The pulmonary artery catheter: the tool versus treatments based on the tool

Clinical Impact of Standardized Interpretation and Reporting of Multimodality Neuromonitoring Data

OBJECTIVE

Evaluate the consistency and clinical impact of standardized multimodality neuromonitoring (MNM) interpretation and reporting within a system of care for patients with severe traumatic brain injury (sTBI).

DESIGN

Retrospective, observational historical case-control study.

SETTING

Single-center academic level I trauma center.

INTERVENTIONS

Standardized interpretation of MNM data summarized within daily reports.

MEASUREMENTS MAIN RESULTS

Consecutive patients with sTBI undergoing MNM were included. Historical controls were patients monitored before implementation of standardized MNM interpretation; cases were defined as patients with available MNM interpretative reports. Patient characteristics, physiologic data, and clinical outcomes were recorded, and clinical MNM reporting elements were abstracted. The primary outcome was the Glasgow Outcome Scale score 3-6 months postinjury. One hundred twenty-nine patients were included (age 42 ± 18 yr, 82% men); 45 (35%) patients were monitored before standardized MNM interpretation and reporting, and 84 (65%) patients were monitored after that. Patients undergoing standardized interpretative reporting received fewer hyperosmotic agents (3 [1-6] vs. 6 [1-8]; p = 0.04) and spent less time above an intracranial threshold of 22 mm Hg (22% ± 26% vs. 28% ± 24%; p = 0.05). The MNM interpretation cohort had a lower proportion of anesthetic days (48% [24-70%] vs. 67% [33-91%]; p = 0.02) and higher average end-tidal carbon dioxide during monitoring (34 ± 6 mm Hg vs. 32 ± 6 mm Hg; p < 0.01; d = 0.36). After controlling for injury severity, patients undergoing standardized MNM interpretation and reporting had an odds of 1.5 (95% CI, 1.37-1.59) for better outcomes.

CONCLUSIONS

Standardized interpretation and reporting of MNM data are a novel approach to provide clinical insight and to guide individualized critical care. In patients with sTBI, independent MNM interpretation and communication to bedside clinical care teams may result in improved intracranial pressure control, fewer medical interventions, and changes in ventilatory management. In this study, the implementation of a system for management, including standardized MNM interpretation, was associated with a significant improvement in outcome.

Clinical impact of pulmonary artery catheter in patients with cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

The clinical utility of the pulmonary artery catheter (PAC) for the management of cardiogenic shock (CS) remains controversial. We performed a systematic review and meta-analysis exploring the association between PAC use and mortality among patients with CS.

METHODS

Published studies of patients with CS treated with or without PAC hemodynamic guidance were retrieved from MEDLINE and PubMed databases from January 1, 2000, to December 31, 2021. The primary outcome was mortality, which was defined as a combination of in-hospital mortality and 30-day mortality. Secondary outcomes assessed 30-day and in-hospital mortality separately. To assess the quality of nonrandomized studies, the Newcastle-Ottawa Scale (NOS), a well-established scoring system was used. We analyzed outcomes for each study using NOS with a threshold value of >6, indicating high quality. We also performed analyses based on the countries of the studies conducted.

RESULTS

Six studies with a total of 930,530 patients with CS were analyzed. Of these, 85,769 patients were in the PAC-treated group, and 844,761 patients did not receive a PAC. PAC use was associated with a significantly lower risk of mortality (PAC: 4.6 % to 41.5 % vs control: 18.8 % to 51.0 %) (OR 0.63, 95 % CI: 0.41-0.97, I2 = 0.96). Subgroup analyses demonstrated no difference in the risk of mortality between NOS ≥ 6 studies and NOS < 6 studies (p-interaction = 0.57), 30-day and in-hospital mortality (p-interaction = 0.83), or the country of origin of studies (p-interaction = 0.08).

CONCLUSIONS

The use of PAC in patients with CS may be associated with decreased mortality. These data support the need for a randomized controlled trial testing the utility of PAC use in CS.

Ultrasound guidance versus anatomical landmarks for subclavian vein catheterization: a prospective study

BACKGROUND

Several clinical practice guidelines strongly support the use of ultrasound guidance (USG) for internal jugular vein catheterization. The level of evidence concerning the use of USG for subclavian vein (SCV) cannulation remains low.

AIM

To compare the effectiveness and safety of USG and anatomical landmarks approaches for cannulation of SCV.

METHODS

This was a prospective randomized study. Patients aged over 18 years old who requiring elective central venous catheterization were included. Non-inclusion criteria were thrombosis of the vein or major coagulopathy. All catheterizations were performed by two anaesthesiology residents. Patients were randomized into two groups: ultrasound guidance group (US group) and anatomical landmarks (LM group). The main outcome was the success rate. The secondary outcomes were the first attempt success rate and the incidence of complications.

RESULTS

Seventy patients were included (35 in each group). The success rate was higher in US group compared to LM group without statistical significance (100% vs 85.7%; p=0.054). The first attempt success rate was significantly higher in the US group (82.9% vs. 40%; p <10^-3). The incidence of mechanical complications was significantly lower in the US group compared to LM group (5.7% vs. 37.1%; p=0,001).

CONCLUSION

according to our study, US guidance for SCV catheterization seems to be an interesting alternative to anatomical landmarks approaches.

[A critical carol : Being an essay on anemia, suffocation, starvation, and other forms of intensive care, after the manner of Dickens]

Irgendwo in den USA – Einige Tage vor Heiligabend wird der angetrunkene Charlie Cratchit bei dem Versuch, eine Straße zu überqueren, von einem Bus angefahren und schwer verletzt: Rippenserienfraktur, Femur- und Fibulafraktur, Milz- und Pankreaslazeration, Darmrisse. In einem US-amerikanischen Krankenhaus der Maximalversorgung wird er operativ versorgt und anschließend auf die Intensivtherapiestation verlegt und dort kontinuierlich von einem namenlosen, sehr erfahrenen Arzt betreut. Vier Tage vor Heiligabend, erscheint am Patientenbett der Geist des berühmten britischen Physiologen Ernest Henry Starling. Er tritt in einen Dialog mit dem namenlosen Arzt, interessiert sich sehr für den Swan-Ganz-Katheter und verschwindet dann wieder. Die Besuche wiederholen sich in den kommenden 3 Nächten. Einmal kritisiert er Cratchits niedrigen Hämatokrit, beim nächsten Mal zeigt er sich unzufrieden mit der Respiratoreinstellung, und beim letzten Besuch ist er äußerst besorgt über den Ernährungszustand des Patienten. Der namenlose Arzt ist zunächst indigniert über des Geistes Kritik und Belehrungen, erkennt aber, dass darin der Schlüssel zu Cratchits Genesung liegt und handelt letztlich nach seinen Vorschlägen. Mit Erfolg: Nach der vom Geist Starlings angeregten Umstellung der maschinellen Ventilation, Gabe von 3 Erythrozytenkonzentraten und Aufnahme einer parenteralen Ernährung kann Charlie Cratchit am Weihnachtsabend extubiert und am Neujahrstag von der Intensivtherapiestation entlassen werden. In diesem Essay hat Robert Bartlett Charles Dickens’ „Weihnachtsgeschichte“ in die Welt der Intensivmedizin verlegt. Sie soll den Intensivmediziner anregen, therapeutische Interventionen wie maschinelle Ventilation, hämodynamische Interventionen und Gabe von Blutprodukten kritisch zu hinterfragen. Hintergrundinformationen und Kommentare zu den angesprochenen aktuellen Problemen der modernen Intensivmedizin ergänzen den Essay.

Fluid management in abdominal surgery: what, when, and when not to administer

The entire team (including anesthesiologists, surgeons, and intensive care physicians) must work together (before, during, and after abdominal surgery) to determine the optimal amount (quantity) and type (quality) of fluid necessary in the perioperative period. The authors present an overview of the basic principles that underlie fluid management, including evidence-based recommendations (where tenable) and a rational approach for when and what to administer.

Correlation of cardiac output measured by non-invasive continuous cardiac output monitoring (NICOM) and thermodilution in patients undergoing off-pump coronary artery bypass surgery

Purpose

This observational study was designed to evaluate the clinical value of cardiac output (CO) obtained via bioreactance (NICOM™) as compared with values of CO obtained via thermodilution (using pulmonary artery catheter, Vigilance™) and the thoracic bioimpedance (BioZ.com™), in patients undergoing off-pump coronary artery bypass surgery.

Methods

Fifty American Society of Anesthesiologists physical status I–III patients, aged 38–81 years, scheduled for off-pump coronary artery bypass surgery were enrolled in this study. CO data (NCO, BCO, PCO) were recorded during the operative period at ten time points after stable hemodynamic conditions were achieved.

Results

The equation of the relationship between the PCO and NCO is PCO = 0.945 × NCO + 0.328 (r = 0.77), and that of PCO and BCO is PCO = 0.965 × BCO + 0.729 (r = 0.63). Furthermore, no statistical difference was found between PCO versus NCO (mean (SD): 4.4 (1.1) versus 4.4 (0.9), p = 0.431). A significant correlation was found between PCO and NCO (r = 0.77, p < 0.001). Correlation was also found between PCO and BCO (r = 0.63, p < 0.001).

Conclusions

The NICOM device is a safe, convenient, and reliable device for measuring continuous non-invasive cardiac output and cardiac index, and the trends of change in CO during the surgery are similar between NICOM and PAC.

Ultrasound-guided internal jugular vein catheterization: a randomized controlled trial

INTRODUCTION

Even though advantages of ultrasound line placement seem obvious, many countries do not have easy access to such technology. This study aims to compare the degree of difficulty in central venous line placement with or without ultrasound and the incidence of complications, and to establish the effect of the operator's degree of training.

METHODS

The study included 257 patients that required central venous catheterization during the study period. Patients were divided into groups according to the operator's experience: expert group (over 70 central accesses performed before the study) (n=152) and in-training or non-expert group. Procedures were randomized to "without ultrasound" (n=80 expert and 54 non-expert) and "with ultrasound" (n=72 expert and 51 non-expert).

RESULTS

Catheter placements were more successful in the "expert" and in the "with ultrasound" than in the "non-expert" (88% vs 79%; p=0.04) or in the "without ultrasound" groups (91% vs 78%; p=0.005). Incidence of complications was 11.7%, with no significant difference among "with ultrasound" (8.1%) and "without ultrasound" (14.9%) groups. However, the "non-expert" group had fewer complications with the use of ultrasound (7.8% vs 24%).

CONCLUSIONS

Ultrasound reduces the incidence of complications when placement is performed by inexperienced operators. Centers with residents should emphasize the necessity of ultrasound for central line catheterization. Training in ultrasound might be of paramount importance in the effectiveness of the technique.

Evaluation of arterial waveform derived variables for an assessment of volume resuscitation in mechanically ventilated burn patients

OBJECTIVE

The purpose of this study was to assess the usefulness of stroke volume variations to monitor the early fluid resuscitation in mechanically ventilated burn ICU patients.

METHODS AND RESULTS

Data of 29 burn patients (APACHE II - 9.8±3.6, SAPS II - 29±5, TBSA - 39.5±14) were prospectively included in this observational study. Hemodynamic parameters were determined using arterial pressure wave analysis for up to 36h after burn. Statistically significant changes in cardiac index (CI), systemic vascular resistance index (SVRI), stroke volume variation (SVV) were recorded during the observation period. There were significant correlations between CI and SVV (r=-0.454, p=0.03), SVV and SVRI (r=0.482, p=0.02) at 16 h postburn; CI and SVV (r=-0.513, p=0.012), SVV and SVRI (r=0.480, p=0.02) at 24 h postburn, CI and SVV at 36 h postburn (r=-0.478, p=0.021). Significant changes in CI (1.9±1 vs. 3.4±0.9), p=0.02 and in SVV (24.9±3 vs. 14.6±2, p=0.01) were observed in patients with low cardiac output state after administration of 10 ml/kg of Ringer lactate.

CONCLUSION

Our results suggest that measurement of stroke volume variations by arterial pulse contour analysis is valuable in monitoring volume administration and in predicting volume responsiveness during the early postburn period.

History of right heart catheterization: 100 years of experimentation and methodology development

The development of right heart catheterization has provided the clinician the ability to diagnose patients with congenital and acquired right heart disease, and to monitor patients in the intensive care unit with significant cardiovascular illnesses. The development of bedside pulmonary artery catheterization has become a standard of care for the critically ill patient since its introduction into the intensive care unit almost 40 years ago. However, adoption of this procedure into the mainstream of clinical practice occurred without prior evaluation or demonstration of its clinical or cost-effectiveness. Moreover, current randomized, controlled trials provide little evidence in support of the clinical utility of pulmonary artery catheterization in the management of critically ill patients. Nevertheless, the right heart catheter is an important diagnostic tool to assist the clinician in the diagnosis of congenital heart disease and acquired right heart disease, and moreover, when catheter placement is proximal to the right auricle (atria), this catheter provides an important and safe route for administration of fluids, medications, and parenteral nutrition. The purpose of this manuscript is to review the development of right heart catheterization that led to the ability to conduct physiologic studies in cardiovascular dynamics in normal individuals and in patients with cardiovascular diseases, and to review current controversies of the extension of the right heart catheter, the pulmonary artery catheter.

Assessment of cardiac output changes using a modified FloTrac/Vigileo algorithm in cardiac surgery patients

INTRODUCTION

The FloTrac/Vigileo (Edwards Lifesciences, Irvine, CA, USA) allows pulse pressure-derived cardiac output measurement without external calibration. Software modifications were performed in order to eliminate initially observed deficits. The aim of this study was to assess changes in cardiac output determined by the FloTrac/Vigileo system (FCO) with an initially released (FCOA) and a modified (FCOB) software version, as well as changes in cardiac output from the PiCCOplus system (PCO; Pulsion Medical Systems, Munich, Germany). Both devices were compared with cardiac output measured by intermittent thermodilution (ICO).

METHODS

Cardiac output measurements were performed in patients after elective cardiac surgery. Two sets of data (A and B) were obtained using FCOA and FCOB in 50 patients. After calibration of the PiCCOplus system, triplicate FCO and PCO values were recorded and ICO was determined in the supine position and cardiac output changes due to body positioning were recorded 15 minutes later (30 degrees head-up, 30 degrees head-down, supine). Student's t test, analysis of variance and Bland-Altman analysis were calculated.

RESULTS

Significant changes of FCO, PCO and ICO induced by body positioning were observed in both data sets. For set A, DeltaFCOA was significantly larger than DeltaICO induced by positioning the head down. For set B, there were no significant differences between DeltaFCOB and DeltaICO. For set A, increased limits of agreement were found for FCOA-ICO when compared with PCO-ICO. For set B, mean bias and limits of agreement were comparable for FCOB-ICO and PCO-ICO.

CONCLUSIONS

The modification of the FloTrac/Vigileo system resulted in an improved performance in order to reliably assess cardiac output and track the related changes in patients after cardiac surgery.

What technique should I use to measure cardiac output?

PURPOSE OF REVIEW

Several less invasive cardiac output monitoring techniques are now commercially available and have the potential to replace the pulmonary artery catheter under certain clinical circumstances. The aim of this review is to give a synopsis of the currently available cardiac output measurement methods. This information should help in selecting the appropriate technique in a particular clinical setting.

RECENT FINDINGS

An overview is given of the currently available techniques for cardiac output monitoring. Recent validation studies demonstrate that pulse wave analysis may be used reliably as an alternative to the pulmonary artery catheter in different clinical settings. The use of transesophageal echocardiography and Doppler measurements is limited due to high operator dependency, the partial carbon dioxide rebreathing technique should be applied in a precisely defined clinical setting to mechanically ventilated patients only, and pulsed dye densitometry as well as the bioimpedance technique are currently primarily applied in an investigational setting.

SUMMARY

Less invasive cardiac output monitoring techniques may replace the pulmonary artery catheter in different clinical settings considering the specific properties of these techniques. The pulmonary artery catheter, however, may still be recommended for cardiac output measurement in specific clinical situations when monitoring of pulmonary artery pressures is desirable.

Clinical evaluation of the FloTrac/Vigileo system and two established continuous cardiac output monitoring devices in patients undergoing cardiac surgery

BACKGROUND

Assessment of cardiac output (CO) by the FloTrac/Vigileo system may offer a less invasive means of determining the CO than either the pulmonary artery catheter (PAC) or the PiCCOplus system. The aim of this study was to compare CO measurements made using the FloTrac/Vigileo system with upgraded software (FCO, Edwards Lifesciences, Irvine CA, USA), the PiCCOplus system (PCO, Pulsion Medical Systems, Munich, Germany) and continuous CO monitoring using a PAC (CCO; Vigilance monitoring, Edwards Lifesciences, Irvine CA, USA) with intermittent pulmonary artery thermodilution (ICO). The study was conducted in patients undergoing elective cardiac surgery.

METHODS

Thirty-one patients with preserved left ventricular function were enrolled. CCO, FCO, and PCO were recorded in the perioperative period at six predefined time points after achieving stable haemodynamic conditions; ICO was determined from the mean of three bolus injections. Bland-Altman analysis was used to compare CCO, FCO, and PCO with ICO.

RESULTS

Bland-Altman analysis revealed a comparable mean bias and limits of agreement for all tested continuous CO monitoring devices using ICO as reference method. Agreement for all devices decreased in the postoperative period.

CONCLUSION

The performance of the FloTrac/Vigileo system, the PiCCOplus, and the Vigilance CCO monitoring for CO measurement were comparable when tested against intermittent thermodilution in patients undergoing elective cardiac surgery.