1
|
Mendrala K, Darocha T, Brožek T, Kosiński S, Balik M, Cools E, Walpoth B, Nowak E, Dąbrowski W, Miazgowski B, Reszka K, Rutkiewicz A, Debaty G, Segond N, Dudek M, Górski S, Podsiadło P. Prognostic thresholds of outcome predictors in severe accidental hypothermia. Intern Emerg Med 2024:10.1007/s11739-024-03741-1. [PMID: 39264547 DOI: 10.1007/s11739-024-03741-1] [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: 10/29/2023] [Accepted: 08/06/2024] [Indexed: 09/13/2024]
Abstract
Hemodynamically unstable patients with severe hypothermia and preserved circulation should be transported to dedicated extracorporeal life support (ECLS) centers, but not all are eligible for extracorporeal therapy. In this group of patients, the outcome of rewarming may sometimes be unfavorable. It is, therefore, crucial to identify potential risk factors for death. Furthermore, it is unclear what criterion for hemodynamic stability should be adopted for patients with severe hypothermia. The aim of this study is to identify pre-rewarming predictors of death and their threshold values in hypothermic patients with core temperature ≤ 28 °C and preserved circulation, who were treated without extracorporeal rewarming. We conducted a multicenter retrospective study involving patients in accidental hypothermia with core temperature 28 °C or lower, and preserved spontaneous circulation on rewarming initiation. The data were collected from the International Hypothermia Registry, HELP Registry, and additional hospital data. The primary outcome was survival to hospital discharge. We conducted a multivariable logistic regression and receiver operating characteristic curve (ROC) analysis. In the multivariate analysis of laboratory tests and vital signs, systolic blood pressure (SBP) adjusted for cooling circumstances and base excess (BE) were identified as the best predictor of death (OR 0.974 95% CI 0.952-0.996), AUC ROC 0.79 (0.70-0.88). The clinically relevant cutoff for SBP was identified at 90 mmHg with a sensitivity of 0.74 (0.54-0.89) and a specificity of 0.70 (0.60-0.79). The increased risk of death among hypothermic patients with preserved circulation occurs among those with an SBP below 90 mmHg and in those who developed hypothermia in their homes.
Collapse
Affiliation(s)
- Konrad Mendrala
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland.
| | - Tomasz Darocha
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Tomáš Brožek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Sylweriusz Kosiński
- Department of Intensive Interdisciplinary Therapy, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Evelien Cools
- Department of Acute Medicine, Division of Anaesthesiology, University Hospitals, Geneva, Switzerland
| | - Beat Walpoth
- Emeritus. Department of Cardiovascular Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Ewelina Nowak
- Institute of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Wojciech Dąbrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Bartosz Miazgowski
- Emergency Department, University Hospital, Pomeranian Medical University, Szczecin, Poland
| | - Kacper Reszka
- Department of Anaesthesiology and Intensive Care, University Hospital, Łódź, Poland
| | | | - Guillaume Debaty
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, 38000, Grenoble, France
| | - Nicolas Segond
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, 38000, Grenoble, France
| | - Michał Dudek
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko, Biała, Poland
| | - Stanisław Górski
- Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| |
Collapse
|
2
|
Muller G, Kamel T, Contou D, Ehrmann S, Martin M, Quenot JP, Lacherade JC, Boissier F, Monnier A, Vimeux S, Brunet Houdard S, Tavernier E, Boulain T. Early ve rsus differed arterial catheterisation in critically ill patients with acute circulatory failure: a multicentre, open-label, pragmatic, randomised, non-inferiority controlled trial: the EVERDAC protocol. BMJ Open 2021; 11:e044719. [PMID: 34521655 PMCID: PMC8442046 DOI: 10.1136/bmjopen-2020-044719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The use of peripheral indwelling arterial catheter for haemodynamic monitoring is widespread in the intensive care unit and is recommended in patients with shock. However, there is no evidence that the arterial catheter could improve patient's outcome, whereas the burden of morbidity generated is significant (pain, thrombosis, infections). We hypothesise that patients with shock may be managed without an arterial catheter. METHODS AND ANALYSIS The EVERDAC study is an investigator-initiated, pragmatic, multicentre, randomised, controlled, open-label, non-inferiority clinical trial, comparing a less invasive intervention (ie, no arterial catheter insertion until felt absolutely needed, according to predefined safety criteria) or usual care (ie, systematic arterial catheter insertion in the early hours of shock). 1010 patients will be randomised with a 1:1 ratio in two groups according to the strategy. The primary outcome is all-cause mortality by 28 days after inclusion. A health economic analysis will be carried out. ETHICS AND DISSEMINATION The study has been approved by the Ethics Committee (Comité de Protection des Personnes Île de France V, registration number 61606 CAT 2, 19 july 2018) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03680963.
Collapse
Affiliation(s)
- Grégoire Muller
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans, France
- CRICS-TriggerSEP F-CRIN research network, Tours, France
| | - Toufik Kamel
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans, France
- CRICS-TriggerSEP F-CRIN research network, Tours, France
| | - Damien Contou
- Réanimation Polyvalente, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Stephan Ehrmann
- Médecin Intensive Réanimation, CIC 1415, CRICS-TriggerSEP F-CRIN research network and Centre d'étude des Pathologies Respiratoires, INSERM U1100, Université de Tours, Centre Hospitalier Régional Universitaire de Tours, Tours, Centre, France
| | - Maëlle Martin
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, Pays de la Loire, France
| | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Jean-Claude Lacherade
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Departmental La Roche-sur-Yon, La Roche-sur-Yon, Pays de la Loire, France
| | - Florence Boissier
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- ALIVE group, INSERM CIC 1402, Université de Poitiers, Poitiers, France
| | - Alexandra Monnier
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, Alsace, France
| | - Sylvie Vimeux
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Montauban, Montauban, Midi-Pyrénées, France
| | | | - Elsa Tavernier
- Clinical Investigation Center, INSERM 1415, CHRU Tours, Tours, France
- Methods in Patients-Centered Outcomes and Health Research, INSERM UMR 1246, Nantes, France
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans, France
- CRICS-TriggerSEP F-CRIN research network, Tours, France
| |
Collapse
|
3
|
Hamzaoui O, Teboul JL. Importance of diastolic arterial pressure in septic shock: PRO. J Crit Care 2018; 51:238-240. [PMID: 30447892 DOI: 10.1016/j.jcrc.2018.10.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, Hôpitaux universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Jean-Louis Teboul
- Service de réanimation médicale, Hôpital Bicêtre, Hôpitaux universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, Faculté de médecine Paris-Sud, Université Paris-Sud, France.
| |
Collapse
|
4
|
Boulain T, Garot D, Vignon P, Lascarrou JB, Benzekri-Lefevre D, Dequin PF. Predicting arterial blood gas and lactate from central venous blood analysis in critically ill patients: a multicentre, prospective, diagnostic accuracy study. Br J Anaesth 2018; 117:341-9. [PMID: 27543529 DOI: 10.1093/bja/aew261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The estimation of arterial blood gas and lactate from central venous blood analysis and pulse oximetry [Formula: see text] readings has not yet been extensively validated. METHODS In this multicentre, prospective study performed in 590 patients with acute circulatory failure, we measured blood gases and lactate in simultaneous central venous and arterial blood samples at 6 h intervals during the first 24 h after insertion of central venous and arterial catheters. The study population was randomly divided in a 2:1 ratio into model derivation and validation sets. We derived predictive models of arterial pH, carbon dioxide partial pressure, oxygen saturation, and lactate, using clinical characteristics, [Formula: see text], and central venous blood gas values as predictors, and then tested their performance in the validation set. RESULTS In the validation set, the agreement intervals between predicted and actual values were -0.078/+0.084 units for arterial pH, -1.32/+1.36 kPa for arterial carbon dioxide partial pressure, -5.15/+4.47% for arterial oxygen saturation, and -1.07/+1.05 mmol litre(-1) for arterial lactate (i.e. around two times our predefined clinically tolerable intervals for all variables). This led to ∼5% (or less) of extreme-to-extreme misclassifications, thus giving our predictive models only marginal agreement. Thresholds of predicted variables (as determined from the derivation set) showed high predictive values (consistently >94%), to exclude abnormal arterial values in the validation set. CONCLUSIONS Using clinical characteristics, [Formula: see text], and central venous blood analysis, we predicted arterial blood gas and lactate values with marginal accuracy in patients with circulatory failure. Further studies are required to establish whether the developed models can be used with acceptable safety.
Collapse
Affiliation(s)
- T Boulain
- Medical-Surgical Intensive Care Unit, Regional Hospital Centre, avenue de l'Hôpital, Orléans F-45067, France
| | - D Garot
- Medical Intensive Care Unit, University Hospital, Tours, France
| | - P Vignon
- Medical-Surgical Intensive Care Unit, University Hospital, Limoges, France CIC-P 1435, Inserm U1092, Limoges, France
| | - J-B Lascarrou
- Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France
| | - D Benzekri-Lefevre
- Medical-Surgical Intensive Care Unit, Regional Hospital Centre, Orléans, France
| | - P-F Dequin
- Medical Intensive Care Unit, University Hospital, Tours, France
| | | |
Collapse
|
5
|
Bellini L, Veladiano IA, Schrank M, Candaten M, Mollo A. Prospective clinical study to evaluate an oscillometric blood pressure monitor in pet rabbits. BMC Vet Res 2018; 14:52. [PMID: 29482612 PMCID: PMC5827987 DOI: 10.1186/s12917-018-1369-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 02/12/2018] [Indexed: 01/17/2023] Open
Abstract
Background Rabbits are particularly sensitive to develop hypotension during sedation or anaesthesia. Values of systolic or mean non-invasive arterial blood pressure below 80 or 60 mmHg respectively are common under anaesthesia despite an ongoing surgery. A reliable method of monitoring arterial blood pressure is extremely important, although invasive technique is not always possible due to the anatomy and dimension of the artery. The aim of this study was to evaluate the agreement between a new oscillometric device for non-invasive arterial blood pressure measurement and the invasive method. Moreover the trending ability of the device, ability to identify changes in the same direction with the invasive methods, was evaluated as well as the sensibility of the device in identifying hypotension arbitrarily defined as invasive arterial blood pressure below 80 or 60 mmHg. Results Bland-Altman analysis for repeated measurements showed a poor agreement between the two methods; the oscillometric device overestimated the invasive arterial blood pressure, particularly at high arterial pressure values. The same analysis repeated considering oscillometric measurement that match invasive mean pressure lower or equal to 60 mmHg showed a decrease in biases and limits of agreement between methods. The trending ability of the device, evaluated with both the 4-quadrant plot and the polar plot was poor. Concordance rate of mean arterial blood pressure was higher than systolic and diastolic pressure although inferior to 90%. The sensibility of the device in detecting hypotension defined as systolic or mean invasive arterial blood pressure lower than 80 or 60 mmHg was superior for mean oscillometric pressure rather than systolic. A sensitivity of 92% was achieved with an oscillometric measurement for mean pressure below 65 mmHg instead of 60 mmHg. Non-invasive systolic blood pressure is less sensitive as indicator of hypotension regardless of the cutoff limit considered. Conclusions Although mean invasive arterial blood pressure is overestimated by the device, the sensitivity of this non-invasive oscillometric monitor in detecting invasive mean pressure below 60 mmHg is acceptable but a cutoff value of 65 mmHg needs to be used.
Collapse
Affiliation(s)
- Luca Bellini
- Veterinary Teaching Hospital, University of Padua, Viale dell'Università 16, 35020, Legnaro, PD, Italy.
| | - Irene A Veladiano
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università 16, 35020, Legnaro, PD, Italy
| | - Magdalena Schrank
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università 16, 35020, Legnaro, PD, Italy
| | - Matteo Candaten
- Veterinary Teaching Hospital, University of Padua, Viale dell'Università 16, 35020, Legnaro, PD, Italy
| | - Antonio Mollo
- Department of Animal Medicine, Production and Health, University of Padua, Viale dell'Università 16, 35020, Legnaro, PD, Italy
| |
Collapse
|
6
|
Noninvasive BP Monitoring in the Critically Ill: Time to Abandon the Arterial Catheter? Chest 2017; 153:1023-1039. [PMID: 29108815 DOI: 10.1016/j.chest.2017.10.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/11/2017] [Accepted: 10/26/2017] [Indexed: 12/17/2022] Open
Abstract
Although its reliability is often questioned, noninvasive BP (NIBP)-monitoring with an oscillometric arm cuff is widely used, even in critically ill patients in shock. When correctly implemented, modern arm NIBP devices can provide accurate and precise measurements of mean BP, as well as clinically meaningful information such as identification of hypotension and hypertension and monitoring of patient response to therapy. Even in specific circumstances such as arrhythmia, hypotension, vasopressor infusion, and possibly in obese patients, arm NIBP may be useful, contrary to widespread belief. Hence, postponing the arterial catheter insertion pending the initiation of more urgent diagnostic and therapeutic measures could be a suitable strategy. Given the arterial catheter-related burden, fully managing critically ill patients without any arterial catheter may also be an option. Indeed, the benefit that patients may experience from an arterial catheter has been questioned in studies failing to show that its use reduces mortality. However, randomized controlled trials to confirm that NIBP can safely fully replace the arterial catheter have yet to be performed. In addition to intermittent measurements, continuous NIBP monitoring is a booming field, as illustrated by the release onto the market of user-friendly devices, based on digital volume clamp and applanation tonometry. Although the imperfect accuracy and precision of these devices would probably benefit from technical refinements, their good ability to track, in real time, the direction of changes in BP is an undeniable asset. Their drawbacks and advantages and whether these devices are currently ready to use in the critically ill patient are discussed in this review.
Collapse
|
7
|
Hundeshagen G, Kramer GC, Ribeiro NM, Salter M, Koutrouvelis AK, Li H, Solanki D, Indrikovs A, Seeton R, Henkel SN, Kinsky MP. Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage. Crit Care Med 2017; 45:e1068-e1074. [PMID: 28682837 PMCID: PMC5600681 DOI: 10.1097/ccm.0000000000002593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation. DESIGN Experimental human hemorrhage and resuscitation. SETTING Clinical research laboratory. SUBJECTS Healthy volunteers. INTERVENTIONS Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency. MEASUREMENTS AND MAIN RESULTS All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: -0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration. CONCLUSIONS We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.
Collapse
Affiliation(s)
- Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - George C. Kramer
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Nicole M. Ribeiro
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael Salter
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Aristides K. Koutrouvelis
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Husong Li
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Daneshvari Solanki
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Alexander Indrikovs
- Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Hofstra Northwell School of Medicine, Department of Pathology, 500 Hofstra Blvd, Hempstead, NY 11549
| | - Roger Seeton
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Sheryl N Henkel
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael P Kinsky
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| |
Collapse
|
8
|
Reshetnik A, Compton F, Schölzel A, Tölle M, Zidek W, Giet MVD. Noninvasive oscillometric cardiac output determination in the intensive care unit - comparison with invasive transpulmonary thermodilution. Sci Rep 2017; 7:9997. [PMID: 28855727 PMCID: PMC5577225 DOI: 10.1038/s41598-017-10527-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/09/2017] [Indexed: 11/09/2022] Open
Abstract
Assessment of the cardiac output (CO) is usually performed with invasive techniques requiring specialized equipment in the intensive care unit (ICU). With TEL-O-GRAPH (TG), CO can be derived from the oscillometrically obtained brachial pulse wave during the measurement of brachial blood pressure. CO and stroke volume (SV) determinations with TG were compared with transpulmonary thermodilution measurements with the PICCO system (PICCO) in 38 haemodynamically unstable ICU patients with a total of 84 comparison measurements performed. SV (33.3 ± 9.0 ml/m2 vs. 44.3 ± 14.4 ml/m2, p < 0.001) and CO (2.7 ± 0.5 l/min/m2 vs. 3.8 ± 1.2 l/min/m2, p < 0.001) were underestimated significantly with TG and oscillometric brachial systolic blood pressure (BP) was significantly lower and diastolic BP significantly higher than invasive femoral artery pressure. A linear correlation was found between CO dimension and CO underestimation with TG. Correct tracking of CO changes with a fluid challenge was possible in 69.5% of measurements. Oscillometric noninvasive CO is possible in the ICU, but accuracy and precision of this new method are lacking. Implementation of a correction factor accounting for the linear increase in CO underestimation observed with increasing CO could improve CO assessment with TG in haemodynamically unstable patients.
Collapse
Affiliation(s)
- Alexander Reshetnik
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Friederike Compton
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Anna Schölzel
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Markus Tölle
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Walter Zidek
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Markus van der Giet
- Department of Nephrology and intensive care medicine, Charité Universitaetsmedizin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| |
Collapse
|
9
|
Lakhal K, Martin M, Faiz S, Ehrmann S, Blanloeil Y, Asehnoune K, Rozec B, Boulain T. The CNAP™ Finger Cuff for Noninvasive Beat-To-Beat Monitoring of Arterial Blood Pressure. Anesth Analg 2016; 123:1126-1135. [DOI: 10.1213/ane.0000000000001324] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
10
|
Joffe R, Duff J, Garcia Guerra G, Pugh J, Joffe AR. The accuracy of blood pressure measured by arterial line and non-invasive cuff in critically ill children. Crit Care 2016; 20:177. [PMID: 27268414 PMCID: PMC4897864 DOI: 10.1186/s13054-016-1354-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The accuracy of arterial lines (AL) using the flush test or stopcock test has not been described in children, nor has the difference between invasive arterial blood pressure (IABP) versus non-invasive cuff (NIBP) blood pressure. METHODS After ethics approval and consent, we performed the flush test and stopcock test on AL (to determine over damping, under damping, and optimal damping), and determined the difference (NIBP-IABP) in systolic, diastolic, and mean blood pressure (ΔSBP, ΔDBP, and ΔMAP). The primary outcome was incidence (95 % CI) of optimally damped AL. Predictors of ΔBP (effect size (95 % CI)) were determined using multiple linear regression. RESULTS There were 147 AL tests in 100 enrolled patients with mean age 44.7 (SD 56) months, weight 16.8 (SD 18.3) kg, male 59 %, postoperative-cardiovascular 52 %, peripheral-AL 78 %, inotropes 29 %, vasodilators 15 %, and ventilated 73 %. The flush test performed in 66 patients (45 %) showed optimal damping in 30 (46 %; 95 % CI 34, 57 %), over damping in 25 (38 %) and under damping in 11 patients (17 %). The stopcock test was over-damped in 128/146 patients (88 %), with the same damping as the flush test in 24/64 (38 %). In optimally damped (flush test) AL, ΔSBP, ΔDBP, and ΔMAP were 0.8 (SD 12.2), -5.2 (SD 8.7), and -4.9 (7.6) respectively. A second set of AL tests was done 2 h later on the same day in 62 patients; AL damping often changed (10/28 flush tests) and ΔBPs correlated poorly (r = 0.31-0.55). Predictors (effect size) of ΔDBP were vasodilator infusion (15.6 (2.9 to 28.3); p = 0.016) and optimal damping (-7.2 (-12.2 to 2.2); p = 0.005); and of ΔMAP were vasodilator infusion (10.0 (-0.3 to 20.4); p = 0.057) and optimal damping (-4.0 (-8 to 0.1); p = 0.058). There were no independent predictors of damping category (n = 66 flush tests). CONCLUSIONS Optimally damped AL occur in half of critically ill children, and this is not predictable. There is much variability in ∆BP between NIBP and the gold standard IABP, and this varies even in the same patient on the same day, and is not easily predictable. In critically ill children, NIBP may not be accurate enough to guide management, and more attention to ensuring the AL is optimally damped is needed.
Collapse
Affiliation(s)
- Rachel Joffe
- University of Alberta, Faculty of Science, Edmonton, Alberta, Canada
| | - Jonathan Duff
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jodie Pugh
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada. .,4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| |
Collapse
|
11
|
Kumasawa J, Ohara A, Kohata H, Aoyagi K, Fukuma S, Fukuhara S. Detecting central-venous oxygen desaturation without a central-venous catheter: Utility of the difference between invasively and noninvasively measured blood pressure. J Crit Care 2016; 33:257-61. [PMID: 26994778 DOI: 10.1016/j.jcrc.2016.02.022] [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: 12/28/2015] [Revised: 02/05/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective was to determine whether central-venous oxygen saturation (ScvO2<70%) can be detected from the difference between invasively and noninvasively measured systolic blood pressure (BP) (ie, ΔBP defined as arterial BP minus noninvasive BP). METHODS This is a cross-sectional study at a single medical and surgical intensive care unit in Japan. All hypotensive patients admitted to intensive care unit were eligible. Arterial BP was measured via a radial-artery catheter, and noninvasive BP on the same side was measured via a brachial cuff. ScvO2 was measured by gas analysis of blood sampled from a central-venous chatheter (CVC). We calculate the area under the curve for ΔBP as an indicator of ScvO2<70%. RESULTS Usable data were obtained from the records of 111 patients. The median and interquartile range of ΔBP and ScvO2 were -4mm Hg (-11, 6) and 67% (60.9, 73.9), respectively. The area under the curve of ΔBP as an indicator of ScvO2<70% was 0.81 (95% confidence interval [CI], 0.73-0.89). With a cutoff ΔBP of 0, sensitivity was 65.7% (95% CI, 53.1-76.8), specificity was 97.7% (95% CI, 88.0-99.8), and positive predictive value was 97.8 (95% CI, 88.2-99.9). CONCLUSIONS ΔBP can indicate whether ScvO2 is lower than 70%. When that difference is greater than 0, ScvO2 is very likely to be lower than 70%.
Collapse
Affiliation(s)
- Junji Kumasawa
- Department of Healthcare Epidemiology, School of Public Health, Kyoto University Faculty of Medicine, Yoshidakonoe-cho, Sakyo-ku, Kyoto City, Japan 606-8315; Department of Critical Care Medicine, Sakai City Medical Center, Ebaraji-cho 1-1-1, Nishi-ku, Sakai City, Japan 593-8304.
| | - Akitoshi Ohara
- Department of Critical Care Medicine, Sakai City Medical Center, Ebaraji-cho 1-1-1, Nishi-ku, Sakai City, Japan 593-8304
| | - Hisakazu Kohata
- Department of Critical Care Medicine, Sakai City Medical Center, Ebaraji-cho 1-1-1, Nishi-ku, Sakai City, Japan 593-8304
| | - Kenichi Aoyagi
- Department of Critical Care Medicine, Sakai City Medical Center, Ebaraji-cho 1-1-1, Nishi-ku, Sakai City, Japan 593-8304
| | - Shingo Fukuma
- Department of Healthcare Epidemiology, School of Public Health, Kyoto University Faculty of Medicine, Yoshidakonoe-cho, Sakyo-ku, Kyoto City, Japan 606-8315
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health, Kyoto University Faculty of Medicine, Yoshidakonoe-cho, Sakyo-ku, Kyoto City, Japan 606-8315; Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Hikarigaoka, Fukushima City, Japan 960-1295
| |
Collapse
|
12
|
Greau E, Lascarrou JB, Le Thuaut A, Maquigneau N, Alcourt Y, Coutolleau A, Rousseau C, Erragne V, Reignier J. Automatic versus manual changeovers of norepinephrine infusion pumps in critically ill adults: a prospective controlled study. Ann Intensive Care 2015; 5:40. [PMID: 26577132 PMCID: PMC4648838 DOI: 10.1186/s13613-015-0083-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 11/02/2015] [Indexed: 12/21/2022] Open
Abstract
Background Norepinephrine is a key drug for treating shock but has a short half-life that requires continuous intravenous administration to maintain the constant plasma concentration needed to obtain a stable blood pressure. The small volume of the syringes used in power infusion pumps requires frequent changeovers, which can lead to norepinephrine flow interruptions responsible for hemodynamic instability. Changeovers from the nearly empty to the full syringe can be performed manually using the quick change technique (QC) or automatically using smart infusion pumps (SIP) that link two syringes. The purpose of our study was to evaluate the hypothesis that, compared to QC, SIP for norepinephrine changeovers was associated with less hemodynamic instability. Methods After information of the patient or next of kin, patients receiving norepinephrine for shock were allocated to QC or SIP changeovers. QC changeovers were performed by a nurse, who started a new loaded pump when the previous syringe was nearly empty. SIP changeovers were managed automatically by SIP workstations. The primary outcome was the proportion of changeovers followed by a ≥20 % drop in mean arterial pressure (MAP). Results 411 changeovers were performed, 193 in the 18 patients allocated to QC and 218 in the 32 patients allocated to SIP. Baseline patient characteristics were similar in both groups. The proportion of changeovers followed by an MAP drop ≥20 % was 12.4 % (24/193) with QC and 5.5 % (12/218) with SIP (P = 0.01). By multivariate analysis, two factors were independently associated with a significantly decreased risk of ≥20 % MAP drops during changeovers, namely, SIP (odds ratio, 0.47; 95 % confidence interval, 0.22–0.98) and norepinephrine dosage >0.5 μg/kg/min (odds ratio, 0.39; 95 % confidence interval, 0.19–0.81). Conclusions The risk of MAP drops ≥20 % during changeovers can be significantly diminished using SIPs instead of the QC method. Trial registration: Clinicaltrial.gov NCT 01127152
Collapse
Affiliation(s)
- Emilie Greau
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | | | - Aurélie Le Thuaut
- Clinical Research Unit, District Hospital Center, La Roche-sur-Yon, France. .,Délégation à la Recherche Clinique et à l'Innovation, CHU Hôtel Dieu, 44093, Nantes Cedex, France.
| | - Nathalie Maquigneau
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | - Yolaine Alcourt
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | - Anne Coutolleau
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | - Cécile Rousseau
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | - Vanessa Erragne
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France.
| | - Jean Reignier
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. .,UPRES EA-3826, Clinical and Experimental Therapies for Infections, University of Nantes, Nantes, France. .,Medical Intensive Care Unit, Nantes University Hospital, Nantes, France.
| |
Collapse
|
13
|
Romagnoli S, Ricci Z, Quattrone D, Tofani L, Tujjar O, Villa G, Romano SM, De Gaudio AR. Accuracy of invasive arterial pressure monitoring in cardiovascular patients: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:644. [PMID: 25433536 PMCID: PMC4279904 DOI: 10.1186/s13054-014-0644-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 11/05/2014] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Critically ill patients and patients undergoing high-risk and major surgery, are instrumented with intra-arterial catheters and invasive blood pressure is considered the "gold standard" for arterial pressure monitoring. Nonetheless, artifacts due to inappropriate dynamic response of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values. We sought to analyze the incidence and causes of resonance/underdamping phenomena in patients undergoing major vascular and cardiac surgery. METHODS Arterial pressures were measured invasively and, according to the fast-flush Gardner's test, each patient was attributed to one of two groups depending on the presence (R-group) or absence (NR-group) of resonance/underdamping. Invasive pressure values were then compared with the non-invasive ones. RESULTS A total of 11,610 pulses and 1,200 non-invasive blood pressure measurements were analyzed in 300 patients. Ninety-two out of 300 (30.7%) underdamping/resonance arterial signals were found. In these cases (R-group) systolic invasive blood pressure (IBP) average overestimation of non-invasive blood pressure (NIBP) was 28.5 (15.9) mmHg (P <0.0001) while in the NR-group the overestimation was 4.1(5.3) mmHg (P < 0.0001). The mean IBP-NIBP difference in diastolic pressure in the R-group was -2.2 (10.6) mmHg and, in the NR-group -1.1 (5.8) mmHg. The mean arterial pressure difference was 7.4 (11.2) mmHg in the R-group and 2.3 (6.4) mmHg in the NR-group. A multivariate logistic regression identified five parameters independently associated with underdamping/resonance: polydistrectual arteriopathy (P = 0.0023; OR = 2.82), history of arterial hypertension (P = 0.0214; OR = 2.09), chronic obstructive pulmonary disease (P = 0.198; OR = 2.61), arterial catheter diameter (20 vs. 18 gauge) (P < 0.0001; OR = 0.35) and sedation (P = 0.0131; OR = 0.5). The ROC curve for the maximal pressure-time ratio, showed an optimum selected cut-off point of 1.67 mmHg/msec with a specificity of 97% (95% CI: 95.13 to 99.47%) and a sensitivity of 77% (95% CI: 67.25 to 85.28%) and an area under the ROC curve by extended trapezoidal rule of 0.88. CONCLUSION Physicians should be aware of the possibility that IBP can be inaccurate in a consistent number of patients due to underdamping/resonance phenomena. NIBP measurement may help to confirm/exclude the presence of this artifact avoiding inappropriate treatments.
Collapse
Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Diego Quattrone
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Omar Tujjar
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Gianluca Villa
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Salvatore M Romano
- Department of Heart and Vessels, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - A Raffaele De Gaudio
- Department of Anesthesia and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| |
Collapse
|
14
|
Lakhal K, Ehrmann S, Perrotin D, Wolff M, Boulain T. Fluid challenge: tracking changes in cardiac output with blood pressure monitoring (invasive or non-invasive). Intensive Care Med 2013; 39:1953-62. [PMID: 24061631 DOI: 10.1007/s00134-013-3086-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess whether invasive and non-invasive blood pressure (BP) monitoring allows the identification of patients who have responded to a fluid challenge, i.e., who have increased their cardiac output (CO). METHODS Patients with signs of circulatory failure were prospectively included. Before and after a fluid challenge, CO and the mean of four intra-arterial and oscillometric brachial cuff BP measurements were collected. Fluid responsiveness was defined by an increase in CO ≥10 or ≥15% in case of regular rhythm or arrhythmia, respectively. RESULTS In 130 patients, the correlation between a fluid-induced increase in pulse pressure (Δ500mlPP) and fluid-induced increase in CO was weak and was similar for invasive and non-invasive measurements of BP: r² = 0.31 and r² = 0.29, respectively (both p < 0.001). For the identification of responders, invasive Δ500mlPP was associated with an area under the receiver-operating curve (AUC) of 0.82 (0.74-0.88), similar (p = 0.80) to that of non-invasive Δ500mlPP [AUC of 0.81 (0.73-0.87)]. Outside large gray zones of inconclusive values (5-23% for invasive Δ500mlPP and 4-35% for non-invasive Δ500mlPP, involving 35 and 48% of patients, respectively), the detection of responsiveness or unresponsiveness to fluid was reliable. Cardiac arrhythmia did not impair the performance of invasive or non-invasive Δ500mlPP. Other BP-derived indices did not outperform Δ500mlPP. CONCLUSIONS As evidenced by large gray zones, BP-derived indices poorly reflected fluid responsiveness. However, in our deeply sedated population, a high increase in invasive pulse pressure (>23%) or even in non-invasive pulse pressure (>35%) reliably detected a response to fluid. In the absence of a marked increase in pulse pressure (<4-5%), a response to fluid was unlikely.
Collapse
Affiliation(s)
- Karim Lakhal
- Réanimation Chirurgicale Polyvalente, Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes Cedex 1, France,
| | | | | | | | | |
Collapse
|
15
|
The pulse pressure/heart rate ratio as a marker of stroke volume changes during hemorrhagic shock and resuscitation in anesthetized swine. J Trauma Acute Care Surg 2013; 74:1438-45. [PMID: 23694870 DOI: 10.1097/ta.0b013e31828c3565] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emergency physicians and anesthesiologists need accurate estimates of stroke volume when massive unexpected hemorrhage occurs. Using an animal model of hemorrhagic shock under general anesthesia, we hypothesized that the pulse pressure-heart rate ratio (PP/HR) would be an accurate marker of stroke volume changes during hemorrhage and resuscitation. METHODS In 16 swine under bispectral index-controlled, intravenous propofol-remifentanil anesthesia, pressure-controlled hemorrhagic shock was induced to achieve 30 mm Hg of mean arterial pressure, after which treatment was randomized to fluid (HES, n = 4), norepinephrine (NE, n = 4), both (HES + NE, n = 4), or neither (control, n = 4). Pulmonary artery thermodilution continuous cardiac output, stroke volume, and central arterial pressures were recorded at baseline (T0), after 30 minutes (T30) and 60 (T60) minutes of hemorrhage, during treatment (T90 and T120) and after blood retransfusion (T180). RESULTS At T60, blood withdrawal was 995 (301) mL (38 [8] mL/kg), resulting in a 70% decrease in stroke volume and a 3.3-fold decrease in PP/HR (each p < 0.01). When stroke volume data pointed at T0, T30 and T60 were plotted against the various hemodynamic variables under study, the PP/HR ratio exhibited the strongest relationship to stroke volume (r = 0.72). The area under the receiver operating characteristic curve set to detect a 15% stroke volume decrease was larger for PP/HR (0.95 [0.94-0.97]) than for mean arterial pressure (0.91 [0.89-0.93]) (p < 0.013). During resuscitation in the HES and NE groups, correlation coefficients were significantly higher between stroke volume and PP/HR (0.75 [0.63-0.84] and 0.79 [0.67-0.86]) than between stroke volume and mean arterial pressure (0.52 [0.32-0.67], p = 0.042, and 0.49 [0.28-0.65], p = 0.0018, respectively). CONCLUSION The PP/HR ratio was strongly related to stroke volume during hemorrhagic shock and resuscitation in anesthetized swine.
Collapse
|
16
|
Abstract
This article provides an update for the anesthesiology community on the mechanisms and limitations of common modalities used to assess the early hemodynamic status in patients with trauma. Figures are provided to illustrate important concepts through the use of computer simulation and real-world examples. This article is of value to anesthesiologists whose practice includes management of hemorrhagic shock.
Collapse
Affiliation(s)
- Richard R McNeer
- Division of Trauma Anesthesiology, Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL 33101, USA.
| | | |
Collapse
|
17
|
Abstract
OBJECTIVE Minimal clinical research has investigated the significance of different blood pressure monitoring techniques in the ICU and whether systolic vs. mean blood pressures should be targeted in therapeutic protocols and in defining clinical study cohorts. The objectives of this study are to compare real-world invasive arterial blood pressure with noninvasive blood pressure, and to determine if differences between the two techniques have clinical implications. DESIGN We conducted a retrospective study comparing invasive arterial blood pressure and noninvasive blood pressure measurements using a large ICU database. We performed pairwise comparison between concurrent measures of invasive arterial blood pressure and noninvasive blood pressure. We studied the association of systolic and mean invasive arterial blood pressure and noninvasive blood pressure with acute kidney injury, and with ICU mortality. SETTING Adult intensive care units at a tertiary care hospital. PATIENTS Adult patients admitted to intensive care units between 2001 and 2007. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pairwise analysis of 27,022 simultaneously measured invasive arterial blood pressure/noninvasive blood pressure pairs indicated that noninvasive blood pressure overestimated systolic invasive arterial blood pressure during hypotension. Analysis of acute kidney injury and ICU mortality involved 1,633 and 4,957 patients, respectively. Our results indicated that hypotensive systolic noninvasive blood pressure readings were associated with a higher acute kidney injury prevalence (p = 0.008) and ICU mortality (p < 0.001) than systolic invasive arterial blood pressure in the same range (≤70 mm Hg). Noninvasive blood pressure and invasive arterial blood pressure mean arterial pressures showed better agreement; acute kidney injury prevalence (p = 0.28) and ICU mortality (p = 0.76) associated with hypotensive mean arterial pressure readings (≤60 mm Hg) were independent of measurement technique. CONCLUSIONS Clinically significant discrepancies exist between invasive and noninvasive systolic blood pressure measurements during hypotension. Mean blood pressure from both techniques may be interpreted in a consistent manner in assessing patients' prognosis. Our results suggest that mean rather than systolic blood pressure is the preferred metric in the ICU to guide therapy.
Collapse
|
18
|
États de choc. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
19
|
Réminiac F, Saint-Etienne C, Runge I, Ayé DY, Benzekri-Lefevre D, Mathonnet A, Boulain T. Are central venous lactate and arterial lactate interchangeable? A human retrospective study. Anesth Analg 2012; 115:605-10. [PMID: 22745117 DOI: 10.1213/ane.0b013e31825e703e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In critically ill patients, arterial blood lactate concentration (Lact(a)) and Lact(a) clearance are used for the diagnosis of shock, for prognosis assessment, and to guide therapy. In recent years, central venous oxygen saturation (ScvO(2)), a surrogate for mixed venous blood saturation, either measured by fiberoptic catheters or from central venous blood samples, was used in shock to estimate the global balance between oxygen delivery and consumption. When central venous blood is drawn for ScvO(2) measurement, it also could be used to measure central venous lactate concentration (Lact(cv)). In this study, we evaluated the utility of Lact(cv) and Lact(cv) clearance as predictors of Lact(a) and Lact(a) clearance, respectively, in critically ill patients. METHODS This retrospective study was performed in an intensive care unit of a regional and teaching hospital. Using the electronic registry of our blood gas analyzer from March 2007 to December 2009, we identified patients with circulatory or respiratory failure who had pairs of Lact(cv) and Lact(a) obtained within a 30-minute interval. To assess the utility of Lact(cv) as a predictor of Lact(a) above 2 and 4 mmol/L, we calculated the area under receiver operating characteristic curves (AUCs) for these thresholds. We also calculated AUC of Lact(cv) clearance to detect a Lact(a) clearance <10% or >10%. RESULTS Six hundred seventy-three Lact(cv)/Lact(a) pairs in 188 patients were analyzed. AUC of Lact(cv) to predict a Lact(a) above 2 and 4 mmol/L was 0.98 (95% confidence interval: 0.97-0.99) and 0.98 (95% confidence interval: 0.96-0.99), respectively. Lact(cv) with the cutoff value of 2 mmol/L can predict a Lact(a) above 2 mmol/L with sensitivity >92% and specificity >90%. AUC for Lact(cv) clearance to detect a Lact(a) clearance <10% or >10% was 0.93 or 0.94, respectively. CONCLUSION Lact(cv) and Lact(a) collected within a 30-minute range are interchangeable for clinical practice.
Collapse
Affiliation(s)
- François Réminiac
- Medical-Surgical ICU, Centre Hospitalier Régional d'Orléans, Orléans, France
| | | | | | | | | | | | | |
Collapse
|
20
|
Blood pressure monitoring in the critically ill patient: a place for noninvasive assessment? Crit Care Med 2012; 40:1366-7. [PMID: 22425846 DOI: 10.1097/ccm.0b013e3182413a07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
|
22
|
Lakhal K, Ehrmann S, Benzekri-Lefèvre D, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Régnier B, Boulain T. Brachial cuff measurements of blood pressure during passive leg raising for fluid responsiveness prediction. ACTA ACUST UNITED AC 2012; 31:e67-72. [PMID: 22464162 DOI: 10.1016/j.annfar.2012.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 01/10/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The passive leg raising maneuver (PLR) for fluid responsiveness testing relies on cardiac output (CO) measurements or invasive measurements of arterial pressure (AP) whereas the initial hemodynamic management during shock is often based solely on brachial cuff measurements. We assessed PLR-induced changes in noninvasive oscillometric readings to predict fluid responsiveness. STUDY DESIGN Multicentre interventional study. PATIENTS AND METHODS In ICU sedated patients with circulatory failure, AP (invasive and noninvasive readings) and CO measurements were performed before, during PLR (trunk supine, not modified) and after 500-mL volume expansion. Areas under the ROC curves (AUC) were determined for fluid responsiveness (>10% volume expansion-induced increase in CO) prediction. RESULTS In 112 patients (19% with arrhythmia), changes in noninvasive systolic AP during PLR (noninvasiveΔ(PLR)SAP) only predicted fluid responsiveness (cutoff 17%, n=21, positive likelihood ratio [LR] of 26 [18-38]), not unresponsiveness. If PLR-induced change in central venous pressure (CVP) was at least of 2 mm Hg (n=60), suggesting that PLR succeeded in altering cardiac preload, noninvasiveΔ(PLR)SAP performance was good: AUC of 0.94 [0.85-0.98], positive and negative LRs of 5.7 [4.6-6.8] and 0.07 [0.009-0.5], respectively, for a cutoff of 9%. Of note, invasive AP-derived indices did not outperform noninvasiveΔ(PLR)SAP. CONCLUSION Regardless of CVP (i.e., during "blind PLR"), noninvasiveΔ(PLR)SAP more than 17% reliably identified fluid responders. During "CVP-guided PLR", in case of sufficient change in CVP, noninvasiveΔ(PLR)SAP performed better (cutoff of 9%). These findings, in sedated patients who had already undergone volume expansion and/or catecholamines, have to be verified during the early phase of circulatory failure (before an arterial line and/or a CO measuring device is placed).
Collapse
Affiliation(s)
- K Lakhal
- Service de réanimation médicale et maladies infectieuses, hôpital Bichat-Claude Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris cedex 18, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Dueck R, Goedje O, Clopton P. Noninvasive continuous beat-to-beat radial artery pressure via TL-200 applanation tonometry. J Clin Monit Comput 2012; 26:75-83. [DOI: 10.1007/s10877-012-9336-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 01/05/2012] [Indexed: 11/30/2022]
|
24
|
Monitoring of standard hemodynamic parameters: heart rate, systemic blood pressure, atrial pressure, pulse oximetry, and end-tidal CO2. Pediatr Crit Care Med 2011; 12:S2-S11. [PMID: 22129545 DOI: 10.1097/pcc.0b013e318220e7ea] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Continuous monitoring of various clinical parameters of hemodynamic and respiratory status in pediatric critical care medicine has become routine. The evidence supporting these practices is examined in this review. METHODOLOGY A search of MEDLINE, EMBASE, PubMed, and the Cochrane Database was conducted to find controlled trials of heart rate, electrocardiography, noninvasive and invasive blood pressure, atrial pressure, end-tidal carbon dioxide, and pulse oximetry monitoring. Adult and pediatric data were considered. Guidelines published by the Society for Critical Care Medicine, the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed, including further review of references cited. RESULTS AND CONCLUSIONS Use of heart rate, electrocardiography, noninvasive and arterial blood pressure, atrial pressure, pulse oximetry, and end-tidal carbon dioxide monitoring in the pediatric critical care unit is commonplace; this practice, however, is not supported by well-controlled clinical trials. Despite the majority of literature being case series, expert opinion would suggest that use of routine pulse oximetry and end-tidal carbon dioxide is the current standard of care. In addition, literature would suggest that invasive arterial monitoring is the current standard for monitoring in the setting of shock. The use of heart rate, electrocardiography. and atrial pressure monitoring is advantageous in specific clinical scenarios (postoperative cardiac surgery); however, the evidence for this is based on numerous case series only.
Collapse
|
25
|
Lakhal K, Ehrmann S, Benzekri-Lefèvre D, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Régnier B, Boulain T. Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R85. [PMID: 21385348 PMCID: PMC3219343 DOI: 10.1186/cc10083] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 02/02/2011] [Accepted: 03/07/2011] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Fluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (ΔRESPPP) has scarcely been reported. In patients with ARDS, the pathophysiology of ΔRESPPP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess ΔRESPPP in a large ARDS population. METHODS Our study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion. RESULTS Among the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for ΔRESPPP was 0.75 (95% confidence interval (CI95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI95: 3.6 to 6.2) and 0.32 (CI95: 0.1 to 0.8), respectively. Adjusting ΔRESPPP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for ΔRESPPP was 1 (CI95: 0.73 to 1) as compared with 0.79 (CI95: 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥ 2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion. CONCLUSIONS During protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, ΔRESPPP performance was poor. Careful fluid challenges may be a safe alternative.
Collapse
Affiliation(s)
- Karim Lakhal
- Service de réanimation médicale et maladies infectieuses, Hôpital Bichat- Claude Bernard, Assistance Publique des Hôpitaux de Paris, 18 rue Henri Huchard, F-75018 Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Results of a survey of blood pressure monitoring by intensivists in critically ill patients: a preliminary study. Crit Care Med 2010; 38:2335-8. [PMID: 20890190 DOI: 10.1097/ccm.0b013e3181fa057f] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Maintenance of mean arterial pressure>65 mm Hg has been associated with improved clinical outcomes in many studies of critically ill patients. Current guidelines for the management of septic shock and guidelines for managing other critical illnesses suggest intra-arterial blood pressure measurement is preferred over automated oscillometric noninvasive blood pressure measurement. Despite these recommendations, anecdotal experience suggested that the use of noninvasive blood pressure measurement in our institution and others in preference to intra-arterial blood pressure measurement remained prevalent. DESIGN We designed an online survey and sent it by e-mail. SETTING Intensive care units. PATIENTS AND SUBJECTS A randomly selected group from the membership of the Society for Critical Care Medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Use of non-invasive and invasive blood pressure devices. Eight hundred eighty individuals received an invitation to complete the survey and 149 responded. We found that 71% (105 of 149) of intensivists estimated the correct cuff size rather than measuring arm circumference directly. In hypotensive patients, 73% of respondents (108 of 149) reported using noninvasive blood pressure measurement measurements for patient management. In patients on a vasopressor medication, 47% (70 of 149) of respondents reported using noninvasive blood pressure measurement for management. CONCLUSIONS The use of noninvasive blood pressure measurement measurements in critically ill patients is common despite the paucity of evidence validating its accuracy in critically ill patients. Given this widespread use, accuracy and precision validation studies comparing noninvasive blood pressure measurement with intra-arterial blood pressure measurement in critically ill patients should be performed.
Collapse
|
27
|
Garland EM, Gamboa A, Okamoto L, Raj SR, Black BK, Davis TL, Biaggioni I, Robertson D. Renal impairment of pure autonomic failure. Hypertension 2009; 54:1057-61. [PMID: 19738158 DOI: 10.1161/hypertensionaha.109.136853] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supine hypertension is difficult to manage in patients with pure autonomic failure (PAF), because treatment can worsen orthostatic hypotension. Supine hypertension in PAF has been associated with left ventricular hypertrophy, but end organ damage in the kidney has not been assessed. We reviewed hemodynamic and laboratory data of 64 male patients with PAF who were 69+/-11 (mean+/-SD) years old. Systolic blood pressure fell by 67+/-40 mm Hg within 10 minutes of standing, with an inappropriately low 13+/-11-bpm increase in heart rate. Plasma norepinephrine levels were below normal (0.62+/-0.32 nmol/L supine and 1.28+/-1.25 nmol/L standing). A control data set of 75 men (67+/-12 years) was obtained from a deidentified version of the Vanderbilt University Medical Center electronic medical chart database. Compared with controls, PAF patients had lower hemoglobin (8.3+/-0.9 versus 9.3+/-0.8 mmol/L; P<0.001), packed cell volume (0.40+/-0.04 versus 0.45+/-0.04; P<0.001), and red blood cell count (4.4+/-0.5 x 10(12) versus 5.0+/-0.5 x 10(12) cells/L; P<0.001). Serum creatinine and blood urea nitrogen levels were elevated in patients. Forty-eight percent of patients with PAF had supine hypertension (supine systolic blood pressure: > or = 150 mm Hg). Serum creatinine was higher in patients with supine hypertension (133+/-44 versus 106+/-27 micromol/L; P=0.021) and estimated glomerular filtration rate was lower (57+/-22 versus 70+/-20 mL/min per 1.73 m2; P=0.022) compared with patients who did not have supine hypertension. These findings may indicate that renal function is diminished in PAF in association with supine hypertension.
Collapse
Affiliation(s)
- Emily M Garland
- Autonomic Dysfunction Center, Vanderbilt University, Nashville, TN 37232-2195, USA.
| | | | | | | | | | | | | | | |
Collapse
|