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Beydoun HA, Beydoun MA, Eid SM, Zonderman AB. Pulmonary artery catheter receipt among cardiac surgery patients from the national inpatient sample (1999-2019): Prevalence, predictors and hospitalization charges. Heliyon 2024; 10:e24902. [PMID: 38317919 PMCID: PMC10839978 DOI: 10.1016/j.heliyon.2024.e24902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 02/07/2024] Open
Abstract
Despite limited evidence to support its efficacy, use of pulmonary artery catheter (PAC), a relatively expensive medical device, for monitoring clinical status and guiding therapeutic interventions, has become standard of care in many settings, and especially during and after cardiac surgery. We examined the prevalence and predictors of PAC use and its association with hospitalization charges among cardiac surgery patients generally and for each selected subgroup of high-risk or complex surgical procedures. We conducted an analysis on 1,442,528 records from the National Inpatient Sample (1999-2019) that included cardiac surgery patients ≥18 years of age. Subgroups were categorized based on the presence of specific disorders like tricuspid or mitral valve disease, pulmonary hypertension, heart failure, or cardiac surgery combinations. Multivariable regression models were constructed to assess predictors of PAC use as well as PAC use as a predictor of loge hospitalization charges controlling for patient and hospital characteristics. Based on International Classification of Diseases procedure codes, PAC use was prevalent among 7.15 % of cardiac surgery hospitalizations, and hospitalization charges were estimated at $191,345, with no differences according to PAC use. Overall, being female, having Charlson comorbidity index (CCI) > 0, and non-payer (versus Medicare) status were independently associated with PAC use. Among the subgroup with the selected conditions, being female, having CCI>0, and being a Medicaid (versus Medicare) recipient were independently associated with PAC use, whereas elective admission was inversely related to PAC use. Among the subgroup without the selected conditions, having a CCI >0, elective admission, and non-payer (vs. Medicare) status were independently associated with PAC use. PAC use was not independently related to hospitalization charges overall or among subgroups. In conclusion, approximately 7 % of cardiac surgery hospitalizations received a PAC, with no differences in charges according to PAC use and disparities in PAC use driven by sex, elective admission, CCI and health insurance status. Large randomized trials are required to characterize the safety, efficacy, and cost-effectiveness of PAC use among distinct groups of patients undergoing cardiac surgery.
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Affiliation(s)
- Hind A. Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - May A. Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
| | - Shaker M. Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan B. Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
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2
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Khanna AK, Garcia JO, Saha AK, Harris L, Baruch M, Martin RS. Agreement between cardiac output estimation with a wireless, wearable pulse decomposition analysis device and continuous thermodilution in post cardiac surgery intensive care unit patients. J Clin Monit Comput 2024; 38:139-146. [PMID: 37458916 DOI: 10.1007/s10877-023-01059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/07/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE Pulse Decomposition Analysis (PDA) uses integration of the systolic area of a distally transmitted aortic pulse as well as arterial stiffness estimates to compute cardiac output. We sought to assess agreement of cardiac output (CO) estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CCO) and a wireless, wearable noninvasive device, (Vitalstream, Caretaker Medical, Charlottesville, VA), that utilizes the Pulse Decomposition Analysis (CO-PDA) method in postoperative cardiac surgery patients in the intensive care unit. METHODS CO-CCO measurements were compared with post processed CO-PDA measurements in prospectively enrolled adult cardiac surgical intensive care unit patients. Uncalibrated CO-PDA values were compared for accuracy with CO-CCO via a Bland-Altman analysis considering repeated measurements and a concordance analysis with a 10% exclusion zone. RESULTS 259.7 h of monitoring data from 41 patients matching 15,583 data points were analyzed. Mean CO-CCO was 5.55 L/min, while mean values for the CO-PDA were 5.73 L/min (mean of differences +- SD 0.79 ± 1.11 L/min; limits of agreement - 1.43 to 3.01 L/min), with a percentage error of 37.5%. CO-CCO correlation with CO-PDA was moderate (0.54) and concordance was 0.83. CONCLUSION Compared with the CO-CCO Swan-Ganz, cardiac output measurements obtained using the CO-PDA were not interchangeable when using a 30% threshold. These preliminary results were within the 45% limits for minimally invasive devices, and pending further robust trials, the CO-PDA offers a noninvasive, wireless solution to complement and extend hemodynamic monitoring within and outside the ICU.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Julio O Garcia
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Lynnette Harris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | - R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Shi Y, Zhu B, Zhang Y, Huang Y. Anesthetic management of a huge retroperitoneal leiomyoma: a case report. Perioper Med (Lond) 2023; 12:64. [PMID: 38017529 PMCID: PMC10683212 DOI: 10.1186/s13741-023-00352-w] [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: 08/21/2023] [Accepted: 11/12/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Retroperitoneal leiomyomas are rare, with just over 100 cases reported in the literature. Perioperative management of retroperitoneal leiomyomas can be challenging due to the large tumor size and the risk of hemorrhage. CASE PRESENTATION We report a case of a 40-year-old Han woman with a 40-cm retroperitoneal leiomyoma. General anesthesia was performed for the surgical resection. Key flow parameters like cardiac output and stroke volume variation, as shown by the Vigileo™-FloTrac™ system, enabled the anesthesiologist to implement goal-directed fluid optimization. Acute normovolemic hemodilution and cell salvage technique were used resulting in a successful en bloc tumor resection with a 6000-mL estimated blood loss. Although the patient experienced postoperative bowel obstruction, no other significant complications were observed. CONCLUSION Advanced hemodynamic monitoring and modern patient blood management strategies are particularly helpful for anesthetic management of huge retroperitoneal leiomyomas.
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Affiliation(s)
- Yue Shi
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Bo Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yu Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
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Chandrasekhar A, Padrós-Valls R, Pallarès-López R, Palanques-Tost E, Houstis N, Sundt TM, Lee HS, Sodini CG, Aguirre AD. Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit. Nat Med 2023; 29:1998-2006. [PMID: 37550417 DOI: 10.1038/s41591-023-02474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/09/2023]
Abstract
Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.
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Affiliation(s)
- Anand Chandrasekhar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimon Padrós-Valls
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Roger Pallarès-López
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Palanques-Tost
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas Houstis
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hae-Seung Lee
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charles G Sodini
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
- Center for Systems Biology, Massachusetts General Hospital, Boston, MA, USA.
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Gratz I, Baruch M, Awad A, McEniry B, Allen I, Seaman J. A new continuous noninvasive finger cuff device (Vitalstream) for cardiac output that communicates wirelessly via bluetooth or Wi-Fi. BMC Anesthesiol 2023; 23:180. [PMID: 37231335 DOI: 10.1186/s12871-023-02114-z] [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: 12/27/2022] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The new noninvasive Vitalstream (VS) continuous physiological monitor (Caretaker Medical LLC, Charlottesville, Virginia), allows continuous cardiac output by a low pump-inflated, finger cuff that pneumatically couples arterial pulsations via a pressure line to a pressure sensor for detection and analysis. Physiological data are communicated wirelessly to a tablet-based user interface via Bluetooth or Wi-Fi. We evaluated its performance against thermodilution cardiac output in patients undergoing cardiac surgery. METHODS We compared the agreement between thermodilution cardiac output to that obtained by the continuous noninvasive system during cardiac surgery pre and post-cardiac bypass. Thermodilution cardiac output was performed routinely when clinically indicated by an iced saline cold injectate system. All comparisons between VS and TD/CCO data were post-processed. In order to match the VS CO readings to the averaged discrete TD bolus data, the averaged CO readings of the ten seconds of VS CO data points prior to a sequence of TD bolus injections was matched. Time alignment was based on the medical record time and the VS time-stamped data points. The accuracy against reference TD measurements was assessed via Bland-Altman analysis of the CO values and standard concordance analysis of the ΔCO values (with a 15% exclusion zone). RESULTS Analysis of the data compared the accuracy of the matched measurement pairs of VS and TD/CCO VS absolute CO values with and without initial calibration to the discrete TD CO values, as well as the trending ability, i.e., ΔCO values of the VS physiological monitor compared to those of the reference. The results were comparable with other non-invasive as well as invasive technologies and Bland-Altman analyses showed high agreement between devices in a diverse patient population. The results are significant regarding the goal of expanding access to effective, wireless and readily implemented fluid management monitoring tools to hospital sections previously not covered because of the limitations of traditional technologies. CONCLUSION This study demonstrated that the agreement between the VS CO and TD CO was clinically acceptable with a percent error (PE) of 34.5 to 38% with and without external calibration. The threshold for an acceptable agreement between the VS and TD was considered to be below 40% which is below the threshold recommended by others.
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Affiliation(s)
- Irwin Gratz
- Cooper University Hospital, Camden, NJ, USA.
| | | | - Ahmed Awad
- Cooper University Hospital, Camden, NJ, USA
| | | | - Isabel Allen
- University of California, San Francisco, CA, USA
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Kee A, Kirchhoff B, Grigsby J, Proch K, Ji Y, Agashe H, Flynn BC. Prospective Evaluation of a Multibeat Analysis Cardiac Index Estimation in Patients With Cardiogenic Shock. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00236-7. [PMID: 37121841 DOI: 10.1053/j.jvca.2023.04.003] [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: 12/02/2022] [Revised: 03/22/2023] [Accepted: 04/02/2023] [Indexed: 05/02/2023]
Abstract
OBJECTIVES The decision algorithm for managing patients in cardiogenic shock depends on cardiac index (CI) estimates. Cardiac index estimation via thermodilution (CI-TD) using a pulmonary artery catheter is used commonly for obtaining CI in these patients. Minimally invasive methods of estimating CI, such as multibeat analysis (CI-MBA), may be an alternative in this population. DESIGN A prospective, observational study. SETTING Cardiac intensive care unit. PARTICIPANTS Twenty-two subjects in cardiogenic shock provided 101 paired CI measurements. INTERVENTIONS Measurements were obtained concomitantly by intermittent CI-TD and CI-MBA (Argos Cardiac Output Monitor; Retia Medical, Valhalla, NY). For each CI-TD, CI-MBA estimates were averaged over 1 minute to provide paired values. Bland-Altman and 4-quadrant analyses were performed by plotting changes between successive CI measurements (ΔCI) from each of the 2 methods. Concordance was calculated as a percentage using ΔCI data points from the 2 methods, outside an exclusion zone of 15%. MEASUREMENTS AND MAIN RESULTS The correlation coefficient between CI-MBA and CI-TD was 0.78 across patients. Mean CI-TD was 2.19 ± 0.46 L/min/m2 and mean CI-MBA was 2.38 ± 0.59 L/min/m2. The mean difference between CI-MBA and CI-TD (bias ± SD) was 0.20 ± 0.47 L/min/m2, and the limits of agreement were -0.72 to 1.11 L/min/m2. The percentage error was 40.0%. The concordance rate was 94%. A secondary analysis of a subgroup of patients during periods of arrhythmia demonstrated a similar accuracy of performance of CI-MBA. CONCLUSIONS Cardiac index-MBA is not interchangeable with CI-TD. However, CI-MBA provides reasonable correlation and clinically acceptable trending ability compared with CI-TD. Cardiac output-MBA may be useful in trending changes in CI in patients with cardiogenic shock, especially in those whose pulmonary artery catheterization placement carries a high risk or is unobtainable.
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Affiliation(s)
- Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center
| | - Brian Kirchhoff
- Department of Anesthesiology, University of Kansas Medical Center
| | - Joel Grigsby
- Department of Anesthesiology, University of Kansas Medical Center
| | - Katherine Proch
- Department of Anesthesiology, University of Kansas Medical Center
| | - Yoon Ji
- Department of Anesthesiology, University of Kansas Medical Center
| | | | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center.
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7
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Khanna AK, Nosow L, Sands L, Saha AK, Agashe H, Harris L, Martin RS, Marchant B. Agreement between cardiac output estimation by multi-beat analysis of arterial blood pressure waveforms and continuous thermodilution in post cardiac surgery intensive care unit patients. J Clin Monit Comput 2023; 37:559-565. [PMID: 36269451 PMCID: PMC10068656 DOI: 10.1007/s10877-022-00924-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
We sought to assess agreement of cardiac output estimation between continuous pulmonary artery catheter (PAC) guided thermodilution (CO-CTD) and a novel pulse wave analysis (PWA) method that performs an analysis of multiple beats of the arterial blood pressure waveform (CO-MBA) in post-operative cardiac surgery patients. PAC obtained CO-CTD measurements were compared with CO-MBA measurements from the Argos monitor (Retia Medical; Valhalla, NY, USA), in prospectively enrolled adult cardiac surgical intensive care unit patients. Agreement was assessed via Bland-Altman analysis. Subgroup analysis was performed on data segments identified as arrhythmia, or with low CO (less than 5 L/min). 927 hours of monitoring data from 79 patients was analyzed, of which 26 had arrhythmia. Mean CO-CTD was 5.29 ± 1.14 L/min (bias ± precision), whereas mean CO-MBA was 5.36 ± 1.33 L/min, (4.95 ± 0.80 L/min and 5.04 ± 1.07 L/min in the arrhythmia subgroup). Mean of differences was 0.04 ± 1.04 L/min with an error of 38.2%. In the arrhythmia subgroup, mean of differences was 0.14 ± 0.90 L/min with an error of 35.4%. In the low CO subgroup, mean of differences was 0.26 ± 0.89 L/min with an error of 40.4%. In adult patients after cardiac surgery, including those with low cardiac output and arrhythmia CO-MBA is not interchangeable with the continuous thermodilution method via a PAC, when using a 30% error threshold.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA.
| | - Lillian Nosow
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lauren Sands
- University of Maryland School of Medicine, Baltimore, USA
| | - Amit K Saha
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | | | - Lynnette Harris
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - R Shayn Martin
- Department of Surgery, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Bryan Marchant
- Section on Critical Care Medicine, Section on Cardiac Anesthesiology, Department of Anesthesiology, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Ramírez M, Mazwi ML, Bronicki RA, Checchia PA, Ong JSM. Beyond Conventional Hemodynamic Monitoring-Monitoring to Improve Our Understanding of Disease Process and Interventions. Crit Care Clin 2023; 39:243-254. [PMID: 36898771 DOI: 10.1016/j.ccc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring the hemodynamic state of patients is a hallmark of any intensive care environment. However, no single monitoring strategy can provide all the necessary data to paint the entire picture of the state of a patient; each monitor has strengths and weaknesses, advantages, and limitations. We review the currently available hemodynamic monitors used in pediatric critical care units using a clinical scenario. This provides the reader with a construct to understand the progression from basic to more advanced monitoring modalities and how they serve to inform the practitioner at the bedside.
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Affiliation(s)
- Michelle Ramírez
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Langone Medical Center, Hassenfeld Children's Hospital, New York, NY 10016, USA
| | - Mjaye L Mazwi
- Department of Critical Care Medicine, Division of Cardiology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Ronald A Bronicki
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, WT6-006, Houston, TX 77030, USA
| | - Paul A Checchia
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, WT6-006, Houston, TX 77030, USA
| | - Jacqueline S M Ong
- Division of Paediatric Critical Care, Khoo Teck Puat - University Children's Medical Institute, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore 119228; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 21 Lower Kent Ridge Road, Singapore 119077.
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Central Venous Waveform Analysis and Cardiac Output in a Porcine Model of Endotoxemic Hypotension and Resuscitation. J Am Coll Surg 2023; 236:294-304. [PMID: 36648257 DOI: 10.1097/xcs.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cardiac output (CO) is a valuable proxy for perfusion, and governs volume responsiveness during resuscitation from distributive shock. The underappreciated venous system has nuanced physiology that confers valuable hemodynamic information. In this investigation, deconvolution of the central venous waveform by the fast Fourier transformation (FFT) algorithm is performed to assess its ability to constitute a CO surrogate in a porcine model of endotoxemia-induced distributive hypotension and resuscitation. STUDY DESIGN Ten pigs were anesthetized, catheterized, and intubated. A lipopolysaccharides infusion protocol was used to precipitate low systemic vascular resistance hypotension. Four crystalloid boluses (10 cc/kg) were then given in succession, after which heart rate, mean arterial pressure, thermodilution-derived CO, central venous pressure (CVP), and the central venous waveform were collected, the last undergoing fast Fourier transformation analysis. The amplitude of the fundamental frequency of the central venous waveform's cardiac wave (f0-CVP) was obtained. Heart rate, mean arterial pressure, CVP, f0-CVP, and CO were plotted over the course of the boluses to determine whether f0-CVP tracked with CO better than the vital signs, or than CVP itself. RESULTS Distributive hypotension to a 25% mean arterial pressure decrement was achieved, with decreased systemic vascular resistance (mean 918 ± 227 [SD] dyne/s/cm-5 vs 685 ± 180 dyne/s/cm-5; p = 0.038). Full hemodynamic parameters characterizing this model were reported. Slopes of linear regression lines of heart rate, mean arterial pressure, CVP, f0-CVP, and CO were -2.8, 1.7, 1.8, 0.40, and 0.35, respectively, demonstrating that f0-CVP values closely track with CO over the 4-bolus range. CONCLUSIONS Fast Fourier transformation analysis of the central venous waveform may allow real-time assessment of CO during resuscitation from distributive hypotension, possibly offering a venous-based approach to clinical estimation of volume responsiveness.
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Oh C, Lee S, Oh P, Chung W, Ko Y, Yoon SH, Kim YH, Ji SM, Hong B. Comparison between Fourth-Generation FloTrac/Vigileo System and Continuous Thermodilution Technique for Cardiac Output Estimation after Time Adjustment during Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11206093. [PMID: 36294414 PMCID: PMC9605331 DOI: 10.3390/jcm11206093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 12/01/2022] Open
Abstract
(1) Background: Previous studies reported limited performance of arterial pressure waveform-based cardiac output (CO) estimation (FloTrac/Vigileo system; CO-FloTrac) compared with the intermittent thermodilution technique (COint). However, errors due to bolus maneuver and intermittent measurements of COint could limit its use as a reference. The continuous thermodilution technique (COcont) may relieve such limitations. (2) Methods: The performance of CO-FloTrac was retrospectively assessed using continuous recordings of intraoperative physiological data acquired from patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery with CO monitoring using both CO-FloTrac and COcont. Optimal time adjustments between the two measurements were determined based on R-squared values. (3) Results: A total of 134.2 h of data from 30 patients was included in the final analysis. The mean bias was -0.94 (95% CI, -1.35 to -0.52) L/min and the limits of agreements were -3.64 (95% CI, -4.44 to -3.08) L/min and 1.77 (95% CI, 1.21 to 2.57) L/min. The percentage error was 66.1% (95% CI, 52.4 to 85.8%). Depending on the time scale and the size of the exclusion zone, concordance rates ranged from 61.0% to 75.0%. (4) Conclusion: Despite the time adjustments, CO-FloTrac showed non-negligible overestimation, clinically unacceptable precision, and poor trending ability during OPCAB surgery.
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Affiliation(s)
- Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Soomin Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Pyeonghwa Oh
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan 31116, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Seok-Hwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Yoon-Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
| | - Sung-Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan 31116, Korea
- Correspondence: (S.-M.J.); (B.H.)
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon 34134, Korea
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, Daejeon 35015, Korea
- Correspondence: (S.-M.J.); (B.H.)
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Effect of Early Exercise Rehabilitation on Cardiopulmonary Function and Quality of Life in Patients after Coronary Artery Bypass Grafting. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4590037. [PMID: 36003994 PMCID: PMC9385281 DOI: 10.1155/2022/4590037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to analyze the effect of early exercise rehabilitation on cardiopulmonary function and quality of life in patients after coronary artery bypass grafting (CABG). Eighty patients with coronary heart disease who underwent CABG from April 2020 to April 2022 were divided into the study group (n = 40) and control group (n = 40). The control group was given conventional treatment and routine care after CABG, and the study group received early exercise rehabilitation according to the control group. The cardiac function indexes, 6-minute walking test (6MWT), and cardiopulmonary function indexes and quality of life of the two groups were compared before and after the intervention, and the length of hospitalization and hospital costs as well as the occurrence of pulmonary complications in both groups were recorded. Left ventricular ejection fraction (LVEF) was significantly higher (P < 0.05), and left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic diameter (LVESD) were significantly lower (P < 0.05) in the study group than in the control group after the intervention; 6MWT, maximal oxygen consumption (VO2max), and anaerobic threshold (AT) were significantly higher (P < 0.05) in the study group than in the control group after the intervention; physical function (PF), role physical (RP), general health (GH), and role emotional (RE) dimension scores were significantly higher (P < 0.05) in the study group compared with the control group after the intervention The differences in the scores of the remaining dimensions were not statistically significant (P > 0.05); the total hospitalization time in the test group was significantly shorter than that in the control group (P < 0.05), the hospitalization cost was significantly less than that in the control group (P < 0.05), and the total incidence of pulmonary infection and hypoxemia was significantly lower than that in the control group (P < 0.05). Early exercise rehabilitation can effectively improve cardiopulmonary function and exercise tolerance and improve the quality of life of patients after CABG.
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The Use of the Hypotension Prediction Index Integrated in an Algorithm of Goal Directed Hemodynamic Treatment during Moderate and High-Risk Surgery. J Clin Med 2021; 10:jcm10245884. [PMID: 34945177 PMCID: PMC8707257 DOI: 10.3390/jcm10245884] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022] Open
Abstract
(1) Background: The Hypotension Prediction Index (HPI) is an algorithm that predicts hypotension, defined as mean arterial pressure (MAP) less than 65 mmHg for at least 1 min, based on arterial waveform features. We tested the hypothesis that the use of this index reduces the duration and severity of hypotension during noncardiac surgery. (2) Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized 1:1 to standard of care or hemodynamic management with HPI guidance with a goal directed hemodynamic treatment protocol. The trigger to initiate treatment (with fluids, vasopressors, or inotropes) was a value of HPI of 85 (range, 0–100) or higher in the intervention group. Primary outcome was the amount of hypotension, defined as time-weighted average (TWA) MAP less than 65 mmHg. Secondary outcomes were time spent in hypertension defined as MAP more than 100 mmHg for at least 1 min; medication and fluids administered and postoperative complications. (3) Results: We obtained data from 99 patients. The median (IQR) TWA of hypotension was 0.16 mmHg (IQR, 0.01–0.32 mmHg) in the intervention group versus 0.50 mmHg (IQR, 0.11–0.97 mmHg) in the control group, for a median difference of −0.28 (95% CI, −0.48 to −0.09 mmHg; p = 0.0003). We also observed an increase in hypertension in the intervention group as well as a higher weight-adjusted administration of phenylephrine in the intervention group. (4) Conclusions: In this single-center prospective study of patients undergoing elective noncardiac surgery, the use of this prediction model resulted in less intraoperative hypotension compared with standard care. An increase in the time spent in hypertension in the treatment group was also observed, probably as a result of overtreatment. This should provide an insight for refining the use of this prediction index in future studies to avoid excessive correction of blood pressure.
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