jvca.2013.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Indexed: 11/11/2022]
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Bubenek-Turconi SI, Craciun M, Miclea I, Perel A. Noninvasive Continuous Cardiac Output by the Nexfin Before and After Preload-Modifying Maneuvers. Anesth Analg 2013; 117:366-72. [DOI: 10.1213/ane.0b013e31829562c3] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth 2012; 27:121-34. [PMID: 22609340 DOI: 10.1053/j.jvca.2012.03.022] [Citation(s) in RCA: 201] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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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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Lipman J, Udy AA, Roberts JA. Do we understand the impact of altered physiology, consequent interventions and resultant clinical scenarios in the intensive care unit? The antibiotic story. Anaesth Intensive Care 2012; 39:999-1000. [PMID: 22165348 DOI: 10.1177/0310057x1103900602] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early, appropriate antibacterial therapy is a key factor in effectively managing septic critically ill patients1. The prescriber must not only employ an agent of appropriate spectrum, but also in an adequate dose to achieve bacterial eradication at the site of infection. However, the relationship between drug administration and therapeutic success is complex in the critically ill, such that a patient's physiology heavily influences the way drugs distribute into tissue and are eliminated. This represents a significant challenge to the emergency or intensive care physician, and in this manner, personalising therapy, through a greater understanding of how a drug will behave in an individual patient, is likely to lead to improved outcomes.
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