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Papolos AI, Kenigsberg BB, Singam NSV, Berg DD, Guo J, Bohula EA, Katz JN, Diepen SVAN, Morrow DA. Pulmonary Artery Diastolic Pressure as a Surrogate for Pulmonary Capillary Wedge Pressure in Cardiogenic Shock. J Card Fail 2024:S1071-9164(24)00088-5. [PMID: 38513886 DOI: 10.1016/j.cardfail.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND It is common for clinicians to use the pulmonary artery diastolic pressure (PADP) as a surrogate for the pulmonary capillary wedge pressure (PCWP). Here, we determine the validity of this relationship in patients with various phenotypes of cardiogenic shock (CS). METHODS AND RESULTS In this analysis of the Critical Care Cardiology Trials Network registry, we identified 1225 people admitted with CS who received pulmonary artery catheters. Linear regression, Bland-Altman and receiver operator characteristic analyses were performed to determine the strength of the association between PADP and PCWP in patients with left-, right-, biventricular, and other non-myocardia phenotypes of CS (eg, arrhythmia, valvular stenosis, tamponade). There was a moderately strong correlation between PADP and PCWP in the total population (r = 0.64, n = 1225) and in each CS phenotype, except for right ventricular CS, for which the correlation was weak (r = 0.43, n = 71). Additionally, we found that a PADP ≥ 24 mmHg can be used to infer a PCWP ≥ 18 mmHg with ≥ 90% confidence in all but the right ventricular CS phenotype. CONCLUSIONS This analysis validates the practice of using PADP as a surrogate for PCWP in most patients with CS; however, it should generally be avoided in cases of right ventricular-predominant CS.
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Affiliation(s)
- Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, New York University, New York, NY, USA
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Holm P, Erkinaro TM, Karhu JM, Ohtonen PP, Liisanantti JH, Taskinen P, Ala-Kokko TI, Kaakinen TI. Unresponsive Low Mixed Venous Oxygen Saturation During Early Intensive Care Unit Stay is Associated With Increased Risk of Organ Dysfunction After Cardiac Surgery: A Single-Center Retrospective Study. J Cardiothorac Vasc Anesth 2024; 38:423-429. [PMID: 38114371 DOI: 10.1053/j.jvca.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/11/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES The aim of the study was to determine if unresponsive mixed venous oxygen saturation (SvO2) values during early postoperative hours are associated with postoperative organ dysfunction. DESIGN A single-center retrospective observational study. SETTING A university hospital. PARTICIPANTS A total of 6,282 adult patients requiring cardiac surgery who underwent surgery in a University Hospital from 2007 to 2020. INTERVENTIONS A pulmonary artery catheter was used to gather SvO2 samples after surgery at admission to the intensive care unit (ICU) and 4 hours later. For the analysis, patients were divided into 4 groups according to their SvO2 values. The rate of organ dysfunctions categorized according to the SOFA score was then studied among these subgroups. MEASUREMENTS AND MAIN RESULTS The crude mortality rate for the cohort at 1 year was 4.3%. Multiple organ dysfunction syndrome (MODS) was present in 33.0% of patients in the early postoperative phase. During the 4-hour initial treatment period, 43% of the 931 patients with low SvO2 on admission responded to goal-directed therapy to increase SvO2 >60%; whereas, in 57% of the 931 patients, the low SvO2 was sustained. According to the adjusted logistic regression analyses, the odds ratio for MODS (4.23 [95% CI 3.41-5.25]), renal- replacement therapy (4.97 [95% CI 3.28-7.52]), time on a ventilator (2.34 [95% CI 2.17-2.52]), and vasoactive-inotropic score >30 (3.62 [95% CI 2.96-4.43]) were the highest in the group with sustained low SvO2. CONCLUSIONS Patients with SvO2 <60% at ICU admission and 4 hours later had the greatest risk of postoperative MODS. Responsiveness to a goal-directed therapy protocol targeting maintaining or increasing SvO2 ≥60% at and after ICU admission may be beneficial.
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Affiliation(s)
- Petteri Holm
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; OYS Heart, Oulu University Hospital, Research Group of Anaesthesiology, MRC Oulu and University of Oulu, Oulu, Finland.
| | - Tiina M Erkinaro
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; OYS Heart, Oulu University Hospital, Research Group of Anaesthesiology, MRC Oulu and University of Oulu, Oulu, Finland
| | - Jaana M Karhu
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; OYS Heart, Oulu University Hospital, Research Group of Anaesthesiology, MRC Oulu and University of Oulu, Oulu, Finland
| | - Pasi P Ohtonen
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Janne H Liisanantti
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Panu Taskinen
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; OYS Heart, Oulu University Hospital, Research Group of Anaesthesiology, MRC Oulu and University of Oulu, Oulu, Finland
| | - Tero I Ala-Kokko
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Critical Care Center and Research Group of Intensive Care Medicine, Oulu University Hospital, MRC Oulu and University of Oulu, Oulu, Finland
| | - Timo I Kaakinen
- Research Group of Surgery, Intensive Care Unit, Anaesthesiology and Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; OYS Heart, Oulu University Hospital, Research Group of Anaesthesiology, MRC Oulu and University of Oulu, Oulu, Finland
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Basir MB, Lemor A, Gorgis S, Patel KC, Kolski BC, Bharadwaj AS, Todd JW, Tehrani BN, Truesdell AG, Lasorda DM, Lalonde TA, Kaki A, Schrieber TL, Patel NC, Senter SR, Gelormini JL, Marso SP, Rahman AM, Federici RE, Wilkins CE, Thomas McRae A, Nsair A, Caputo CP, Khuddus MA, Chahin JJ, Dupont AG, Goldsweig AM, Lim MJ, Kapur NK, Wohns DHW, Zhou Y, Hacala MJ, O'Neill WW. Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative. J Am Heart Assoc 2023; 12:e031401. [PMID: 38014676 PMCID: PMC10727311 DOI: 10.1161/jaha.123.031401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Amir Kaki
- Ascension St. John HospitalDetroitMI
| | | | | | | | | | | | | | | | | | | | - Ali Nsair
- Ronald Reagan UCLA Medical CenterLos AngelesCA
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5
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Heringlake M, Kouz K, Saugel B. A classification system for pulmonary artery catheters. Br J Anaesth 2023; 131:971-974. [PMID: 37714751 DOI: 10.1016/j.bja.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/17/2023] Open
Abstract
Flow-directed, balloon-tipped pulmonary artery catheters allow measuring cardiac output and other haemodynamic variables including intracardiac pressures. We propose classifying pulmonary artery catheters by generations and specifying additional measurement modalities. Based on the method used to measure cardiac output, pulmonary artery catheters can be classified into three generations: first-generation using intermittent pulmonary artery thermodilution; second-generation using a thermal filament for automated pulmonary artery thermodilution; and third-generation combining thermal filament-based automated pulmonary artery thermodilution and pulmonary artery pulse wave analysis. Each of these pulmonary artery catheter generations can include additional measurements, such as continuous mixed venous oxygen saturation, right ventricular ejection fraction and end-diastolic volume, and right ventricular pressure. This classification should help define indications for pulmonary artery catheters in clinical practice and research.
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Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
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6
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Lorenz JD, Chandrashekarappa K, Pagel PS, Hang D. Difficult Placement of a Pulmonary Artery Catheter: Stenosis of the Internal Jugular Vein From Previous Cannulation or a Pathologic Cause? J Cardiothorac Vasc Anesth 2023; 37:2378-2381. [PMID: 37543475 DOI: 10.1053/j.jvca.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Joseph D Lorenz
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | | | - Paul S Pagel
- Anesthesiology Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Dustin Hang
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI.
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7
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Ortega-Hernández JA, González-Pacheco H, Argüello-Bolaños J, Arenas-Díaz JO, Pérez-López R, García-Arias MR, Gopar-Nieto R, Sierra-Lara-Martínez D, Araiza-Garaygordobil D, Manzur-Sandoval D, Soliz-Uriona LA, Astudillo-Alvarez GM, Hernández-Montfort J, Arias-Mendoza A. Invasive Phenoprofiling of Acute-Myocardial-Infarction-Related Cardiogenic Shock. J Clin Med 2023; 12:5818. [PMID: 37762759 PMCID: PMC10532159 DOI: 10.3390/jcm12185818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Studies had previously identified three cardiogenic shock (CS) phenotypes (cardiac-only, cardiorenal, and cardiometabolic). Therefore, we aimed to understand better the hemodynamic profiles of these phenotypes in acute myocardial infarction-CS (AMI-CS) using pulmonary artery catheter (PAC) data to better understand the AMI-CS heterogeneity. METHODS We analyzed the PAC data of 309 patients with AMI-CS. The patients were classified by SCAI shock stage, congestion profile, and phenotype. In addition, 24 h hemodynamic PAC data were obtained. RESULTS We identified three AMI-CS phenotypes: cardiac-only (43.7%), cardiorenal (32.0%), and cardiometabolic (24.3%). The cardiometabolic phenotype had the highest mortality rate (70.7%), followed by the cardiorenal (52.5%) and cardiac-only (33.3%) phenotypes, with significant differences (p < 0.001). Right atrial pressure (p = 0.001) and pulmonary capillary wedge pressure (p = 0.01) were higher in the cardiometabolic and cardiorenal phenotypes. Cardiac output, index, power, power index, and cardiac power index normalized by right atrial pressure and left-ventricular stroke work index were lower in the cardiorenal and cardiometabolic than in the cardiac-only phenotypes. We found a hazard ratio (HR) of 2.1 for the cardiorenal and 3.3 for cardiometabolic versus the cardiac-only phenotypes (p < 0.001). Also, multi-organ failure, acute kidney injury, and ventricular tachycardia/fibrillation had a significant HR. Multivariate analysis revealed that CS phenotypes retained significance (p < 0.001) when adjusted for the Society for Cardiovascular Angiography & Interventions score (p = 0.011) and ∆congestion (p = 0.028). These scores independently predicted mortality. CONCLUSIONS Accurate patient prognosis and treatment strategies are crucial, and phenotyping in AMI-CS can aid in this effort. PAC profiling can provide valuable prognostic information and help design new trials involving AMI-CS.
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Affiliation(s)
- Jorge A. Ortega-Hernández
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Héctor González-Pacheco
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Jardiel Argüello-Bolaños
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - José Omar Arenas-Díaz
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Roberto Pérez-López
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Mario Ramón García-Arias
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Rodrigo Gopar-Nieto
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Daniel Sierra-Lara-Martínez
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Diego Araiza-Garaygordobil
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Daniel Manzur-Sandoval
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Luis Alejandro Soliz-Uriona
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Gloria Monserrath Astudillo-Alvarez
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
| | - Jaime Hernández-Montfort
- Advanced Heart Failure and Recovery Program for Central Texas Baylor Scott & White Health, 302 University Blvd, Round Rock, TX 78665, USA
| | - Alexandra Arias-Mendoza
- Instituto Nacional de Cardiología Ignacio Chávez, Coronary Care Unit, Juan Badiano 1, Sección XVI, Tlalpan, Ciudad De Mexico 14080, Mexico; (J.A.-B.); (J.O.A.-D.); (R.P.-L.); (M.R.G.-A.); (R.G.-N.); (D.S.-L.-M.); (D.A.-G.); (D.M.-S.); (L.A.S.-U.); (G.M.A.-A.); (A.A.-M.)
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Kanwar MK, Blumer V, Zhang Y, Sinha SS, Garan AR, Hernandez-Montfort J, Khalif A, Hickey GW, Abraham J, Mahr C, Li B, Sangal P, Walec KD, Zazzali P, Kataria R, Pahuja M, Ton VANK, Harwani NM, Wencker D, Nathan S, Vorovich E, Hall S, Khalife W, Li S, Schwartzman A, Kim JU, Vishnevsky OA, Trinquart L, Burkhoff D, Kapur NK. Pulmonary Artery Catheter Use and Risk of In-hospital Death in Heart Failure Cardiogenic Shock. J Card Fail 2023; 29:1234-1244. [PMID: 37187230 DOI: 10.1016/j.cardfail.2023.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Pulmonary artery catheters (PACs) are increasingly used to guide management decisions in cardiogenic shock (CS). The goal of this study was to determine if PAC use was associated with a lower risk of in-hospital mortality in CS owing to acute heart failure (HF-CS). METHODS AND RESULTS This multicenter, retrospective, observational study included patients with CS hospitalized between 2019 and 2021 at 15 US hospitals participating in the Cardiogenic Shock Working Group registry. The primary end point was in-hospital mortality. Inverse probability of treatment-weighted logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CI), accounting for multiple variables at admission. The association between the timing of PAC placement and in-hospital death was also analyzed. A total of 1055 patients with HF-CS were included, of whom 834 (79%) received a PAC during their hospitalization. In-hospital mortality risk for the cohort was 24.7% (n = 261). PAC use was associated with lower adjusted in-hospital mortality risk (22.2% vs 29.8%, OR 0.68, 95% CI 0.50-0.94). Similar associations were found across SCAI stages of shock, both at admission and at maximum SCAI stage during hospitalization. Early PAC use (≤6 hours of admission) was observed in 220 PAC recipients (26%) and associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, OR 0.54, 95% CI 0.37-0.81). CONCLUSIONS This observational study supports PAC use, because it was associated with decreased in-hospital mortality in HF-CS, especially if performed within 6 hours of hospital admission. CONDENSED ABSTRACT An observational study from the Cardiogenic Shock Working Group registry of 1055 patients with HF-CS showed that pulmonary artery catheter (PAC) use was associated with a lower adjusted in-hospital mortality risk (22.2% vs 29.8%, odds ratio 0.68, 95% confidence interval 0.50-0.94) compared with outcomes in patients managed without PAC. Early PAC use (≤6 hours of admission) was associated with a lower adjusted risk of in-hospital mortality compared with delayed (≥48 hours) or no PAC use (17.3% vs 27.7%, odds ratio 0.54, 95% confidence interval 0.37-0.81).
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Yijing Zhang
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, Virginia
| | - Arthur R Garan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts'
| | | | - Adnan Khalif
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Gavin W Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Portland, OR
| | - Claudius Mahr
- University of Washington Medical Center, Seattle, Washington
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Karol D Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Rachna Kataria
- Lifespan Cardiovascular Institute, Brown University, Providence, Rhode Island
| | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - VAN-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Detlef Wencker
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, Texas
| | | | | | - Shelley Hall
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, Texas
| | | | - Song Li
- University of Washington Medical Center, Seattle, Washington
| | | | - J U Kim
- Houston Methodist Research Institute, Houston, Texas
| | | | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
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9
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Kadosh BS, Berg DD, Bohula EA, Park JG, Baird-Zars VM, Alviar C, Alzate J, Barnett CF, Barsness GW, Burke J, Chaudhry SP, Daniels LB, DeFilippis A, Delicce A, Fordyce CB, Ghafghazi S, Gidwani U, Goldfarb M, Katz JN, Keeley EC, Kenigsberg B, Kontos MC, Lawler PR, Leibner E, Menon V, Metkus TS, Miller PE, O'Brien CG, Papolos AI, Prasad R, Shah KS, Sinha SS, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, Toole J, van Diepen S, Morrow DA, Roswell RO. Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. JACC Heart Fail 2023; 11:903-914. [PMID: 37318422 PMCID: PMC10527413 DOI: 10.1016/j.jchf.2023.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
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Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA; Lenox Hospital, Northwell Health, New York, New York, USA.
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, USA
| | - James Alzate
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | | | - Christopher B Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, Georgia, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Toole
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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10
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Dan K, Takahashi K, Lefor AK. Measuring and maintaining organ perfusion in a patient with Takayasu's arteritis undergoing cardiac surgery. Anaesth Rep 2023; 11:e12236. [PMID: 37408768 PMCID: PMC10318576 DOI: 10.1002/anr3.12236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/07/2023] Open
Abstract
Takayasu's arteritis is a rare vasculitis affecting the aorta and its branches. Disease progression can result in arterial stenosis and subsequent organ dysfunction. Estimating organ perfusion by measuring the peripheral blood pressure can be challenging because it may be altered by arterial stenosis. We report the case of a 61-year-old woman with Takayasu's arteritis with aortic and mitral regurgitation who presented for aortic valve replacement and mitral valvuloplasty. Peripheral arterial pressure was considered a less reliable surrogate for organ perfusion because the patient had diminished blood flow in both the lower and upper extremities. In addition to the bilateral radial arterial pressure, the blood pressure in the ascending aorta was monitored to estimate the patient's organ perfusion pressure during cardiopulmonary bypass. The initial target blood pressure was determined based on the pre-operative baseline and modified by measurement of the aortic pressure. Cerebral oximetry using near-infrared spectroscopy and mixed venous saturation was monitored to estimate oxygen supply-demand balance, which helped evaluate cerebral perfusion and determine the transfusion threshold. The entire procedure was uneventful, and no organ dysfunction was observed postoperatively.
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Affiliation(s)
- K. Dan
- Department of AnaesthesiaTokyo Bay Urayasu Ichikawa Medical CenterChibaJapan
| | - K. Takahashi
- Department of AnaesthesiaJichi Medical University Saitama Medical CenterSaitamaJapan
| | - A. K. Lefor
- Department of SurgeryJichi Medical UniversityTochigiJapan
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11
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Miszczenkow H, Krzych Ł. Insights into Hemodynamic Features of Survivors and the Deceased with Acute Brain Injury: A Step Forward Tailored Treatment. J Clin Med 2023; 12:4021. [PMID: 37373714 DOI: 10.3390/jcm12124021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/24/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Pulmonary artery catheters are widely used for hemodynamical monitoring in critically ill patients. Acute brain injury is among the severe conditions treated in an intensive care unit. The advanced monitoring of hemodynamical parameters, fluid balance and adequate administered treatment based on those values are components of goal-directed therapy. METHODS A prospective observational study included adult patients who were hospitalized in the ICU due to acute bran injury, excluding brain oedema after cardiac arrest. Each patient had PAC inserted and hemodynamic data were collected during the first 3 days of the ICU stay every 6 h. Patients were divided into two groups based on the endpoint: the survivors and the deceased. RESULTS Length of stay in hospital differed between patiens. All patients, regardless of their outcome, had noradrenaline administered. The initial values of PAP differed between the groups (p = 0.05). There were positive correlations noticed between noradrenaline dose, CVP and fluid balance when compared to PCWP in a group of survivors and a positive correlation in the fluid balance when compared to PAP and PVRI. Lactate serum concentrations presented a correlation with the dose of noradrenaline in both groups. CONCLUSIONS Upon acute brain injury, values of PVRI and PAP increase. This is corelated with fluid load and worsened by an excessive fluid treatment in the case of an inconsiderate approach for stabilizing the patient hemodynamically. PAC may present limited advantages in terms of PAP and PVRI control during the treatment.
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Affiliation(s)
- Hanna Miszczenkow
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Medyków 14, 40-752 Katowice, Poland
| | - Łukasz Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Medyków 14, 40-752 Katowice, Poland
- Department of Cardiac Anesthesia and Intensive Care, Silesian Centre for Heart Diseases, Marii Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
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12
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Jerman CF, Baker KH, Fitzsimons MG. Invasive Pressure Monitors: Leveling the Playing Field. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00331-2. [PMID: 37286401 DOI: 10.1053/j.jvca.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
Invasive pressure monitors are ubiquitous in cardiothoracic and vascular anesthesia. This technology allows beat-to-beat assessment of central venous, pulmonary, and arterial blood pressures during surgery, procedural interventions, and critical care. Education is commonly focused on the procedural aspects and the complications associated with the initial placement of these monitors without instruction on the technical concepts required for obtaining accurate data. Anesthesiologists must understand the fundamental concepts on which measurements are made to effectively use invasive pressure monitors, including pulmonary artery catheters, central venous catheters, intra-arterial catheters, external ventricular drains, and spinal or lumbar drains. This review will address important gaps in knowledge surrounding leveling and zeroing of invasive pressure monitors, emphasizing the impact of varied practice patterns on patient care.
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Affiliation(s)
- Catherine Foley Jerman
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith H Baker
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.
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13
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Denault A, Canevet M, Couture EJ. Pro: We Should Use a Pulmonary Artery Catheter with Right Ventricular Pressure Waveforms in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2023; 37:659-662. [PMID: 36870782 DOI: 10.1053/j.jvca.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/02/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Affiliation(s)
- André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Manon Canevet
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada
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14
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Shaver S, Bailey C, Jain A. Spontaneous Hemorrhage of the Distal Segment of the Left Pulmonary Artery After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:457-460. [PMID: 36517334 DOI: 10.1053/j.jvca.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Shanthi Shaver
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Caryl Bailey
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Ankit Jain
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA.
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15
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Couture EJ, Moses K, Monge García MI, Potes C, Haddad F, Grønlykke L, Garcia F, Paster E, Pibarot P, Denault AY. Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model. Crit Care Explor 2023; 5:e0847. [PMID: 36699251 DOI: 10.1097/CCE.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (Ees) following the development of an acute RV ischemic in a porcine model. HYPOTHESIS RV pressure monitoring can detect changes in RV systolic performance assess by RV Ees following the development of an acute RV ischemic model. METHODS AND MODELS Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV Ees obtained using a conductance catheter during inferior vena cava occlusions. RESULTS Acute ischemia resulted in a significant reduction in RV Ees from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between Ees and RV pressure-derived parameters. The reduction in RV Ees best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dtmax) and single-beat RV Ees. Adjusting RV dP/dtmax for heart rate resulted in an improved surrogate of RV Ees. INTERPRETATION AND CONCLUSIONS Stepwise decreases in RV Ees during acute ischemic RV dysfunction were accurately tracked by RV dP/dtmax derived from the RV pressure waveform.
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16
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Zeliaś A, Zajdel W, Malinowski K, Geremek J, Tokarek T, Dudek D, Żmudka K. Hemodynamic effects of larger volume intra-aortic balloon pump during high-risk percutaneous coronary interventions. Kardiol Pol 2023; 81:1257-1264. [PMID: 38189506 DOI: 10.33963/v.kp.98410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Percutaneous coronary intervention in high-risk patients (HRPCI) is associated with increased risk of complications. Mechanical circulatory support devices, including intra-aortic balloon pump (IABP) may bridge patient safely throughout the procedure. AIM We aimed to describe hemodynamic effects of larger (MEGA) compared to standard (STRD) volume IABP or no balloon control group (CTRL) during HRPCI. METHODS In this single-center, open-label randomized controlled trial HRPCI were randomly assigned to three groups according to planned hemodynamic support: MEGA, STDR and CTRL in a 1:1:1 scheme. Screening failure patients formed registry (REG). We analyzed data from pulmonary artery catheter especially cardiac output and cardiac power output (CPO) with Fick method and pulmonary artery wedge pressure (PCWP), as well as left ventricle systolic pressure (LVSP) with PIGTAIL catheter. We also calculated endocardial viability ratio (EVR) and analyzed pressure tracings from the IABP console. We compared baseline and on-support values. Final hemodynamic analysis was done on per-treatment basis, including REG patients. RESULTS A total of 47 patients were analyzed (16 MEGA, 10 STRD and 21 CTRL). Compared to CTRL we found significant increase from baseline to on-support value for cardiac output and CPO in the MEGA, but not in the STRD group. The change in EVR (increase) and in LVSP (decrease) was significant equally in MEGA and STRD vs. CTRL group, but PCWP did not change significantly for both balloons vs. CTRL. Diastolic augmented pressure with IABP was higher in MEGA than STRD and was positively correlated with systolic unloading. CONCLUSIONS We observed more favorable hemodynamic effects of larger compared to standard volume balloon.
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Affiliation(s)
- Aleksander Zeliaś
- The Faculty of Medicine and Health Sciences, University of Applied Sciences in Nowy Sacz, Nowy Sącz, Poland.
- Center for Innovative Medical Education, Jagiellonian University Medical College, Kraków, Poland.
| | - Wojciech Zajdel
- Clinic of Interventional Cardiology, John Paul II Hospital, Kraków, Poland
| | - Krzysztof Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Jolanta Geremek
- Clinic of Interventional Cardiology, John Paul II Hospital, Kraków, Poland
| | - Tomasz Tokarek
- Center for Innovative Medical Education, Jagiellonian University Medical College, Kraków, Poland
- Center for Innovative Medical Education, Jagiellonian University Medical College, Kraków, Poland
| | - Dariusz Dudek
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Krzysztof Żmudka
- Clinic of Interventional Cardiology, John Paul II Hospital, Kraków, Poland
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17
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Gonzalez LS, Coghlan C, Alsatli RA, Alsatli O, Tam CW, Kumar SR, Thalappillil R, Chaney MA. The Entrapped Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2022; 36:4198-4207. [PMID: 35843773 DOI: 10.1053/j.jvca.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen Coghlan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Raed A Alsatli
- Department of Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ola Alsatli
- Kenneth Jansz Medicine Professional Corporation, Burlington, Ontario, Canada
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Shreyajit R Kumar
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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18
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Cousin N, Goutay J, Cailliau E, Gaudet A, Duburcq T. Effects of High PEEP on Intrapulmonary Shunt Ratio in Patients With SARS-CoV-2-Induced ARDS. Respir Care 2022; 67:1456-1459. [PMID: 35820702 PMCID: PMC9993964 DOI: 10.4187/respcare.09941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nicolas Cousin
- CHU Lille, Medical Intensive Care Unit, Lille, France; and CHU Lille, Pôle d'Anesthésie Réanimation, Clinique Cardio-vasculaire et thoracique, Lille, France
| | - Julien Goutay
- CHU Lille, Medical Intensive Care Unit, Lille, France
| | - Emeline Cailliau
- Univ Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France; and CHU Lille, Department of Biostatistics, Lille, France
| | - Alexandre Gaudet
- CHU Lille, Medical Intensive Care Unit, Lille, France; and University Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France.
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19
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Fernandez TMA, Schofield N, Krenn CG, Rizkalla N, Spiro M, Raptis DA, De Wolf AM, Merritt WT. What is the optimal anesthetic monitoring regarding immediate and short-term outcomes after liver transplantation?-A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14643. [PMID: 35262975 PMCID: PMC10077907 DOI: 10.1111/ctr.14643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. OBJECTIVES To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT). METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring, (2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908). RESULTS Of 2619 articles screened 16 were included. Studies were small, retrospective, and observational. Vascular access studies demonstrated low rates of insertion complications. TEE studies demonstrated low rates of esophageal hemorrhage. One study found lower hospital-LOS and 30-day mortality in patients monitored with both PAC and TEE. Other monitoring studies were heterogenous in design and outcomes. Temperature studies showed increased blood transfusion and ventilation times in hypothermic groups. CONCLUSIONS Recommendations were made for; routine arterial and CVP monitoring as a minimum standard of practice, consideration of discrepancy between peripheral and central arterial BP in patients with hemodynamic instability and high vasopressor requirements, and routine use of high flow cannulae while monitoring for extravasation and hematoma formation. Availability and expertise in PAC and/or TEE monitoring is strongly recommended particularly in hemodynamic instability, portopulmonary HT and/or cardiac dysfunction. TEE use is recommended as an acceptable risk in patients with treated esophageal varices and is an effective diagnostic tool for emergency cardiovascular collapse. Maintenance of intraoperative normothermia is strongly recommended.
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Affiliation(s)
- Thomas M A Fernandez
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand.,Department of Anesthesia, University of Auckland, Auckland, New Zealand
| | - Nick Schofield
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK
| | - Claus G Krenn
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Nicole Rizkalla
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William T Merritt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
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20
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Knio ZO, Thiele RH, Wright WZ, Mazimba S, Naik BI, Hulse MC. A Novel Hemodynamic Index of Post-operative Right Heart Dysfunction Predicts Mortality in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2022; 26:200-208. [PMID: 35332827 DOI: 10.1177/10892532221080382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This study aimed to investigate whether mortality following cardiac surgery was associated with the pulmonary artery pulsatility index (PAPi): pulmonary artery pulse pressure divided by central venous pressure (CVP), and a novel index: mean pulmonary artery pressure (mPAP) minus CVP. METHODS This retrospective analysis investigated all cardiac surgery patients in the Society of Thoracic Surgeons registry at a single academic medical center from January 2017 through March 2020 (n = 1510). The primary and secondary outcomes were mortality at 1 year and serum creatinine increase during index surgical admission, respectively. CVP, mPAP, PAPi, mPAP-CVP gradient, mean arterial pressure (MAP), and cardiac index (CI) were sampled continually from invasive hemodynamic monitors post-operatively. Associations with mortality were tested with univariate and multivariate analyses. The relationship with serum creatinine was investigated with Pearson's correlation at alpha = .05. RESULTS One-year mortality was observed in 44/1200 patients (3.7%). On univariate analysis, mortality was associated with minimums for mPAP, MAP, and CI and maximums for CVP, mPAP, PAPi, mPAP-CVP gradient, and CI (all P < .10). Model selection revealed that the only independently predictive parameters were minimum MAP (AOR = .880 [.819-.944]), maximum mPAP-CVP gradient (AOR = 1.082 [1.031-1.133]), and maximum CI (AOR = 1.421 [.928-2.068]), with model c-statistic = .770. A maximum mPAP-CVP gradient >20.5 predicted mortality with 54.5% sensitivity and 79.30% specificity, maintaining significance on survival analysis (P < .001). Peak increase in serum creatinine from baseline demonstrated a weak association with all parameters (max |r| = .33). CONCLUSIONS Mortality was not predicted by the post-operative PAPi; rather, it was independently predicted by the mPAP-CVP gradient, MAP, and CI.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Robert H Thiele
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - W Zachary Wright
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Sula Mazimba
- Department of Medicine, Division of Cardiovascular Medicine, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA.,Department of Neurosurgery, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Matthew C Hulse
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
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21
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Coverdale G, Patteril M. Do pulmonary artery catheters have a role in the 21 st century intensive care unit? Br J Anaesth 2022; 129:3-7. [PMID: 35331542 DOI: 10.1016/j.bja.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Use of pulmonary artery catheters on general intensive care units has declined. Reasons for this decline are explored and the evidence for and against their use is re-examined. We conclude that the growing consensus for a lack of benefit is not justified, and use of pulmonary artery catheters can still be appropriate.
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Affiliation(s)
- Giles Coverdale
- Department of Anaesthesia and Critical Care, University Hospital Coventry and Warwickshire, Coventry, UK.
| | - Mathew Patteril
- Department of Anaesthesia and Critical Care, University Hospital Coventry and Warwickshire, Coventry, UK
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22
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Kuwauchi A, Yoshida S, Tanaka S, Tanaka S, Takeda C, Yonekura H, Nahara I, Kawakami K. Hemodynamic Monitoring Using a Pulmonary Artery Catheter Versus the Vigileo/FloTrac System during Elective Cardiac Surgery Based on Real-world Data in Japan. Ann Clin Epidemiol 2022; 4:81-91. [PMID: 38504946 PMCID: PMC10760491 DOI: 10.37737/ace.22011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/18/2021] [Indexed: 03/21/2024]
Abstract
BACKGROUND The controversy concerning the benefits of pulmonary artery catheter (PAC)-based hemodynamic monitoring in cardiac surgeries has not been adequately addressed. This study aims to compare the all-cause mortality between the PAC with venous oxygen saturation monitoring and the Vigileo/FloTrac (FloTrac) system with central venous oxygen saturation monitoring in cardiac surgeries. METHODS This nationwide retrospective study includes adult patients who underwent elective cardiac surgeries between April 2010 and October 2014, based on the Japanese health insurance claims database. The main outcome was 30-day all-cause mortality. Propensity scores (PS) were used to adjust for the confounding factors. Treatment effects were estimated using multivariable logistic regression analysis, including PS. RESULTS A total of 5,838 patients were included in this study. The crude 30-day mortality rates were 2.4% (8/334) and 1.7% (96/5,504) in the FloTrac and PAC groups, respectively. After PS matching, the ORs for 30-day all-cause mortality, in-hospital mortality after PAC placement (vs. FloTrac) were 0.36 (95% CI: 0.05-2.37; p = 0.28) and 0.59 (95% CI: 0.16-2.20; p = 0.43), respectively. The amount of dobutamine was larger in the PAC group (281 ± 31 mg vs 155 ± 19 mg; p < 0.001). There were no significant differences in the amounts of other inotropes, the volume of fluids, or blood transfusions. CONCLUSIONS The association between PAC (with venous oxygen saturation monitoring) and mortality in patients who underwent elective cardiac surgeries was unclear compared to FloTrac (with central venous oxygen saturation monitoring). Additional investigation is needed to evaluate the benefits of PAC-specific hemodynamic parameters in this population.
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Affiliation(s)
- Aki Kuwauchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University
| | - Sachiko Tanaka
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | | | - Hiroshi Yonekura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Isao Nahara
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
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23
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Durack JC, Chen LL, Imran S, Halpern NA. A Tale of Two Pulmonary Artery Catheters. Crit Care Nurs Q 2022; 45:8-12. [PMID: 34818292 PMCID: PMC9911303 DOI: 10.1097/cnq.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report.
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Affiliation(s)
- Jeremy C Durack
- Interventional Radiology Service, Department of Radiology (Dr Durack), and Critical Care Center and Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine (Drs Chen, Imran, and Halpern), Memorial Sloan Kettering Cancer Center, New York City, New York
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24
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Meraj PM, O'Neill WW. Cardiogenic Shock Management Should Be a Team Sport. J Am Coll Cardiol 2021; 78:1318-1320. [PMID: 34556317 DOI: 10.1016/j.jacc.2021.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Perwaiz M Meraj
- Department of Cardiology, Northwell Health, Manhasset, New York, USA.
| | - William W O'Neill
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan, USA. https://twitter.com/BillONeillMD
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25
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Papolos AI, Kenigsberg BB, Berg DD, Alviar CL, Bohula E, Burke JA, Carnicelli AP, Chaudhry SP, Drakos S, Gerber DA, Guo J, Horowitz JM, Katz JN, Keeley EC, Metkus TS, Nativi-Nicolau J, Snell JR, Sinha SS, Tymchak WJ, Van Diepen S, Morrow DA, Barnett CF. Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams. J Am Coll Cardiol 2021; 78:1309-1317. [PMID: 34556316 DOI: 10.1016/j.jacc.2021.07.044] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Single-center studies suggest that implementation of multidisciplinary cardiogenic shock (CS) teams is associated with improved CS survival. OBJECTIVES The aim was to characterize practice patterns and outcomes in the management of CS across multiple centers with versus without shock teams. METHODS The Critical Care Cardiology Trials Network is a multicenter network of cardiac intensive care units (CICUs) in North America. All consecutive medical admissions to each CICU (n = 24) were captured during annual 2-month collection periods (2017-2019; n = 6,872). Shock management and CICU mortality among centers with versus without shock teams were compared using inverse probability weighting. RESULTS Ten of the 24 centers had shock teams. Among 1,242 CS admissions, 44% were at shock team centers. The groups were well-balanced with respect to demographics, shock etiology, Sequential Organ Failure Assessment score, biochemical markers of end organ dysfunction, and invasive hemodynamics. Centers with shock teams used more pulmonary artery catheters (60% vs 49%; adjusted odds ratio [OR]: 1.86; 95% CI: 1.47-2.35; P < 0.001), less overall mechanical circulatory support (MCS) (35% vs 43%; adjusted OR: 0.74; 95% CI: 0.59-0.95; P = 0.016), and more advanced types of MCS (53% vs 43% of all MCS; adjusted OR: 1.73; 95% CI: 1.19-2.51; P = 0.005) rather than intra-aortic balloon pumps. The presence of a shock team was independently associated with lower CICU mortality (23% vs 29%; adjusted OR: 0.72; 95% CI: 0.55-0.94; P = 0.016). CONCLUSIONS In this multicenter observational study, centers with shock teams were more likely to obtain invasive hemodynamics, use advanced types of MCS, and have lower risk-adjusted mortality. A standardized multidisciplinary shock team approach may improve outcomes in CS.
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Affiliation(s)
- Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Erin Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | | | - Stavros Drakos
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniel A Gerber
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James M Horowitz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Jason N Katz
- Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Ellen C Keeley
- Department of Medicine University of Florida Gainesville, Gainesville, Florida, USA
| | - Thomas S Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey R Snell
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Wayne J Tymchak
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sean Van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher F Barnett
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
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26
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Mora B, Roth D, Bernardi MH, Base E, Weber U. Estimation of pulmonary artery pressure with transesophageal echocardiography: An observer-blinded test accuracy study. Medicine (Baltimore) 2021; 100:e26988. [PMID: 34414978 PMCID: PMC8376331 DOI: 10.1097/md.0000000000026988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/26/2021] [Indexed: 01/04/2023] Open
Abstract
With the declining use of the pulmonary artery catheter (PAC), transesophageal echocardiography (TEE) has become an appealing alternative to obtain pulmonary artery pressure non-invasively using the simplified Bernoulli equation. The validation of this method in the perioperative setting has been scarce with no clear recommendations about which view is the most accurate to estimate right ventricular systolic pressure (RVSP).Therefore, we performed a prospective, observer-blinded, diagnostic test accuracy study to assess the difference in systolic pulmonary artery pressure (sysPAP) measuring both, invasively sysPAP and estimated RVSP with TEE in 3 different views: the mid-esophageal (ME) 4Chamber, the ME right ventricular (RV) inflow-outflow and the ME modified bicaval view.To show a clinically significant difference of at least 10% in RVSP, we included 40 cardiac surgical patients divided into 3 subgroups: Patients with mild to moderate tricuspid regurgitation (TR) and mean PAP <25 mm Hg, patients with mild to moderate TR and mean PAP≥ 25 mm Hg, and patients with severe TR.For the whole cohort, bias of estimated RVSP compared to measured sysPAP was 5.27 mm Hg, precision was 7.96 mm Hg, limits of agreement were -10.66 to 21.19 mm Hg. The best agreement between the 2 methods was found in patients with severe TR and in the ME RV inflow-outflow and the modified bicaval view. Good Doppler signals were available in 35% and 46% in these views, and in 20% in the ME 4 chamber view.The estimation of the sysPAP by TEE cannot be considered reliable in the clinical perioperative setting. Only measurements that provide a full Doppler envelope show sufficient precision to provide accurate estimations.
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Affiliation(s)
- Bruno Mora
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin H. Bernardi
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Base
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ulrike Weber
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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27
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Stawiarski K, Ramakrishna H. The Pulmonary Artery Catheter in Cardiogenic and Post-Cardiotomy Shock-Analysis of Recent Data. J Cardiothorac Vasc Anesth 2021; 36:2780-2782. [PMID: 34538559 DOI: 10.1053/j.jvca.2021.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Kristin Stawiarski
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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28
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Walz R, Roth S, Hollmann MW, Huhn R. Formula for safe insertion depth of a pulmonary artery catheter. Br J Anaesth 2021; 127:e25-e27. [PMID: 34052031 DOI: 10.1016/j.bja.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Roland Walz
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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29
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Becker A, Seiler F, Muellenbach RM, Danziger G, Kamphorst M, Lotz C, Bals R, Lepper PM. Pulmonary Hemodynamics and Ventilation in Patients With COVID-19-Related Respiratory Failure and ARDS. J Intensive Care Med 2021; 36:655-663. [PMID: 33678052 DOI: 10.1177/0885066621995386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND It has been suggested that COVID-19-associated severe respiratory failure (CARDS) might differ from usual acute respiratory distress syndrome (ARDS) due to failing autoregulation of pulmonary vessels and higher shunt. We sought to investigate pulmonary hemodynamics and ventilation properties in patients with CARDS compared to patients with ARDS of pulmonary origin. METHODS This was a retrospective analysis of prospectively collected data from consecutive adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 patients treated in our ICU in 04/2020 and a comparison of the data to matched controls with ARDS due to respiratory infections treated in our ICU from 01/2014 to 08/2019 for whom pulmonary artery catheter data were available. RESULTS CARDS patients (n = 10) had ventilation characteristics similar to those of ARDS (n = 10) patients. Nevertheless, mechanical power applied by ventilation was significantly higher in CARDS patients (23.4 ± 8.9 J/min) than in ARDS (15.9 ± 4.3 J/min; P < 0.05). COVID-19 patients had similar pulmonary artery pressure but significantly lower pulmonary vascular resistance, as cardiac output was higher in CARDS vs. ARDS patients (P < 0.05). Shunt fraction and dead space were similar in CARDS compared to ARDS (P > 0.05) and were correlated with hypoxemia in both groups. The arteriovenous pCO2 difference (▵pCO2) was elevated (CARDS 5.5 ± 2.8 mmHg vs. ARDS 4.7 ± 1.1 mmHg; P > 0.05), as was the P(v-a)CO2/C(a-v)O2 ratio (CARDS mean 2.2 ± 1.5 vs. ARDS 1.7 ± 0.8; P > 0.05). CONCLUSIONS Respiratory failure in COVID-19 patients seems to differ only slightly from ARDS regarding ventilation characteristics and pulmonary hemodynamics. Our data indicate microcirculatory dysfunction. More data need to be collected to assure these findings and gain more pathophysiological insights into COVID-19 and respiratory failure.
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Affiliation(s)
- André Becker
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Frederik Seiler
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Guy Danziger
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Maren Kamphorst
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Christopher Lotz
- Department of Anaesthesiology and Critical Care Medicine, 9190University of Würzburg, Würzburg, Germany
| | | | - Robert Bals
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V-Pneumology, Allergology and Critical Care Medicine, 39072University Hospital of Saarland and Saarland University, Homburg/Saar, Germany.,Interdisciplinary COVID-19-Center, 39072University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
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Bootsma IT, de Lange F, Scheeren TWL, Jainandunsing JS, Boerma EC. High Versus Normal Blood Pressure Targets in Relation to Right Ventricular Dysfunction After Cardiac Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2021; 35:2980-2990. [PMID: 33814247 DOI: 10.1053/j.jvca.2021.02.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Management of right ventricular (RV) dysfunction is challenging. Current practice predominantly is based on data from experimental and small uncontrolled studies and includes augmentation of blood pressure. However, whether such intervention is effective in the clinical setting of cardiac surgery is unknown. DESIGN Randomized controlled trial. SETTING Single-center study in a tertiary teaching hospital. PARTICIPANTS The study comprised 78 patients equipped with a pulmonary artery catheter (PAC), classified according to PAC-derived RV ejection fraction (RVEF); 44 patients had an RVEF of <20%, and 34 patients had an RVEF between ≥20% and <30%. INTERVENTIONS Patients randomly were assigned to either a normal target group (mean arterial pressure 65 mmHg) or a high target group [mean arterial pressure 85 mmHg]). The primary end- point was the change in RVEF over a one-hour study period. MEASUREMENTS AND MAIN RESULTS There was no significant between-group difference in change of RVEF <20% (-1% [-3.3 to 1.8] in the normal-target group v 0.5% [-1 to 4] in the high-target group; p = 0.159). There was no significant between-group difference in change in RVEF 20%-to-30% (-1% [-3 to 0] in the normal-target group v 1% [-1 to 3] in the high-target group; p = 0.074). These results were in line with the simultaneous observation that echocardiographic variables of RV and left ventricular function also remained unaltered over time, irrespective of either baseline RVEF or treatment protocol. CONCLUSION In a mixed cardiac surgery population with RV dysfunction, norepinephrine-mediated high blood pressure targets did not result in an increase in PAC-derived RVEF compared with normal blood pressure targets.
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Affiliation(s)
- Inge T Bootsma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands.
| | - Fellery de Lange
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jayant S Jainandunsing
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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Gonzalez MH, Wang Q, Yaranov DM, Albert C, Wolski K, Wagener J, Aggarwal A, Menon V, Jacob M, Tang W, Hsich E, Taylor D, Tong M, Soltesz E, Estep JD, Starling RC, Joyce E. Dynamic Assessment of Pulmonary Artery Pulsatility Index Provides Incremental Risk Assessment for Early Right Ventricular Failure After Left Ventricular Assist Device. J Card Fail 2021; 27:777-785. [PMID: 33640481 DOI: 10.1016/j.cardfail.2021.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The pulmonary artery pulsatility index (PAPi) has been studied to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation, but only as a single time point before LVAD implantation. Multiple clinical factors and therapies impact RV function in pre-LVAD patients. Thus, we hypothesized that serial PAPi measurements during cardiac intensive care unit (CICU) optimization before LVAD implantation would provide incremental risk stratification for early RVF after LVAD implantation. METHODS AND RESULTS Consecutive patients who underwent sequential pulmonary artery catherization with cardiac intensive care optimization before durable LVAD implantation were included. Serial hemodynamics were reviewed retrospectively across the optimization period. The optimal PAPi was defined by the initial PAPi + the PAPi at optimized hemodynamics. RVF was defined as need for a right ventricular assist device or prolonged inotrope use (>14 days postoperatively). Patients with early RVF had significantly lower mean optimal PAPi (3.5 vs 7.5, P < .001) compared with those who did not develop RVF. After adjusting for established risk factors of early RVF after LVAD implantation, the optimal PAPi was independently and incrementally associated with early RVF after LVAD implantation (odds ratio 0.64, 95% confidence interval 0.532-0.765, P < .0001). CONCLUSIONS Optimal PAPi achieved during medical optimization before LVAD implantation provides independent and incremental risk stratification for early RVF, likely identifying dynamic RV reserve.
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Affiliation(s)
- Matthew H Gonzalez
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Spectrum Health Medical Group, Grand Rapids, Michigan.
| | - Qiuqing Wang
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Chony Albert
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kathy Wolski
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Wagener
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Appas Aggarwal
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Miriam Jacob
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Tang
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eileen Hsich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Taylor
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jerry D Estep
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emer Joyce
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
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Cavaliere F, Bevilacqua F, Cesana BM, Calabrese M, Arlotta G, Antoniucci ME, Corsi F, Corrado M, De Paulis S, Scapigliati A. Carbon dioxide partial pressure and oxygen saturation in venous blood from the upper body compared with mixed venous blood. Br J Anaesth 2021; 126:e177-e179. [PMID: 33632520 DOI: 10.1016/j.bja.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 01/23/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Francesca Bevilacqua
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Bruno M Cesana
- G.A. Maccacaro Unit of Medical Statistics, Biometry, and Bioinformatics, Department of Clinical Sciences and Community Health, Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Maria Calabrese
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gabriella Arlotta
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Maria E Antoniucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Corsi
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Michele Corrado
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefano De Paulis
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Andrea Scapigliati
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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Brown JA, Aranda-Michel E, Kilic A, Serna-Gallegos D, Bianco V, Thoma FW, Sultan I. The impact of pulmonary artery catheter use in cardiac surgery. J Thorac Cardiovasc Surg 2021; 164:1965-1973.e6. [PMID: 33642109 DOI: 10.1016/j.jtcvs.2021.01.086] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring. METHODS This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups. RESULTS Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05). CONCLUSIONS These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Abstract
The aim of this review is to present the current options for cardiac output (CO) monitoring in children undergoing cardiac surgery. Current technologies for monitoring identified were a range of invasive, minimally invasive, and non-invasive technologies. These include pulmonary artery catheter, transoesophageal echocardiography, pulse contour analysis, electrical cardiography, and thoracic bioreactance. A literature search was conducted using evidence databases which identified two current guidelines; the NHS Greater Glasgow and Clyde guideline and Royal College of Anaesthetics Guideline. These were appraised using the AGREE II tool and the evidence identified was used to create an overview summary of each technological option for CO monitoring. There is limited evidence regarding the accuracy of modalities available for CO monitoring in paediatric patients during cardiac surgery. Each technology has advantages and disadvantages; however, none could be championed as the most beneficial. Furthermore, a gold standard for CO monitoring has not yet been identified for paediatric populations, nor is it apparent whether one modality is preferable based on the available evidence. Additional evidence using a standardised method for comparing CO measurements should be conducted in order to determine the best option for CO monitoring in paediatrics. Furthermore, cost-effectiveness assessment of each modality should be conducted. Only then will it be possible for clear, evidence-based guidance to be written.
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Abstract
The year 2020 marks the 50th anniversary of the landmark publication on the bedside clinical use of a flow-directed catheter. The catheter, now known as the Swan-Ganz catheter, truly revolutionized practice and care of the critically ill. Use of the catheter proliferated nearly without rigorous validation or evidence base until a moratorium was called in regard to its use. This article describes the history of the development of the Swan-Ganz catheter, its uses, and its near downfall. The authors, both involved in educating clinicians in the use of the pulmonary artery catheter, hope that telling this story shares tribal knowledge and lessons learned with newer generations of nurses who did not experience the explosion of development and knowledge in the area of hemodynamic monitoring. Partly because of advances in technology, and the catheter's application for heart failure in particular, use of the pulmonary catheter is being resurrected.
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Affiliation(s)
- Jan M Headley
- Jan M. Headley is Principal, Consultants in Acute and Critical Care, PTY 880853, PO Box 025724, Miami, FL 33102-5724
| | - Thomas Ahrens
- Thomas Ahrens is Chief Learning Officer, NovEx, St Louis, Missouri
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Abstract
The pulmonary artery catheter is a valuable tool available to the clinician for use in deciphering complex hemodynamic scenarios. Patients in shock, particularly those who are elderly or have premorbid conditions such as heart failure, may have atypical presentations. Additional hemodynamic data may help identify interventions that might seem counterintuitive, such as the use of vasoconstrictors in patients with low cardiac output. Interpretation of pulmonary artery hemodynamic data is a skill that should not be relegated to the past. This article reviews the use of a pulmonary artery catheter in mixed shock states. A case study is used to demonstrate how pulmonary artery catheter hemodynamic values can guide the care of these patients.
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Affiliation(s)
- Paul Thurman
- Paul Thurman is Nurse Scientist, Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Mary-land Medical Center, and Assistant Professor, Doctor of Nursing Practice Program, University of Maryland School of Nursing, 22 S Greene St, Baltimore, MD 21201
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Garg L, Arkles JS, Schaller RD. Percutaneous Removal of a Pulmonary Artery Catheter Inadvertently Sutured to the Heart During Valve Surgery. JACC Case Rep 2020; 2:2323-2326. [PMID: 34317164 PMCID: PMC8304588 DOI: 10.1016/j.jaccas.2020.07.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/31/2020] [Indexed: 11/17/2022]
Abstract
A 74-year old woman underwent "mini-mitral" valve surgery via a right thoracotomy. The pulmonary artery catheter could not be removed thereafter and was found to be pierced by the atriotomy suture. Removal was performed by percutaneously lacerating the catheter above and below the suture, leaving behind a small segment. (Level of Difficulty: Advanced.).
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Affiliation(s)
| | | | - Robert D. Schaller
- Address for correspondence: Dr. Robert D. Schaller, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA. @rdschaller
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Yano K, Toyama Y, Iida T, Hayashi K, Takahashi K, Kanda H. Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2020; 35:1663-1669. [PMID: 33268041 DOI: 10.1053/j.jvca.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE. DESIGN Prospective observational. SETTING Cardiac operating room at a single university hospital. PARTICIPANTS All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements. CONCLUSION A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.
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Affiliation(s)
- Kiichi Yano
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan.
| | - Yuki Toyama
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takafumi Iida
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Hayashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Keiya Takahashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
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Fang JC, Jones TL. Can a Pulmonary Artery Catheter Improve Outcomes in Cardiogenic Shock? JACC Heart Fail 2020; 8:914-916. [PMID: 33121703 DOI: 10.1016/j.jchf.2020.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022]
Affiliation(s)
- James C Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah.
| | - Tara L Jones
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
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Rong LQ, Kaushal M, Mauer E, Pryor KO, Kenfield M, Shore-Lesseron L, Gaudino MFL, Neuburger PJ. Two- or 3-Dimensional Echocardiography-Derived Cardiac Output Cannot Replace the Pulmonary Artery Catheter in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:2691-2697. [PMID: 32693966 DOI: 10.1053/j.jvca.2020.06.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Three-dimensional (3D) transesophageal echocardiography (TEE) has been shown to be more accurate than 2D TEE for the evaluation of the left ventricular outflow tract area. The aim of the present study was to compare the agreement of 3D echocardiography-derived cardiac output (CO) with thermodilution-derived CO (TDCO) before and after cardiopulmonary bypass (CPB). DESIGN This was a prospective observational study of patients who underwent cardiac surgery between 2016 and 2018. SETTING Weill Cornell Medicine, a single large academic medical center. PARTICIPANTS The study comprised 78 patients undergoing elective cardiac surgery. INTERVENTIONS CPB, TEE, pulmonary artery catheter, and elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS Two-dimensional CO, 3D CO-diameter, and 3D CO-area values pre-CPB were strongly correlated with one another both pre-CPB and post-CPB. The 3D CO-diameter and the 3D CO-area were mildly correlated, with TDCO measurements pre-CPB (r = 0.46 and 0.39, respectively) and post-CBP (r = 0.43 and 0.47, respectively). Pre-CPB 3D CO-diameter had the most agreement with TDCO in terms of bias (-0.13 L/min); however, the limits of agreement (LOA) were wide (-2.2- to- 2.45 L/min). Post-CPB, 3D CO-diameter had the most agreement with TDCO in terms of bias (0.41) but with wide LOA (-3.29 to 2.47). All pre-CPB echocardiography-derived CO (2D CO, 3D CO-diameter, 3D CO-area) had more agreement with TDCO than did post-CPB measurements. CONCLUSIONS Three-dimensional CO measurements were only modestly correlated with pulmonary artery catheter-derived CO pre-bypass and post-bypass. Despite low bias, the wide LOA from 2D CO, 3D CO-diameter, and 3D-area compared with TDCO suggested that the 2 methods are not interchangeable.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY.
| | - Mudit Kaushal
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Elizabeth Mauer
- Department of Health Policy and Research, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Meaghan Kenfield
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY
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Hamaba H, Miyata Y, Wada T, Hayasaka T, Hayashi Y. An analysis of prior experience influencing quality of pulmonary artery catheter placement in residents. Ann Card Anaesth 2020; 23:161-164. [PMID: 32275029 PMCID: PMC7336959 DOI: 10.4103/aca.aca_220_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Prior experience may be important for successful placement of a pulmonary artery catheter (PAC). However, there is no report about the minimum number of the placement to reach acceptable technique for the catheter placement during residency. Aims: This study was designed to examine quality of the catheter placement and to assess the effect of prior experience. Setting and Design: Prospective, observational, cohort study. Methods: This study included eight residents and one experienced staff in our hospital. We prospectively examined the performance of placement of a PAC in eight residents for the first 2 months of their training period and one staff for previous 2 years. We examined the time required for the catheter placement and probability of ventricular arrhythmias during the placement. Each resident and the staff reported approximate number of past experience of the catheter placement according to the self-statement. In addition, we continued to examine the placement of a PAC in one resident with zero experience to show his improvement. Statistical Analysis: Statistical analysis was performed by Kruskal–Wallis test, Mann–Whitney test, or Fisher's exact test as appropriate and Benjamini and Hochberg method was used for multiple comparisons. Results: The catheter placement time and probability of the ventricular arrhythmias of two residents with zero experience of the placement were significantly larger than those of the staff. On the other hand, the placement quality of the other residents who experienced at least 20 PAC placements was not significantly different from that of the staff. The placement quality of one resident with zero experience became comparable with that of the staff after 20 placements. Conclusion: Our data suggested that about 20 catheter placements may be required to reach acceptable technical level for the PAC placement.
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Affiliation(s)
- Hirofumi Hamaba
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Yuka Miyata
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Tsutomu Wada
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Tomohiko Hayasaka
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Yukio Hayashi
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
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Bootsma IT, Scheeren TWL, de Lange F, Jainandunsing JS, Boerma EC. The Reduction in Right Ventricular Longitudinal Contraction Parameters Is Not Accompanied by a Reduction in General Right Ventricular Performance During Aortic Valve Replacement: An Explorative Study. J Cardiothorac Vasc Anesth 2020; 34:2140-2147. [PMID: 32139346 DOI: 10.1053/j.jvca.2020.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of the present study was to identify whether the decrease of longitudinal parameters after cardiothoracic surgery (ie, tricuspid annular systolic plane excursion [TAPSE] and systolic excursion velocity [S']) is accompanied by a reduction in global right ventricular (RV) performance. DESIGN Prospective, observational study. SETTING Single-center explorative study in a tertiary teaching hospital. PARTICIPANTS The study comprised 20 patients who underwent aortic valve replacement with or without coronary artery bypass grafting. INTERVENTIONS During cardiac surgery, simultaneous measurements of RV function were performed with a pulmonary artery catheter and transesophageal echocardiography. MEASUREMENTS AND MAIN RESULTS TAPSE and S' were reduced significantly directly after surgery compared with the time before surgery (TAPSE from 20.8 [16.6-23.4] mm to 9.1 [5.6-15.5] mm; p < 0.001 and S' from 8.7 [7.9-10.7] cm/s to 7.2 [5.7-8.6] cm/s; p = 0.041). However, the reduction in TAPSE and S' was not accompanied by a reduction in RV performance, as assessed with the TEE-derived myocardial performance index (MPI) and pulmonary artery catheter-derived RV ejection fraction (RVEF). Both remained statistically unaltered before and after the procedure (MPI from 0.52 [0.43-0.58] to 0.50 [0.42-0.88]; p = 0.278 and RVEF from 27% [22%-32%] to 26% [22%-28%]; p = 0.294). CONCLUSIONS In the direct postoperative phase, the reduction of echocardiographic parameters of longitudinal RV contractility (TAPSE and S') were not accompanied by a reduction in global RV performance, expressed as MPI and RVEF. Solely relying on a single RV parameter as a marker for global RV performance may not be adequate to assess the complex adaptation of the right ventricle to aortic valve replacement.
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Affiliation(s)
- Inge T Bootsma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Fellery de Lange
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Jayant S Jainandunsing
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Schmidt C, Berggreen AE, Heringlake M. Perioperative hemodynamic monitoring: Still a place for cardiac filling pressures? Best Pract Res Clin Anaesthesiol 2019; 33:155-63. [PMID: 31582095 DOI: 10.1016/j.bpa.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/21/2022]
Abstract
The clinical usefulness of the so-called "static" cardiac filling pressures - central (CVP) and pulmonary-artery-occlusion-pressure (PAOP) - has come into question for guiding hemodynamic therapy due to their poor ability to predict fluid responsiveness in comparison with other monitoring modalities such as transpulmonary thermodilution-derived volumetric measurements, dynamic variables for assessing fluid responsiveness, and the potential risks associated with pulmonary artery catheterization. This contrasts with observations in multiple patient populations showing a clear association between increased CVP and PAOP levels and poor outcomes, probably due to a reduction in effective perfusion pressure (mean arterial pressure minus CVP) and their role as effectiveness parameters of the cardiovascular system. Furthermore, clinical studies have revealed beneficial effects when interpreting CVP and PAOP dynamically and combining them with flow-related hemodynamic variables. Taking into account the additional information derived from bedside CVP and PAOP pulse curve interpretation, cardiac filling pressures remain an important hemodynamic monitoring tool.
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Boumpoulis K, Chatzis AC, Balanika M, Milonakis M, Khoury M. Tying the knot: An uncommon complication. Clin Case Rep 2019; 7:1619-1620. [PMID: 31428406 PMCID: PMC6692977 DOI: 10.1002/ccr3.2279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022] Open
Abstract
Cardiothoracic procedures require continuous hemodynamic monitoring and a fair proportion of these require the insertion of a pulmonary artery catheter, known also as Swan-Ganz catheter. Given, however, the invasive nature of these procedures, unforeseen complications may ensue. Early recognition and appropriate handling are essential to minimize adverse outcomes.
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Affiliation(s)
| | - Andrew C. Chatzis
- 2nd Department of Cardiac SurgeryOnassis Cardiac Surgery CentreAthensGreece
| | - Marina Balanika
- Department of AnaesthesiaOnassis Cardiac Surgery CentreAthensGreece
| | - Michael Milonakis
- 2nd Department of Cardiac SurgeryOnassis Cardiac Surgery CentreAthensGreece
| | - Mazen Khoury
- 2nd Department of Cardiac SurgeryOnassis Cardiac Surgery CentreAthensGreece
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Bijl RC, Valensise H, Novelli GP, Vasapollo B, Wilkinson I, Thilaganathan B, Stöhr EJ, Lees C, van der Marel CD, Cornette JMJ. Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics. Ultrasound Obstet Gynecol 2019; 54:35-50. [PMID: 30737852 DOI: 10.1002/uog.20231] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
Cardiac output (CO), along with blood pressure and vascular resistance, is one of the most important parameters of maternal hemodynamic function. Substantial changes in CO occur in normal pregnancy and in most obstetric complications. With the development of several non-invasive techniques for the measurement of CO, there is a growing interest in the determination of this parameter in pregnancy. These techniques were initially developed for use in critical-care settings and were subsequently adopted in obstetrics, often without appropriate validation for use in pregnancy. In this article, methods and devices for the measurement of CO are described and compared, and recommendations are formulated for their use in pregnancy, with the aim of standardizing the assessment of CO and peripheral vascular resistance in clinical practice and research studies on maternal hemodynamics. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R C Bijl
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Valensise
- Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - G P Novelli
- Department of Cardiology, San Sebastiano Martire Hospital, Frascati, Italy
| | - B Vasapollo
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - I Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - E J Stöhr
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - C Lees
- Department of Obstetrics, Imperial College, London, UK
| | - C D van der Marel
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J M J Cornette
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
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Sionis A, Rivas-Lasarte M, Mebazaa A, Tarvasmäki T, Sans-Roselló J, Tolppanen H, Varpula M, Jurkko R, Banaszewski M, Silva-Cardoso J, Carubelli V, Lindholm MG, Parissis J, Spinar J, Lassus J, Harjola VP, Masip J. Current Use and Impact on 30-Day Mortality of Pulmonary Artery Catheter in Cardiogenic Shock Patients: Results From the CardShock Study. J Intensive Care Med 2019; 35:1426-1433. [PMID: 30732522 DOI: 10.1177/0885066619828959] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) is the most life-threatening manifestation of acute heart failure. Its complexity and high in-hospital mortality may justify the need for invasive monitoring with a pulmonary artery catheter (PAC). METHODS Patients with CS included in the CardShock Study, an observational, prospective, multicenter, European registry, were analyzed, aiming to describe the real-world use of PAC, evaluate its impact on 30-day mortality, and the ability of different hemodynamic parameters to predict outcomes. RESULTS Pulmonary artery catheter was used in 82 (37.4%) of the 219 patients. Cardiogenic shock patients who managed with a PAC received more frequently treatment with inotropes and vasopressors, mechanical ventilation, renal replacement therapy, and mechanical assist devices (P < .01). Overall 30-day mortality was 36.5%. Pulmonary artery catheter use did not affect mortality even after propensity score matching analysis (hazard ratio = 1.17 [0.59-2.32], P = .66). Cardiac index, cardiac power index (CPI), and stroke volume index (SVI) showed the highest areas under the curve for 30-day mortality (ranging from 0.752-0.803) and allowed for a significant net reclassification improvement of 0.467 (0.083-1.180), 0.700 (0.185-1.282), 0.683 (0.168-1.141), respectively, when added to the CardShock risk score. CONCLUSIONS In our contemporary cohort of CS, over one-third of patients were managed with a PAC. Pulmonary artery catheter use was associated with a more aggressive treatment strategy. Nevertheless, PAC use was not associated with 30-day mortality. Cardiac index, CPI, and SVI were the strongest 30-day mortality predictors on top of the previously validated CardShock risk score.
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Affiliation(s)
- Alessandro Sionis
- Cardiology Department, Intensive Cardiac Care Unit, 16689Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBER-CV, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Mercedes Rivas-Lasarte
- Cardiology Department, Intensive Cardiac Care Unit, 16689Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBER-CV, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Alexandre Mebazaa
- INSERM U942, Hopital Lariboisiere, APHP and University Paris Diderot, Paris, France
| | - Tuukka Tarvasmäki
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.,Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Jordi Sans-Roselló
- Cardiology Department, Intensive Cardiac Care Unit, 16689Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBER-CV, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Heli Tolppanen
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland.,Heart Center, Päijät-Häme Central Hospital, Lahti, Finland
| | - Marjut Varpula
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Raija Jurkko
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Marek Banaszewski
- Institute of Cardiology, Intensive Cardiac Therapy Clinic, Warsaw, Poland
| | - Jose Silva-Cardoso
- Department of Cardiology, Faculty of Medicine, CINTESIS-Center for Health Technology and Services Research, University of Porto, São João Medical Center, Porto, Portugal
| | - Valentina Carubelli
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Matias Greve Lindholm
- Division of Heart Failure, Pulmonary Hypertension and Heart Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - John Parissis
- Heart Failure Clinic and Secondary Cardiology Department, Attikon University Hospital, Athens, Greece
| | - Jindrich Spinar
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic
| | - Johan Lassus
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Josep Masip
- Critical Care Department, Hospital Sant Joan Despi Moisès Broggi, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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Abstract
The management of patients after cardiothoracic surgery can be very complex. Variabilities exist in hemodynamic status after cardiac surgery and the use of cardiopulmonary bypass – all of which can have a significant impact on myocardial Frank–Starling curves. Typically, invasive monitoring with pulmonary artery catheters is used to assess the complex physiology that these patients experience in the perioperative setting. However, the use of invasive monitoring is not without risk, and the broader benefits are poorly defined. Furthermore, there is growing evidence to support the use of hemodynamic early goal-directed therapy to optimize outcomes in critically ill patients. The purpose of this editorial statement is the review of some of the current literature with regards to the utility of goal-directed therapy as applied to the postoperative cardiac surgical patient.
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Affiliation(s)
- Zoe Goldthwaite
- Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, Aurora, CO, USA
| | - Michael S Firstenberg
- Department of Cardiothoracic and Vascular Surgery, The Medical Center of Aurora, Aurora, CO, USA
| | - Alex Botsch
- Department of Critical Care Medicine, Summa Akron City Hospital, Akron, OH, USA
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Cronin B, Kolotiniuk N, Youssefzadeh K, Newhouse B, Schmidt U, O'Brien EO, Maus T. Pulmonary Artery Catheter Placement Aided by Transesophageal Echocardiography versus Pressure Waveform Transduction. J Cardiothorac Vasc Anesth 2018; 32:2578-2582. [PMID: 29929894 DOI: 10.1053/j.jvca.2018.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare pulmonary artery catheter (PAC) placement by transesophageal echocardiography combined with pressure waveform transduction versus the traditional technique of pressure waveform transduction alone. DESIGN A prospective, randomized trial. SETTING Single university hospital. PARTICIPANTS Forty-eight patients with chronic thromboembolic pulmonary hypertension (CTEPH) scheduled for pulmonary thromboendarterectomy. INTERVENTIONS PACs were placed in 48 patients with CTEPH scheduled for pulmonary thromboendarterectomy by either a combined approach (eg, transesophageal echocardiography [TEE] and pressure waveform transduction) or by pressure waveform transduction alone. MEASUREMENTS AND MAIN RESULTS Successful placement of the PAC via a combined technique or pressure waveform transduction alone was timed, number of attempts recorded, and final location noted. The final location of the pressure waveform-guided catheters was the proximal right pulmonary artery in 6 of 24 cases (25%), whereas the combined method resulted in successful placement in the proximal right pulmonary artery in 24 of 24 cases (100%). The pressure waveform technique resulted in a mean time to placement and mean number of attempts of 74 seconds and 1.70 attempts, respectively. The combined approach resulted in a mean time to placement and mean number of attempts of 89 seconds and 1.79 attempts, respectively. The combined method resulted in placement in the proximal right pulmonary artery significantly more often than the pressure-only method but did not reduce significantly the number of attempts or time required to place the catheter successfully. Additionally, among those cases that required more than 1 attempt or manipulation, there was no difference in the time to successful placement or the number of attempts required for successful placement. CONCLUSION TEE guidance during PAC insertion was hypothesized to result in a higher success rate, precise placement, and shorter times to placement. One hundred percent of the PACs inserted with TEE guidance were positioned successfully in the proximal right pulmonary artery, which is the institutional preference. Although the combined technique resulted in greater precision, the clinical significance of this is unknown. The time to placement benefit was not confirmed by this study.
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Affiliation(s)
- Brett Cronin
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA.
| | - Nikolai Kolotiniuk
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA
| | | | - Beverly Newhouse
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA
| | - Ulrich Schmidt
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA
| | - E Orestes O'Brien
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA
| | - Timothy Maus
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center - Thornton Hospital, La Jolla, CA
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Heming N, Elatrous S, Jaber S, Dumenil AS, Cousson J, Forceville X, Kimmoun A, Trouillet JL, Fichet J, Anguel N, Darmon M, Martin C, Chevret S, Annane D. Haemodynamic response to crystalloids or colloids in shock: an exploratory subgroup analysis of a randomised controlled trial. BMJ Open 2017; 7:e016736. [PMID: 28988172 PMCID: PMC5640079 DOI: 10.1136/bmjopen-2017-016736] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare the haemodynamic effect of crystalloids and colloids during acute severe hypovolaemic shock. DESIGN Exploratory subgroup analysis of a multicentre randomised controlled trial (Colloids Versus Crystalloids for the Resuscitation of the Critically Ill, CRISTAL, ClinicalTrials.gov NCT00318942). SETTING CRISTAL was conducted in intensive care units in Europe, North Africa and Canada. PARTICIPANTS Current analysis included all patients who had a pulmonary artery catheter in place at randomisation. 220 patients (117 received crystalloids vs 103 colloids) underwent pulmonary artery catheterisation. INTERVENTION Crystalloids versus colloids for fluid resuscitation in hypovolaemic shock. OUTCOME MEASURES Haemodynamic data were collected at the time of randomisation and subsequently on days 1, 2, 3, 4, 5, 6 and 7. RESULTS Median cumulative volume of fluid administered during the first 7 days was higher in the crystalloids group than in the colloids group (3500 (2000-6000) vs 2500 (1000-4000) mL, p=0.01). Patients in the colloids arm exhibited a lower heart rate over time compared with those allocated to the crystalloids arm (p=0.014). There was no significant difference in Cardiac Index (p=0.053), mean blood pressure (p=0.4), arterial lactates (p=0.9) or global Sequential Organ Failure Assessment score (p=0.3) over time between arms. CONCLUSIONS During acute severe hypovolaemic shock, patients monitored by a pulmonary artery catheter achieved broadly similar haemodynamic outcomes, using lower volumes of colloids than crystalloids. The heart rate was lower in the colloids arm.
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Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
- U1173 Lab Inflammation& Infection, University of Versailles SQY-Paris Saclay - INSERM, Garches, France
| | - Souheil Elatrous
- service de réanimation, Centre Hospitalo-Universitaire Tahar Sfar, University of Monastir, Mahdia, Tunisia
| | - Samir Jaber
- Saint Eloi University Hospital, Montpellier, France
| | | | - Joël Cousson
- Reims University Hospital, Robert Debré Hospital, Reims, France
| | | | - Antoine Kimmoun
- Intensive Care Unit Brabois, Heart and Vessels Institute, Nancy University Hospital, Nancy, France
| | | | | | | | | | | | | | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France
- U1173 Lab Inflammation& Infection, University of Versailles SQY-Paris Saclay - INSERM, Garches, France
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De la Puente-Diaz de Leon V, de Jesus Jaramillo-Rocha V, Teboul JL, Garcia-Miranda S, Martinez-Guerra BA, Dominguez-Cherit G. Changes in Radial Artery Pulse Pressure During a Fluid Challenge Cannot Assess Fluid Responsiveness in Patients With Septic Shock. J Intensive Care Med 2017; 35:149-153. [PMID: 28931367 DOI: 10.1177/0885066617732291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Arterial blood pressure is the most common variable used to assess the response to a fluid challenge in routine clinical practice. The aim of this study was to evaluate the accuracy of the change in the radial artery pulse pressure (rPP) to detect the change in cardiac output after a fluid challenge in patients with septic shock. METHODS Prospective observational study including 35 patients with septic shock in which rPP and cardiac output were measured before and after a fluid challenge with 400 mL of crystalloid solution. Cardiac output was measured with intermittent thermodilution technique using a pulmonary artery catheter. Patients were divided between responders (increase >15% of cardiac output after fluid challenge) and nonresponders. The area under the receiver operating characteristic curve (AUROC), Pearson correlation coefficient and paired Student t test were used in statistical analysis. RESULTS Forty-three percent of the patients were fluid responders. The change in rPP could not neither discriminate between responders and nonresponders (AUROC = 0.52; [95% confidence interval: 0.31-0.72] P = .8) nor correlate (r = .21, P = .1) with the change in cardiac output after the fluid challenge. CONCLUSIONS The change in rPP neither discriminated between fluid responders and nonresponders nor correlated with the change in cardiac output after a fluid challenge. The change in rPP cannot serve as a surrogate of the change in cardiac output to assess the response to a fluid challenge in patients with septic shock.
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Affiliation(s)
- Victor De la Puente-Diaz de Leon
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | | | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicetre University Hospital, University Paris-Sud, Le Kremlin-Bicetre, Paris, France
| | - Sofia Garcia-Miranda
- Department of Internal Medicine, Fundacion Clinica Medica Sur, Puente de Piedra, Mexico City, Mexico
| | - Bernardo A Martinez-Guerra
- Department of Internal Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | - Guillermo Dominguez-Cherit
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
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