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Putko K, Erber J, Wagner F, Busch D, Schuster H, Schmid RM, Lahmer T, Rasch S. Accuracy of hemodynamic parameters derived by GE E-PiCCO in comparison with PiCCO® in patients admitted to the intensive care unit. Sci Rep 2023; 13:6861. [PMID: 37100865 PMCID: PMC10133386 DOI: 10.1038/s41598-023-34141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/25/2023] [Indexed: 04/28/2023] Open
Abstract
To evaluate the agreement and accuracy of a novel advanced hemodynamic monitoring (AHM) device, the GE E-PiCCO module, with the well-established PiCCO® device in intensive care patients using pulse contour analysis (PCA) and transpulmonary thermodilution (TPTD). A total of 108 measurements were performed in 15 patients with AHM. Each of the 27 measurement sequences (one to four per patient) consisted of a femoral and a jugular indicator injection via central venous catheters (CVC) and measurement using both PiCCO (PiCCO® Jug and Fem) and GE E-PiCCO (GE E-PiCCO Jug and Fem) devices. For statistical analysis, Bland-Altman plots were used to compare the estimated values derived from both devices. The cardiac index measured via PCA (CIpc) and TPTD (CItd) was the only parameter that fulfilled all a priori-defined criteria based on bias and the limits of agreement (LoA) by the Bland-Altman method as well as the percentage error by Critchley and Critchley for all three comparison pairs (GE E-PiCCO Jug vs. PiCCO® Jug, GE E-PiCCO Fem vs. PiCCO® Fem, and GE E-PiCCO Fem vs. GE E-PiCCO Jug), while the GE E-PiCCO did not accurately estimate EVLWI, SVRI, SVV, and PPV values measured via the jugular and femoral CVC compared with values assessed by PiCCO®. Consequently, measurement discrepancy should be considered on evaluation and interpretation of the hemodynamic status of patients admitted to the ICU when using the GE E-PiCCO module instead of the PiCCO® device.
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Affiliation(s)
- Katarzyna Putko
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johanna Erber
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Franziska Wagner
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Busch
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hannah Schuster
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Rasch
- Department of Internal Medicine II, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.
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Schuster H, Haller B, Sancak S, Erber J, Schmid RM, Lahmer T, Rasch S. Transpulmonary thermodilution: A revised correction formula for global end-diastolic volume index derived after femoral indicator injection. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:9876-9890. [PMID: 37322915 DOI: 10.3934/mbe.2023433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Transpulmonary thermodilution (TPTD) is usually performed by jugular indicator injection. In clinical practice, femoral venous access is often used instead, resulting in substantial overestimation of global end-diastolic volume index (GEDVI). A correction formula compensates for that. The objective of this study is to first evaluate the efficacy of the currently implemented correction function and then further improve this formula. METHODS The performance of the established correction formula was investigated in our prospectively collected dataset of 98 TPTD measurements from 38 patients with both, jugular and femoral venous access. Subsequently, a new correction formula was developed: cross validation revealed the favourite covariate combination and a general estimating equation provided the final version, which was tested in a retrospective validation on an external dataset. RESULTS Investigating the current correction function revealed a considerable reduction of bias compared to no correction. Concerning the objective of formula development, the covariate combination of GEDVI obtained after femoral indicator injection, age and body surface area is even favoured, when compared to the parameters of the previously published correction formula, as a further reduction of mean absolute error (68 vs. 61 ml/m2), a better correlation (0.90 vs. 0.91) and an increased adjusted R2 (0.72 vs 0.78) is noticed in the cross validation results. Of particular clinical importance is, that more measurements were correctly assigned to the same GEDVI category (decreased / normal / increased) using the revised formula, compared with the gold standard of jugular indicator injection (72.4 vs. 74.5%). In a retrospective validation, the newly developed formula showed a greater reduction of bias (to 2 vs. 6 %) than the currently implemented formula. CONCLUSIONS The currently implemented correction function partly compensates for GEDVI overestimation. Applying the new correction formula on GEDVI measured after femoral indicator administration enhances the informative value and reliability of this preload parameter.
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Affiliation(s)
- Hannah Schuster
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of AI and Informatics in Medicine, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sengül Sancak
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johanna Erber
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastian Rasch
- Department of Internal Medicine Ⅱ, School of Medicine, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
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Herner A, Heilmaier M, Mayr U, Schmid RM, Huber W. Comparison of global end-diastolic volume index derived from jugular and femoral indicator injection: a prospective observational study in patients equipped with both a PiCCO-2 and an EV-1000-device. Sci Rep 2020; 10:20773. [PMID: 33247165 PMCID: PMC7695713 DOI: 10.1038/s41598-020-76286-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/28/2020] [Indexed: 11/21/2022] Open
Abstract
Transpulmonary thermodilution (TPTD)-derived global end-diastolic volume index (GEDVI) is a static marker of preload which better predicted volume responsiveness compared to filling pressures in several studies. GEDVI can be generated with at least two devices: PiCCO and EV-1000. Several studies showed that uncorrected indicator injection into a femoral central venous catheter (CVC) results in a significant overestimation of GEDVI by the PiCCO-device. Therefore, the most recent PiCCO-algorithm corrects for femoral indicator injection. However, there are no systematic data on the impact of femoral indicator injection for the EV-1000 device. Furthermore, the correction algorithm of the PiCCO is poorly validated. Therefore, we prospectively analyzed 14 datasets from 10 patients with TPTD-monitoring undergoing central venous catheter (CVC)- and arterial line exchange. PiCCO was replaced by EV-1000, femoral CVCs were replaced by jugular/subclavian CVCs and vice-versa. For PiCCO, jugular and femoral indicator injection derived GEDVI was comparable when the correct information about femoral catheter site was given (p = 0.251). By contrast, GEDVI derived from femoral indicator injection using the EV-1000 was obviously not corrected and was substantially higher than jugular GEDVI measured by the EV-1000 (846 ± 250 vs. 712 ± 227 ml/m2; p = 0.001). Furthermore, measurements of GEDVI were not comparable between PiCCO and EV-1000 even in case of jugular indicator injection (p = 0.003). This is most probably due to different indexations of the raw value GEDV. EV-1000 could not be recommended to measure GEDVI in case of a femoral CVC. Furthermore, different indexations used by EV-1000 and PiCCO should be considered even in case of a jugular CVC when comparing GEDVI derived from PiCCO and EV-1000.
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Akohov A, Barner C, Grimmer S, Francis RC, Wolf S. Aortic volume determines global end-diastolic volume measured by transpulmonary thermodilution. Intensive Care Med Exp 2020; 8:1. [PMID: 31897796 PMCID: PMC6940405 DOI: 10.1186/s40635-019-0284-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
Background Global end-diastolic volume (GEDV) measured by transpulmonary thermodilution is regarded as indicator of cardiac preload. A bolus of cold saline injected in a central vein travels through the heart and lung, but also the aorta until detection in a femoral artery. While it is well accepted that injection in the inferior vena cava results in higher values, the impact of the aortic volume on GEDV is unknown. In this study, we hypothesized that a larger aortic volume directly translates to a numerically higher GEDV measurement. Methods We retrospectively analyzed data from 88 critically ill patients with thermodilution monitoring and who did require a contrast-enhanced thoraco-abdominal computed tomography scan. Aortic volumes derived from imaging were compared with GEDV measurements in temporal proximity. Results Median aortic volume was 194 ml (interquartile range 147 to 249 ml). Per milliliter increase of the aortic volume, we found a GEDV increase by 3.0 ml (95% CI 2.0 to 4.1 ml, p < 0.001). In case a femoral central venous line was used for saline bolus injection, GEDV raised additionally by 2.1 ml (95% CI 0.5 to 3.7 ml, p = 0.01) per ml volume of the vena cava inferior. Aortic volume explained 59.3% of the variance of thermodilution-derived GEDV. When aortic volume was included in multivariate regression, GEDV variance was unaffected by sex, age, body height, and weight. Conclusions Our results suggest that the aortic volume is a substantial confounding variable for GEDV measurements performed with transpulmonary thermodilution. As the aorta is anatomically located after the heart, GEDV should not be considered to reflect cardiac preload. Guiding volume management by raw or indexed reference ranges of GEDV may be misleading.
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Affiliation(s)
- Aleksej Akohov
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Barner
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Steffen Grimmer
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Anesthesiology, Vivantes Klinikum Neukölln, Vivantes Netzwerk für Gesundheit, Berlin, Germany
| | - Roland Ce Francis
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Huber W, Mayr U, Umgelter A, Franzen M, Reindl W, Schmid RM, Eckel F. Mandatory criteria for the application of variability-based parameters of fluid responsiveness: a prospective study in different groups of ICU patients. J Zhejiang Univ Sci B 2018; 19:515-524. [PMID: 29971990 DOI: 10.1631/jzus.b1700243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Stroke volume variation (SVV) has high sensitivity and specificity in predicting fluid responsiveness. However, sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for their application. Several studies suggest a limited applicability of SVV in intensive care unit (ICU) patients. We hypothesized that the applicability of SVV might be different over time and within certain subgroups of ICU patients. Therefore, we analysed the prevalence of SR and CV in ICU patients during the first 24 h of PiCCO-monitoring (primary endpoint) and during the total ICU stay. We also investigated the applicability of SVV in the subgroups of patients with sepsis, cirrhosis, and acute pancreatitis. METHODS The prevalence of SR and CV was documented immediately before 1241 thermodilution measurements in 88 patients. RESULTS In all measurements, SVV was applicable in about 24%. However, the applicability of SVV was time-dependent: the prevalence of both SR and CV was higher during the first 24 h compared to measurements thereafter (36.1% vs. 21.9%; P<0.001). Within different subgroups, the applicability during the first 24 h of monitoring ranged between 0% in acute pancreatitis, 25.5% in liver failure, and 48.9% in patients without pancreatitis, liver failure, pneumonia or sepsis. CONCLUSIONS The applicability of SVV in a predominantly medical ICU is only about 25%-35%. The prevalence of both mandatory criteria decreases over time during the ICU stay. Furthermore, the applicability is particularly low in patients with acute pancreatitis and liver failure.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, D-81675 München, Germany
| | - Uli Mayr
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, D-81675 München, Germany
| | - Andreas Umgelter
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, D-81675 München, Germany
| | - Michael Franzen
- Universitätsklinik für Innere Medizin I, Salzburger Landeskliniken, Universitätsklinikum Salzburg, Müllner Hauptstraße 48, A-5020 Salzburg, Austria
| | - Wolfgang Reindl
- II. Medizinische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, D-81675 München, Germany
| | - Florian Eckel
- Klinik für Innere Medizin, RoMed Klinik Bad Aibling, Harthauser Straße 16, D-83043 Bad Aibling, Germany
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Comparison of cardiac function index derived from femoral and jugular indicator injection for transpulmonary thermodilution with the PiCCO-device: A prospective observational study. PLoS One 2018; 13:e0200740. [PMID: 30063736 PMCID: PMC6067690 DOI: 10.1371/journal.pone.0200740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 07/02/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Cardiac function index (CFI) is a trans-pulmonary thermodilution (TPTD)-derived estimate of systolic function. CFI is defined as the ratio of cardiac output divided by global end-diastolic volume GEDV (CFI = CO/GEDV). Several studies demonstrated that the use of femoral venous access results in a marked overestimation of GEDV, while CFI is underestimated. One study suggested a correction formula for femoral venous access that markedly reduced the bias for GEDVI. Therefore, the last PiCCO-algorithm requires information about the CVC-position which suggests a correction of GEDV for femoral access. However, a recent study demonstrated inconsistencies of the last PiCCO algorithm using incorrected GEDV to calculate CFI despite obvious correction of GEDV. Nevertheless, this study was based on mathematical analyses of data displayed in a total of 15 patients equipped with only a femoral, but not with a jugular CVC. Therefore, this study compared CFI derived from the femoral indicator injection TPTD to data derived from jugular indicator injection in 28 patients with both a jugular and a femoral CVC. Methods 28 ICU-patients with PiCCO-monitoring were included. Each dataset consisted of three triplicate TPTDs using the jugular venous gold standard access and the femoral access with and without information about the femoral indicator injection to evaluate, if correction for femoral GEDV also pertains to CFI. (CFI_jug: jugular indicator injection; CFI_fem: femoral indicator injection; CFI_fem_cor: femoral indicator injection with correct information about CVC-position; CFI_fem_uncor: femoral indicator injection with uncorrect information about CVC-position; CFI_fem_uncor_form = CFI_fem_uncor * (GEDVI_fem_uncor/GEDVI_fem_cor)). Results CFI_fem_uncor was significantly lower than CFI_jug (4.28±1.70 vs. 5.21±1.91 min-1; p<0.001). Similarly, CFI_fem_cor was significantly lower than CFI_jug (4.24±1.62 vs. 5.21±1.91 min-1; p<0.001). This is explained by the finding that CFI_fem_uncor was not different to CFI_fem_cor (4.28±1.70 vs. 4.24±1.62 min-1; p = 0.611). This suggests that correction for femoral CVC does not pertain to CFI. Calculative correction of CFI_fem_uncor by multiplying CFI_fem_uncor by the ratio GEDVI_fem_uncor/GEDVI_jug resulted in CFI_fem_uncor_form which was slightly, but significantly different from the gold standard CFI_jug (5.51±2.00 vs. 5.21±1.91 min-1; p = 0.024). The agreement of measurements classified in the same category of CFI (decreased (<4.5), normal (4.5–6.5) and increased (>6.5 min-1)) was high for CFI_jug and CFI_fem_uncor_form (identical categories in 26 of 28 comparisons; p = 0.49). By contrast, the agreement with CFI_jug was significantly lower for CFI_fem_cor (14 out of 28; p<0.001) and CFI_fem_uncor (15 out of 28; p<0.001). Conclusions While the last PiCCO algorithm obviously corrects GEDVI for femoral indicator injection, this correction is not applied to CFI. Therefore, femoral TPTD indicator injection results in substantially lower values for CFI compared to TPTD using a jugular CVC. Necessarily, uncorrected CFI-values derived from femoral TPTD are misleading and have to be corrected.
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Kawaji T, Sakai T, Moriyama K, Hara Y, Nakamura T, Kuriyama N, Shimomura Y, Kato Y, Komura H, Yamashita C, Kurimoto Y, Hasegawa D, Nishida O. Influence of Blood Purification and Differential Injection Sites of Cold Saline on Transpulmonary Thermodilution Values. Ther Apher Dial 2018; 22:290-294. [PMID: 29749700 DOI: 10.1111/1744-9987.12696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/02/2018] [Indexed: 02/03/2023]
Abstract
We aimed to investigate the effects of blood purification and cold saline injection sites on the transpulmonary thermodilution values. We measured the cardiac output of eight pigs in every combination of cold saline injection (left jugular and femoral veins) and blood purification sites (right jugular and femoral veins), with or without blood purification. We examined the influence of the difference between the presence and absence of blood purification, vascular sites for blood purification, and sites for cold saline injection on the transpulmonary thermodilution values. Cardiac output measured during blood purification using transpulmonary thermodilution was underestimated; however, there was no difference between vascular sites. Cardiac output measured via injection of cold saline into the femoral vein was higher than that obtained through injection of cold saline into the jugular vein, with or without blood purification.
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Affiliation(s)
- Takahiro Kawaji
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Toshikazu Sakai
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuhiro Moriyama
- Laboratory for Immune Response and Regulatory Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomoyuki Nakamura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naohide Kuriyama
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasuyo Shimomura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yu Kato
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hidefumi Komura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yasuyoshi Kurimoto
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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Comparison of pulmonary vascular permeability index PVPI and global ejection fraction GEF derived from jugular and femoral indicator injection using the PiCCO-2 device: A prospective observational study. PLoS One 2017; 12:e0178372. [PMID: 29040264 PMCID: PMC5644983 DOI: 10.1371/journal.pone.0178372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 05/11/2017] [Indexed: 11/23/2022] Open
Abstract
Background Transpulmonary thermodilution (TPTD) is used to derive cardiac output CO, global end-diastolic volume GEDV and extravascular lung water EVLW. To facilitate interpretation of these data, several ratios have been developed, including pulmonary vascular permeability index (defined as EVLW/(0.25*GEDV)) and global ejection fraction ((4*stroke volume)/GEDV). PVPI and GEF have been associated to the aetiology of pulmonary oedema and systolic cardiac function, respectively. Several studies demonstrated that the use of femoral venous access results in a marked overestimation of GEDV. This also falsely reduces PVPI and GEF. One of these studies suggested a correction formula for femoral venous access that markedly reduced the bias for GEDV. Consequently, the last PiCCO-algorithm requires information about the CVC, and correction for femoral access has been shown. However, two recent studies demonstrated inconsistencies of the last PiCCO algorithm using incorrected GEDV for PVPI, but corrected GEDV for GEF. Nevertheless, these studies were based on mathematical analyses of data displayed in a total of 15 patients equipped with only a femoral, but not with a jugular CVC. Therefore, this study compared PVPI_fem and GEF_fem derived from femoral TPTD to values derived from jugular indicator injection in 25 patients with both jugular and femoral CVCs. Methods 54 datasets in 25 patients were recorded. Each dataset consisted of three triplicate TPTDs using the jugular venous access as the gold standard and the femoral access with (PVPI_fem_cor) and without (PVPI_fem_uncor) information about the femoral indicator injection to evaluate, if correction for femoral GEDV pertains to PVPI_fem and GEF_fem. Results PVPI_fem_uncor was significantly lower than PVPI_jug (1.48±0.47 vs. 1.84±0.53; p<0.001). Similarly, PVPI_fem_cor was significantly lower than PVPI_jug (1.49±0.46 vs. 1.84±0.53; p<0.001). This is explained by the finding that PVPI_fem_uncor was not different to PVPI_fem_cor (1.48±0.47 vs. 1.49±0.46; n.s.). This clearly suggests that correction for femoral CVC does not pertain to PVPI. GEF_fem_uncor was significantly lower than GEF_jug (20.6±5.1% vs. 25.0±6.1%; p<0.001). By contrast, GEF_fem_cor was not different to GEF_jug (25.6±5.8% vs. 25.0±6.1%; n.s.). Furthermore, GEF_fem_cor was significantly higher than GEF_fem_uncor (25.6±5.8% vs. 20.6±5.1%; p<0.001). This finding emphasizes that an appropriate correction for femoral CVC is applied to GEF_fem_cor. The extent of the correction (25.5/20.6; 124%) for GEF and the relation of PVPI_jug/PVPI_fem_uncor (1.84/1.48; 124%) are in the same range as the ratio of GEDVI_fem_uncor/GEDVI_fem_cor (1056ml/m2/821mL/m2; 129%). This further emphasizes that GEF, but not PVPI is corrected in case of femoral indicator injection. Conclusions Femoral indicator injection for TPTD results in significantly lower values for PVPI and GEF. While the last PiCCO algorithm appropriately corrects GEF, the correction is not applied to PVPI. Therefore, GEF-values can be used in case of femoral CVC, but PVPI-values are substantially underestimated.
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Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28625165 PMCID: PMC5474867 DOI: 10.1186/s13054-017-1739-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Main body Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Conclusions Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
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Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France. .,Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France
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Mair S, Tschirdewahn J, Götz S, Frank J, Phillip V, Henschel B, Schultheiss C, Mayr U, Noe S, Treiber M, Schmid RM, Saugel B, Huber W. Applicability of stroke volume variation in patients of a general intensive care unit: a longitudinal observational study. J Clin Monit Comput 2016; 31:1177-1187. [PMID: 27817009 DOI: 10.1007/s10877-016-9951-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
Abstract
Sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for the applicability of respiratory changes of the arterial curve such as stroke volume variation (SVV) to predict fluid-responsiveness. Furthermore, several secondary limitations including tidal volumes <8 mL/kg and SVV-values within the "gray zone" of 9-13% impair prediction of fluid-responsiveness by SVV. Therefore, we investigated the prevalence of these four conditions in general ICU-patients. This longitudinal observational study analyzed a prospectively maintained haemodynamic database including 4801 transpulmonary thermodilution and pulse contour analysis measurements of 278 patients (APACHE-II 21.0 ± 7.4). The main underlying diseases were cirrhosis (32%), sepsis (28%), and ARDS (17%). The prevalence of SR and CV was only 19.4% (54/278) in the first measurements (primary endpoint), 18.8% (902/4801) in all measurements and 26.5% (9/34) in measurements with MAP < 65 mmHg and CI < 2.5 L/min/m2 and vasopressor therapy. In 69.1% (192/278) of the first measurements and in 65.9% (3165/4801) of all measurements the patients had SR but did not have CV. In 1.8% (5/278) of the first measurements and in 2.5% (119/4801) of all measurements the patients had CV but lacked SR. In 9.7% (27/278) of the first measurements and in 12.8% (615/4801) of all measurements the patients did neither have SR nor CV. Only 20 of 278 (7.2%) of the first measurements and 8.2% of all measurements fulfilled both major criteria (CV, SR) and both minor criteria for the applicability of SVV. The applicability of SVV in ICU-patients is limited due to the absence of mandatory criteria during the majority of measurements.
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Affiliation(s)
- Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Julia Tschirdewahn
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Simon Götz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Johanna Frank
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Benedikt Henschel
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Caroline Schultheiss
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Ulrich Mayr
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Sebastian Noe
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Matthias Treiber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Roland M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.
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