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Murgolo F, Mussi RD, Messina A, Pisani L, Dalfino L, Civita A, Stufano M, Gianluca A, Staffieri F, Bartolomeo N, Spadaro S, Brienza N, Grasso S. Subclinical cardiac dysfunction may impact on fluid and vasopressor administration during early resuscitation of septic shock. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:29. [PMID: 37641139 PMCID: PMC10463881 DOI: 10.1186/s44158-023-00117-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND According to the Surviving Sepsis Campaign (SSC) fluids and vasopressors are the mainstays of early resuscitation of septic shock while inotropes are indicated in case of tissue hypoperfusion refractory to fluids and vasopressors, suggesting severe cardiac dysfunction. However, septic cardiac disfunction encompasses a large spectrum of severities and may remain "subclinical" during early resuscitation. We hypothesized that "subclinical" cardiac dysfunction may nevertheless influence fluid and vasopressor administration during early resuscitation. We retrospectively reviewed prospectically collected data on fluids and vasoconstrictors administered outside the ICU in patients with septic shock resuscitated according to the SSC guidelines that had reached hemodynamic stability without the use of inotropes. All the patients were submitted to transpulmonary thermodilution (TPTD) hemodynamic monitoring at ICU entry. Subclinical cardiac dysfunction was defined as a TPTD-derived cardiac function index (CFI) ≤ 4.5 min-1. RESULTS At ICU admission, subclinical cardiac dysfunction was present in 17/40 patients (42%; CFI 3.6 ± 0.7 min-1 vs 6.6 ± 1.9 min-1; p < 0.01). Compared with patients with normal CFI, these patients had been resuscitate with more fluids (crystalloids 57 ± 10 vs 47 ± 9 ml/kg PBW; p < 0.01) and vasopressors (norepinephrine 0.65 ± 0.25 vs 0.43 ± 0.29 mcg/kg/min; p < 0.05). At ICU admission these patients had lower cardiac index (2.2 ± 0.6 vs 3.6 ± 0.9 L/min/m2, p < 0.01) and higher systemic vascular resistances (2721 ± 860 vs 1532 ± 480 dyn*s*cm-5/m2, p < 0.01). CONCLUSIONS In patients with septic shock resuscitated according to the SSC, we found that subclinical cardiac dysfunction may influence the approach to fluids and vasopressor administration during early resuscitation. Our data support the implementation of early, bedside assessment of cardiac function during early resuscitation of septic shock.
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Affiliation(s)
- Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Rossella di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Messina
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Luigi Pisani
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Lidia Dalfino
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Civita
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Monica Stufano
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Altamura Gianluca
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Bartolomeo
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Savino Spadaro
- Department of translation medicine, University of Ferrara, Ferrara, Italy
| | - Nicola Brienza
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy.
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Hamzaoui O, Boissier F. Hemodynamic monitoring in cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:104-113. [PMID: 37188114 PMCID: PMC10175734 DOI: 10.1016/j.jointm.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by acute end-organ hypoperfusion due to inadequate cardiac output that can result in multiorgan failure, which may lead to death. The diminished cardiac output in CS leads to systemic hypoperfusion and maladaptive cycles of ischemia, inflammation, vasoconstriction, and volume overload. Obviously, the optimal management of CS needs to be readjusted in view of the predominant dysfunction, which may be guided by hemodynamic monitoring. Hemodynamic monitoring enables (1) characterization of the type of cardiac dysfunction and the degree of its severity, (2) very early detection of associated vasoplegia, (3) detection and monitoring of organ dysfunction and tissue oxygenation, and (4) guidance of the introduction and optimization of inotropes and vasopressors as well as the timing of mechanical support. It is now well documented that early recognition, classification, and precise phenotyping via early hemodynamic monitoring (e.g., echocardiography, invasive arterial pressure, and the evaluation of organ dysfunction and parameters derived from central venous catheterization) improve patient outcomes. In more severe disease, advanced hemodynamic monitoring with pulmonary artery catheterization and the use of transpulmonary thermodilution devices is useful to facilitate the right timing of the indication, weaning from mechanical cardiac support, and guidance on inotropic treatments, thus helping to reduce mortality. In this review, we detail the different parameters relevant to each monitoring approach and the way they can be used to support optimal management of these patients.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine Intensive Réanimation, Hôpital Robert Debré, Université de Reims, Reims 51092, France
- Unité HERVI, Hémostase et Remodelage Vasculaire Post-Ischémie, EA 3801, Reims 51092, France
| | - Florence Boissier
- Médecine Intensive Réanimation, Hôpital Universitaire de Poitiers, Poitiers 90577, France
- INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers 90577, France
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Rodríguez-Villar S, Kraut JA, Arévalo-Serrano J, Sakka SG, Harris C, Awad I, Toolan M, Vanapalli S, Collins A, Spataru A, Eiben P, Recea V, Brathwaite-Shirley C, Thompson L, Gurung B, Reece-Anthony R. Systemic acidemia impairs cardiac function in critically Ill patients. EClinicalMedicine 2021; 37:100956. [PMID: 34258569 PMCID: PMC8255172 DOI: 10.1016/j.eclinm.2021.100956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/29/2021] [Accepted: 05/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acidemia, is associated with reduced cardiac function in animals, but no studies showing an effect of acidemia on cardiac function in humans are reported. In the present study, we examined the effect of acidemia on cardiac function assessed with transpulmonary thermodilution technique with integrated pulse contour analysis (Pulse Contour Cardiac Output, PiCCO™) in a large cohort of critically ill patients. METHODS This was a prospective multicenter observational cross-sectional study of 297 patients from 6 intensive care units in London, England selected from all patients admitted consecutively between May 2018 and March 2019. Measurements of lowest plasma pH and concurrent assessment of cardiac function were obtained. FINDINGS There was a significant difference between two pH categories (pH ≤ 7.28 vs. pH > 7.28) for the following variables of cardiac function: SVI (difference in means 32.7; 95% CI: 21 to 45 mL/m2; p < 0.001); GEF (18; 95% CI: 11 to 26%; p < 0.001), dPmax (-331; 95% CI: -510 to -153 mmHg/s; p = 0.001), CFI (0.7; 95% CI: 0.2 to 1.3 1/min; p = 0.01) and CPI (0.09; 95% CI: 0.03 to 0.15 W/m2; p < 0.001). However, there was no significant difference in CI (0.13; 95% CI: -0.20 to 0.47 L/min/m2; p = 0.12) between the pH categories. Also, a significant relationship was found between the quantitative pH and the following variables: SVI (132; 95% CI: 77 to 188 mL/m2; p < 0.001), GEF (74.7; 95% CI: 37.1 to 112.4%; p < 0.001), dPmax (-1587; 95% CI: -2361 to -815 mmHg/s; p < 0.001), CFI (3.5; 95% CI: 0.9 to 6.1 /min; p = 0.009), CPI (0.62; 95% CI: 0.36 to 0.88 W/m2; p < 0.001) and CI (regression coefficient 1.96; 95% CI:0.45 to 3.47 L/min/m2; p = 0.01). INTERPRETATION Acidemia is associated with impaired cardiac function in seriously ill patients hospitalized in the intensive care unit supporting the potential value of early diagnosis and improvement of arterial pH in these patients. FUNDING The study was partially supported by unrestricted funds from the UCLA School of Medicine.
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Affiliation(s)
- S Rodríguez-Villar
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
- Corresponding author.
| | - JA Kraut
- Division of Nephrology and Department of Medicine Veterans Administration Greater Los Angeles Healthcare System and UCLA School Of Medicine, California, United States
| | - J Arévalo-Serrano
- Internal Medicine Department, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - SG Sakka
- Critical Care Department. Gemeinschaftsklinikum Mittelrhein gGmbH, Kemperhof und Ev, Stift St. Martin. Academic Teaching Hospital of the Johannes Gutenberg University Mainz. Germany
| | - C Harris
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - I Awad
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - M Toolan
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - S Vanapalli
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - A Collins
- Critical Care Department. Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, United Kingdom
| | - A Spataru
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - P Eiben
- Critical Care Department. Princess Royal University Hospital, King´s College Hospital NHS Trust Foundation, London, United Kingdom
| | - V Recea
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - C Brathwaite-Shirley
- Critical Care Department. Princess Royal University Hospital, King´s College Hospital NHS Trust Foundation, London, United Kingdom
| | - L Thompson
- Critical Care Department, King´s College Hospital NHS Trust Foundation. London, United Kingdom
| | - B Gurung
- Critical Care Department. Lewisham University Hospital, Lewisham and Greenwich NHS Trust, United Kingdom
| | - R Reece-Anthony
- Critical Care Department. Lewisham University Hospital, Lewisham and Greenwich NHS Trust, United Kingdom
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Kojima K, Ishizuka T, Sasaki N, Nakamura K, Takiguchi M. Cardiovascular effects of dose escalating of norepinephrine in healthy dogs anesthetized with isoflurane. Vet Anaesth Analg 2021; 48:654-662. [PMID: 34332897 DOI: 10.1016/j.vaa.2021.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the systemic cardiovascular effects of dose escalating administration of norepinephrine in healthy dogs anesthetized with isoflurane. STUDY DESIGN Experimental study. ANIMALS A total of six adult laboratory Beagle dogs, 10.5 (9.2-12.0) kg [median (range)]. METHODS Each dog was anesthetized with isoflurane at an end-tidal concentration of 1.7%, mechanically ventilated and administered a continuous rate infusion of rocuronium (0.5 mg kg-1 hour-1). Each dog was administered incremental dose rates of norepinephrine (0.05, 0.125, 0.25, 0.5, 1.0 and 2.0 μg kg-1 minute-1), and each dose was infused for 15 minutes. Cardiovascular variables were recorded before administration and at the end of each infusion period. RESULTS Norepinephrine infusion increased mean arterial pressure (MAP), cardiac output (CO) and oxygen delivery in a dose-dependent manner. Systemic vascular resistance did not significantly change during the experiment. Stroke volume increased at the lower dose rates and heart rate increased at the higher dose rates. Oxygen consumption and lactate concentrations did not significantly change during infusions. CONCLUSIONS In dogs anesthetized with isoflurane, norepinephrine increased MAP by increasing the CO. CO increased with a change in stroke volume at lower dose rates of norepinephrine. At higher dosage, heart rate also contributed to an increase in CO. Norepinephrine did not cause excessive vasoconstriction that interfered with the CO during this study. CLINICAL RELEVANCE Norepinephrine can be useful for treating hypotension in dogs anesthetized with isoflurane.
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Affiliation(s)
- Kazuki Kojima
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Tomohito Ishizuka
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Noboru Sasaki
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kensuke Nakamura
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Mitsuyoshi Takiguchi
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Clinical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
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Increased extravascular lung water index (EVLWI) reflects rapid non-cardiogenic oedema and mortality in COVID-19 associated ARDS. Sci Rep 2021; 11:11524. [PMID: 34075155 PMCID: PMC8169693 DOI: 10.1038/s41598-021-91043-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/19/2021] [Indexed: 12/23/2022] Open
Abstract
Nearly 5% of patients suffering from COVID-19 develop acute respiratory distress syndrome (ARDS). Extravascular lung water index (EVLWI) is a marker of pulmonary oedema which is associated with mortality in ARDS. In this study, we evaluate whether EVLWI is higher in patients with COVID-19 associated ARDS as compared to COVID-19 negative, ventilated patients with ARDS and whether EVLWI has the potential to monitor disease progression. EVLWI and cardiac function were monitored by transpulmonary thermodilution in 25 patients with COVID-19 ARDS subsequent to intubation and compared to a control group of 49 non-COVID-19 ARDS patients. At intubation, EVLWI was noticeably elevated and significantly higher in COVID-19 patients than in the control group (17 (11–38) vs. 11 (6–26) mL/kg; p < 0.001). High pulmonary vascular permeability index values (2.9 (1.0–5.2) versus 1.9 (1.0–5.2); p = 0.003) suggested a non-cardiogenic pulmonary oedema. By contrast, the cardiac parameters SVI, GEF and GEDVI were comparable in both cohorts. High EVLWI values were associated with viral persistence, prolonged intensive care treatment and in-hospital mortality (23.2 ± 6.7% vs. 30.3 ± 6.0%, p = 0.025). Also, EVLWI showed a significant between-subjects (r = − 0.60; p = 0.001) and within-subjects correlation (r = − 0.27; p = 0.028) to Horowitz index. Compared to non COVID-19 ARDS, COVID-19 results in markedly elevated EVLWI-values in patients with ARDS. High EVLWI reflects a non-cardiogenic pulmonary oedema in COVID-19 ARDS and could serve as parameter to monitor ARDS progression on ICU.
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Cao G, Wu Y, Zhao Y, Wang L, Zhang Y. Assessment of extravascular lung water by measuring the number of pulmonary ultrasound B-lines before and after CBP in patients with MODS. Medicine (Baltimore) 2021; 100:e24181. [PMID: 33429806 PMCID: PMC7793418 DOI: 10.1097/md.0000000000024181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 12/14/2020] [Indexed: 01/05/2023] Open
Abstract
To determine whether the change in the number of pulmonary ultrasound B-line can accurately assess the extravascular lung water (EVLW) before and after continuous bedside blood purification (CBP) in patients with multiple organ dysfunction syndrome (MODS).Seventy-six patients with MODS who underwent CBP were examined within 24 hours before and after CBP using pulmonary ultrasound to detect the number of ultrasound B-line or using pulse indicator continuous cardiac output method to examine extravascular lung water, blood oxygenation index, and B-type natriuretic peptide (BNP) content. The correlation of the change in the number of B lines before and after CBP treatment with the negative balance of 24 hours liquid, the change of oxygenation index, and BNP content were analyzed.In the 76 patients, CBP treatment significantly decreased EVLW, the number of B-line, and BNP (P < .05 for all), while it significantly increased the oxygenation index (P < .05). Correlation analysis showed that the decrease in B-line number after CBP treatment was positively correlated with the 24 hours negative lung fluid balance, decrease of EVLW, oxygenation index improvement, and decreased BNP content. The change in the numbers of pulmonary ultrasound B-line can accurately assess the change of EVLW before and after CBP treatment and reflect the efficiency of ventilation in the lungs and the risk of heart failure.Thus, it can replace pulse indicator continuous cardiac output as an indicator for evaluating EVLW in patients with MODS treated with CBP.
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Affiliation(s)
| | - Yu Wu
- Department of Nephrology, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University
| | | | - Ling Wang
- Department of Nephrology, Xuzhou Municipal Hospital Affiliated to Xuzhou Medical University
| | - Yang Zhang
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
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Algahtani R, Merenda A. Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications. Neurocrit Care 2020; 34:1047-1061. [PMID: 32794145 PMCID: PMC7426068 DOI: 10.1007/s12028-020-01072-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.
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Affiliation(s)
- Rami Algahtani
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA. .,Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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Vignon P. Continuous cardiac output assessment or serial echocardiography during septic shock resuscitation? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:797. [PMID: 32647722 PMCID: PMC7333154 DOI: 10.21037/atm.2020.04.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Septic shock is the leading cause of cardiovascular failure in the intensive care unit (ICU). Cardiac output is a primary component of global oxygen delivery to organs and a sensitive parameter of cardiovascular failure. Any mismatch between oxygen delivery and rapidly varying metabolic demand may result in tissue dysoxia, hence organ dysfunction. Since the intricate alterations of both vascular and cardiac function may rapidly and widely change over time, cardiac output should be measured repeatedly to characterize the type of shock, select the appropriate therapeutic intervention, and evaluate patient's response to therapy. Among the numerous techniques commercially available for measuring cardiac output, transpulmonary thermodilution (TPT) provides a continuous monitoring with external calibration capability, whereas critical care echocardiography (CCE) offers serial hemodynamic assessments. CCE allows early identification of potential sources of inaccuracy of TPT, including right ventricular failure, severe tricuspid or left-sided regurgitations, intracardiac shunt, very low flow states, or dynamic left ventricular outflow tract obstruction. In addition, CCE has the unique advantage of depicting the distinct components generating left ventricular stroke volume (large cavity size vs. preserved contractility), providing information on left ventricular diastolic properties and filling pressures, and assessing pulmonary artery pressure. Since inotropes may have deleterious effects if misused, their initiation should be based on the documentation of a cardiac dysfunction at the origin of the low flow state by CCE. Experts widely advocate using CCE as a first-line modality to initially evaluate the hemodynamic profile associated with shock, as opposed to more invasive techniques. Repeated assessments of both the efficacy (amplitude of the positive response) and tolerance (absence of side-effect) of therapeutic interventions are required to best guide patient management. Overall, TPT allowing continuous tracking of cardiac output variations and CCE appear complementary rather than mutually exclusive in patients with septic shock who require advanced hemodynamic monitoring.
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Affiliation(s)
- Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching hospital, Limoges, France.,Faculty of Medicine, University of Limoges, Limoges, France
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Si X, Cao DY, Chen J, Wu JF, Liu ZM, Xu HL, Chen MY, Liu YJ, Guan XD. Effect of Systolic Cardiac Function on Passive Leg Raising for Predicting Fluid Responsiveness: A Prospective Observational Study. Chin Med J (Engl) 2019; 131:253-261. [PMID: 29363638 PMCID: PMC5798044 DOI: 10.4103/0366-6999.223841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Passive leg raising (PLR) represents a "self-volume expansion (VE)" that could predict fluid responsiveness, but the influence of systolic cardiac function on PLR has seldom been reported. This study aimed to investigate whether systolic cardiac function, estimated by the global ejection fraction (GEF) from transpulmonary-thermodilution, could influence the diagnostic value of PLR. METHODS This prospective, observational study was carried out in the surgical Intensive Care Unit of the First Affiliated Hospital of Sun Yat-sen University from December 2013 to July 2015. Seventy-eight mechanically ventilated patients considered for VE were prospectively included and divided into a low-GEF (<20%) and a near-normal-GEF (≥20%) group. Within each group, baseline hemodynamics, after PLR and after VE (250 ml 5% albumin over 30 min), were recorded. PLR-induced hemodynamic changes (PLR-Δ) were calculated. Fluid responders were defined by a 15% increase of stroke volume (SV) after VE. RESULTS Twenty-five out of 38 patients were responders in the GEF <20% group, compared to 26 out of 40 patients in the GEF ≥20% group. The thresholds of PLR-ΔSV and PLR-Δ cardiac output (PLR-ΔCO) for predicting fluid responsiveness were higher in the GEF ≥20% group than in the GEF <20% group (ΔSV: 12% vs. 8%; ΔCO: 7% vs. 6%), with increased sensitivity (ΔSV: 92% vs. 92%; ΔCO: 81% vs. 80%) and specificity (ΔSV: 86% vs. 70%; ΔCO: 86% vs. 77%), respectively. PLR-Δ heart rate could predict fluid responsiveness in the GEF ≥20% group with a threshold value of -5% (sensitivity 65%, specificity 93%) but could not in the GEF <20% group. The pressure index changes were poor predictors. CONCLUSIONS In the critically ill patients on mechanical ventilation, the diagnostic value of PLR for predicting fluid responsiveness depends on cardiac systolic function. Thus, cardiac systolic function must be considered when using PLR. TRIAL REGISTRATION Chinese Clinical Trial Register, ChiCTR-OCH-13004027; http://www.chictr.org.cn/showproj.aspx?proj=5540.
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Affiliation(s)
- Xiang Si
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Dai-Yin Cao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510655, China
| | - Juan Chen
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Jian-Feng Wu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Zi-Meng Liu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Hai-Lin Xu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Min-Ying Chen
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Yong-Jun Liu
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Xiang-Dong Guan
- Department of SICU, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
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Jones D, Story D, Peyton P, Bellomo R. Perioperative Pulse Contour Cardiac Output Analysis in a Patient with Severe Cardiac Dysfunction. Anaesth Intensive Care 2019; 34:97-101. [PMID: 16494159 DOI: 10.1177/0310057x0603400118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe a patient with severe left ventricular dysfunction simultaneously monitored with pulse contour cardiac output (PiCCO) analysis, a continuous cardiac output pulmonary artery catheter (continuous COPAC) and intraoperative transoesophageal echocardiography (TOE). There was good agreement between cardiac output (CO) measurements obtained by the three techniques prior to cardiopulmonary bypass (CPB). Agreement of CO measurements following CPB was initially poor, but improved following recalibration of PiCCO. PiCCO-derived global end-diastolic volume index (GEDVI) and cardiac function index (CFI), were assessed as markers of left ventricular preload and myocardial contractility, respectively. GEDVI correlated well with CO in the postoperative period. CFI increased more than two -fold following coronary revascularization and milrinone administration, and there was also a temporal relationship between the CFI and the dose of milrinone in the first 24 hours of treatment. Global end-diastolic volume and cardiac function index may be useful additional measures of left ventricular preload and myocardial contractility in patients with severe left ventricular dysfunction.
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Affiliation(s)
- D Jones
- Department of Intensive Care, The Alfred Hospital, Departments of Anaesthesia and Surgery, Austin Hospital, Departments of Intensive Care and Medicine, Austin Hospital, Melboume, Victoria
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Comparison of cardiac function index derived from femoral and jugular indicator injection for transpulmonary thermodilution with the PiCCO-device: A prospective observational study. PLoS One 2018; 13:e0200740. [PMID: 30063736 PMCID: PMC6067690 DOI: 10.1371/journal.pone.0200740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 07/02/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Cardiac function index (CFI) is a trans-pulmonary thermodilution (TPTD)-derived estimate of systolic function. CFI is defined as the ratio of cardiac output divided by global end-diastolic volume GEDV (CFI = CO/GEDV). Several studies demonstrated that the use of femoral venous access results in a marked overestimation of GEDV, while CFI is underestimated. One study suggested a correction formula for femoral venous access that markedly reduced the bias for GEDVI. Therefore, the last PiCCO-algorithm requires information about the CVC-position which suggests a correction of GEDV for femoral access. However, a recent study demonstrated inconsistencies of the last PiCCO algorithm using incorrected GEDV to calculate CFI despite obvious correction of GEDV. Nevertheless, this study was based on mathematical analyses of data displayed in a total of 15 patients equipped with only a femoral, but not with a jugular CVC. Therefore, this study compared CFI derived from the femoral indicator injection TPTD to data derived from jugular indicator injection in 28 patients with both a jugular and a femoral CVC. Methods 28 ICU-patients with PiCCO-monitoring were included. Each dataset consisted of three triplicate TPTDs using the jugular venous gold standard access and the femoral access with and without information about the femoral indicator injection to evaluate, if correction for femoral GEDV also pertains to CFI. (CFI_jug: jugular indicator injection; CFI_fem: femoral indicator injection; CFI_fem_cor: femoral indicator injection with correct information about CVC-position; CFI_fem_uncor: femoral indicator injection with uncorrect information about CVC-position; CFI_fem_uncor_form = CFI_fem_uncor * (GEDVI_fem_uncor/GEDVI_fem_cor)). Results CFI_fem_uncor was significantly lower than CFI_jug (4.28±1.70 vs. 5.21±1.91 min-1; p<0.001). Similarly, CFI_fem_cor was significantly lower than CFI_jug (4.24±1.62 vs. 5.21±1.91 min-1; p<0.001). This is explained by the finding that CFI_fem_uncor was not different to CFI_fem_cor (4.28±1.70 vs. 4.24±1.62 min-1; p = 0.611). This suggests that correction for femoral CVC does not pertain to CFI. Calculative correction of CFI_fem_uncor by multiplying CFI_fem_uncor by the ratio GEDVI_fem_uncor/GEDVI_jug resulted in CFI_fem_uncor_form which was slightly, but significantly different from the gold standard CFI_jug (5.51±2.00 vs. 5.21±1.91 min-1; p = 0.024). The agreement of measurements classified in the same category of CFI (decreased (<4.5), normal (4.5–6.5) and increased (>6.5 min-1)) was high for CFI_jug and CFI_fem_uncor_form (identical categories in 26 of 28 comparisons; p = 0.49). By contrast, the agreement with CFI_jug was significantly lower for CFI_fem_cor (14 out of 28; p<0.001) and CFI_fem_uncor (15 out of 28; p<0.001). Conclusions While the last PiCCO algorithm obviously corrects GEDVI for femoral indicator injection, this correction is not applied to CFI. Therefore, femoral TPTD indicator injection results in substantially lower values for CFI compared to TPTD using a jugular CVC. Necessarily, uncorrected CFI-values derived from femoral TPTD are misleading and have to be corrected.
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Vieillard-Baron A, Naeije R, Haddad F, Bogaard HJ, Bull TM, Fletcher N, Lahm T, Magder S, Orde S, Schmidt G, Pinsky MR. Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper. Intensive Care Med 2018; 44:774-790. [PMID: 29744563 DOI: 10.1007/s00134-018-5172-2] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 04/07/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors. RESULTS The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.
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Affiliation(s)
- Antoine Vieillard-Baron
- Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France.
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
| | - R Naeije
- Professor Emeritus at the Université Libre de Bruxelles, Brussels, Belgium
| | - F Haddad
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford, USA
| | - H J Bogaard
- Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - T M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - N Fletcher
- Department of Cardiothoracic Critical Care, St Georges University Hospital NHS Trust, London, SW17 0QT, UK
| | - T Lahm
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - S Magder
- Department of Critical Care, McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - S Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Sydney, NSW, Australia
| | - G Schmidt
- Department of Internal Medicine and Critical Care, University of Iowa, Iowa City, USA
| | - M R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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A comparison of ventricular systolic function indices provided by VolumeView/EV1000™ and left ventricular ejection fraction by echocardiography among septic shock patients. J Clin Monit Comput 2018; 33:233-239. [PMID: 29740730 DOI: 10.1007/s10877-018-0152-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/04/2018] [Indexed: 01/25/2023]
Abstract
The aim of this study was to compare the cardiac function index (CFI) and global ejection fraction (GEF) obtained by VolumeView/EV1000™, with the left ventricular ejection fraction (LVEF) by echocardiography in septic shock patients. A prospective observational study was conducted in a medical intensive care unit of a tertiary, teaching university hospital. Thirty-two, mechanical-ventilated septic shock patients were included in this study. We simultaneously measured CFI and GEF with LVEF. The correlation of CFI, GEF along with LVEF and ability of CFI and GEF to predict LVEF ≥ 40, 50 and 60% were evaluated. There were 192 pairs of CFI, GEF and LVEF. CFI was significantly correlated with GEF (r = 0.82, P < 0.0001). A significant correlation was observed between CFI and LVEF (r = 0.56, P < 0.0001) and GEF and LVEF (r = 0.71, P < 0.0001). The CFI and GEF had a good predictive ability for estimating LVEF ≥ 40, 50 and 60%, with an area under receiving operating characteristic (AUC) 0.875-0.934. The CFI ≥ 3/min predicted LVEF ≥ 40% with sensitivity 95.1% and specificity 48.3%. The GEF ≥ 15%, estimated LVEF ≥ 40% with sensitivity 92.6% and specificity 69%. There were 40 thermodilution and LVEF measurements obtained before and after norepinephrine adjustment. Blood pressure as well as the cardiac index were significantly increased, whereas there were no changes in CFI, GEF and LVEF values. Conclusions: Both CFI and GEF obtained by VolumeView/EV1000™, correlated with LVEF, so as to provide a reliable estimation of LV systolic function in septic shock patients.
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Abstract
Background Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. Methods We undertook a systematic review of the literature using MEDLINE, Google Scholar and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated clinical practice recommendations and/or directions for future research. Results We defined three aspects of fluid monitoring: i) normal and pathophysiological cardiovascular mechanisms; ii) measures of volume responsiveness and impending cardiovascular collapse during volume removal, and; iii) measured indices of each using non-invasive and minimally invasive continuous and intermittent monitoring techniques. The evidence documents that AKI can occur in the setting of normotensive hypovolemia and that under-resuscitation represents a major cause of both AKI and mortality ion critically ill patients. Traditional measures of intravascular volume and ventricular filling do not predict volume responsiveness whereas dynamic functional hemodynamic markers, such as pulse pressure or stroke volume variation during positive pressure breathing or mean flow changes with passive leg raising are highly predictive of volume responsiveness. Numerous commercially-available devices exist that can acquire these signals. Conclusions Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.
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Affiliation(s)
- M.R. Pinsky
- Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA - USA
| | - P. Brophy
- Division of Pediatric Nephrology, Hypertension, Dialysis and Transplantation, University of Iowa, Children's Hospital, Iowa City, Iowa - USA
| | - J. Padilla
- Universidad de Iberoamerica, San Jose - Costa Rica
| | - E. Paganini
- Division of Nephrology, Cleveland Clinic Foundation, Cleveland, OH - USA
| | - N. Pannu
- Division of Nephrology and CCM, University of Alberta, Edmonton, Alberta - Canada
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Comparison of pulmonary vascular permeability index PVPI and global ejection fraction GEF derived from jugular and femoral indicator injection using the PiCCO-2 device: A prospective observational study. PLoS One 2017; 12:e0178372. [PMID: 29040264 PMCID: PMC5644983 DOI: 10.1371/journal.pone.0178372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 05/11/2017] [Indexed: 11/23/2022] Open
Abstract
Background Transpulmonary thermodilution (TPTD) is used to derive cardiac output CO, global end-diastolic volume GEDV and extravascular lung water EVLW. To facilitate interpretation of these data, several ratios have been developed, including pulmonary vascular permeability index (defined as EVLW/(0.25*GEDV)) and global ejection fraction ((4*stroke volume)/GEDV). PVPI and GEF have been associated to the aetiology of pulmonary oedema and systolic cardiac function, respectively. Several studies demonstrated that the use of femoral venous access results in a marked overestimation of GEDV. This also falsely reduces PVPI and GEF. One of these studies suggested a correction formula for femoral venous access that markedly reduced the bias for GEDV. Consequently, the last PiCCO-algorithm requires information about the CVC, and correction for femoral access has been shown. However, two recent studies demonstrated inconsistencies of the last PiCCO algorithm using incorrected GEDV for PVPI, but corrected GEDV for GEF. Nevertheless, these studies were based on mathematical analyses of data displayed in a total of 15 patients equipped with only a femoral, but not with a jugular CVC. Therefore, this study compared PVPI_fem and GEF_fem derived from femoral TPTD to values derived from jugular indicator injection in 25 patients with both jugular and femoral CVCs. Methods 54 datasets in 25 patients were recorded. Each dataset consisted of three triplicate TPTDs using the jugular venous access as the gold standard and the femoral access with (PVPI_fem_cor) and without (PVPI_fem_uncor) information about the femoral indicator injection to evaluate, if correction for femoral GEDV pertains to PVPI_fem and GEF_fem. Results PVPI_fem_uncor was significantly lower than PVPI_jug (1.48±0.47 vs. 1.84±0.53; p<0.001). Similarly, PVPI_fem_cor was significantly lower than PVPI_jug (1.49±0.46 vs. 1.84±0.53; p<0.001). This is explained by the finding that PVPI_fem_uncor was not different to PVPI_fem_cor (1.48±0.47 vs. 1.49±0.46; n.s.). This clearly suggests that correction for femoral CVC does not pertain to PVPI. GEF_fem_uncor was significantly lower than GEF_jug (20.6±5.1% vs. 25.0±6.1%; p<0.001). By contrast, GEF_fem_cor was not different to GEF_jug (25.6±5.8% vs. 25.0±6.1%; n.s.). Furthermore, GEF_fem_cor was significantly higher than GEF_fem_uncor (25.6±5.8% vs. 20.6±5.1%; p<0.001). This finding emphasizes that an appropriate correction for femoral CVC is applied to GEF_fem_cor. The extent of the correction (25.5/20.6; 124%) for GEF and the relation of PVPI_jug/PVPI_fem_uncor (1.84/1.48; 124%) are in the same range as the ratio of GEDVI_fem_uncor/GEDVI_fem_cor (1056ml/m2/821mL/m2; 129%). This further emphasizes that GEF, but not PVPI is corrected in case of femoral indicator injection. Conclusions Femoral indicator injection for TPTD results in significantly lower values for PVPI and GEF. While the last PiCCO algorithm appropriately corrects GEF, the correction is not applied to PVPI. Therefore, GEF-values can be used in case of femoral CVC, but PVPI-values are substantially underestimated.
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Vignon P, Begot E, Mari A, Silva S, Chimot L, Delour P, Vargas F, Filloux B, Vandroux D, Jabot J, François B, Pichon N, Clavel M, Levy B, Slama M, Riu-Poulenc B. Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study. Chest 2017; 153:55-64. [PMID: 28866112 DOI: 10.1016/j.chest.2017.08.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 08/01/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. METHODS Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. RESULTS A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). CONCLUSIONS Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.
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Affiliation(s)
- Philippe Vignon
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France.
| | - Emmanuelle Begot
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Arnaud Mari
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
| | - Stein Silva
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
| | - Loïc Chimot
- Medical Intensive Care Unit, Hospital of Périgueux, Périgueux, France
| | - Pierre Delour
- Medical Intensive Care Unit, Hospital of Périgueux, Périgueux, France
| | - Frédéric Vargas
- Medical Intensive Care Unit, Teaching Hospital of Bordeaux, Bordeaux, France
| | - Bruno Filloux
- Medical Intensive Care Unit, Teaching Hospital of Bordeaux, Bordeaux, France
| | - David Vandroux
- Medical-Surgical Intensive Care Unit, Teaching Hospital of La Réunion, La Réunion, France
| | - Julien Jabot
- Medical-Surgical Intensive Care Unit, Teaching Hospital of La Réunion, La Réunion, France
| | - Bruno François
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Nicolas Pichon
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Marc Clavel
- Medical-surgical Intensive Care Unit, Teaching Hospital of Limoges, Limoges, France; INSERM CIC 1435, Teaching Hospital of Limoges, Limoges, France
| | - Bruno Levy
- Medical Intensive Care Unit, Teaching Hospital of Nancy, Nancy, France
| | - Michel Slama
- Medical Intensive Care Unit, Teaching Hospital of Amiens, Amiens, France
| | - Béatrice Riu-Poulenc
- Medical-Surgical Intensive Care Unit, Teaching Hospital of Toulouse, Toulouse, France
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Validation of transpulmonary thermodilution variables in hemodynamically stable patients with heart diseases. Ann Intensive Care 2017; 7:86. [PMID: 28831765 PMCID: PMC5567579 DOI: 10.1186/s13613-017-0307-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 08/06/2017] [Indexed: 12/22/2022] Open
Abstract
Background Transpulmonary thermodilution is recommended in the treatment of critically ill patients presenting with complex shock. However, so far it has not been validated in hemodynamically stable patients with heart disease. Methods We assessed the validity of cardiac output, global end-diastolic volume index (GEDVI), an established marker of preload thought to reflect the volume of all four heart chambers, global ejection fraction (GEF) and cardiac function index (CFI) as variables of cardiac function, and extravascular lung water index (EVLWI) as indicator of pulmonary edema in 29 patients undergoing elective left and right heart catheterization including left ventricular angiography with stable coronary heart disease and normal cardiac function (controls, n = 11), moderate-to-severe aortic valve stenosis (AS, n = 10), or dilated cardiomyopathy (DCM, n = 8). Results Cardiac output was similar in controls, AS, and DCM, with good correlation between transpulmonary thermodilution and pulmonary artery catheter using the Fick method (r = 0.69, p < 0.0001). Left ventricular end-diastolic volume was normal in controls and AS, but significantly higher in DCM (104 ± 37 vs 135 ± 63 vs 234 ± 24 ml, p < 0.01). GEDVI did not differentiate between patients with normal and patients with enlarged left ventricular end-diastolic volume (848 ± 128 vs 882 ± 213 ml m−2, p = 0.60). No difference in GEF and CFI was found between patients with normal and patients with reduced left ventricular ejection fraction. Patients with AS but not DCM had higher EVLWI than controls (9 ± 2 vs 12 ± 4 vs 11 ± 3 ml kg−1, p = 0.04), while there was only a trend in pulmonary artery occlusion pressure (8 ± 3 vs 10 ± 5 vs 14 ± 7 mmHg, p = 0.05). Conclusions Cardiac output measurement by transpulmonary thermodilution is unaffected by differences in ventricular size and outflow obstruction. However, GEDVI did not identify markedly enlarged left ventricular end-diastolic volumes, and neither GEF nor CFI reflected the increased heart chamber volumes and markedly impaired left ventricular function in patients with DCM. In contrast, EVLWI is probably a sensitive marker of subclinical pulmonary edema particularly in patients with elevated left-ventricular-filling pressure irrespective of differences in left ventricular function.
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Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28625165 PMCID: PMC5474867 DOI: 10.1186/s13054-017-1739-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Main body Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Conclusions Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
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Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France. .,Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France
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Zhang JY, Wang XY, Wang X. Effects of liraglutide on hemodynamic parameters in patients with heart failure. Oncotarget 2017; 8:62693-62702. [PMID: 28977981 PMCID: PMC5617541 DOI: 10.18632/oncotarget.18570] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 06/02/2017] [Indexed: 02/06/2023] Open
Abstract
Glucagon-like peptide-1 analogues improve left ventricular function in patients with acute myocardial infarction. This study aimed to evaluate the effects of liraglutide on hemodynamic parameters in patients with heart failure. A total of 78 patients with heart failure were enrolled in this study between August 2014 and November 2015. Of these, 52 patients were randomized 1:1 to receive either liraglutide or placebo for 7 days. Hemodynamic measurements were made using transpulmonary thermodilution and arterial pulse contour analysis. At 7 days, the difference in change of the primary endpoint of cardiac output between the liraglutide group and control group was +1.1 1/min (95% CI +0.1 to +2.2; P < 0.001). Stroke volume was significantly higher in the liraglutide group compared with the control group (difference: +14.6 ml; P < 0.001). The difference in an increase in the left ventricular contractile index after 7 days of treatment was +210.7 mmHg/s (liraglutide versus control, 95% CI−92.1 to +501.5; P < 0.001). Liraglutide causes favorable changes in markers of inflammation and oxidative stress. Glucagon-like peptide-1 may be associated with improvement in left ventricular function in patients with heart failure. These findings need to be confirmed by larger invasive trials.
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Affiliation(s)
- Jin Ying Zhang
- Department of Emergency, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xin Yun Wang
- Department of Emergency, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xiang Wang
- Department of Emergency, Binzhou Medical University Hospital, Binzhou, Shandong, China
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Anile A, Russo J, Castiglione G, Volpicelli G. A simplified lung ultrasound approach to detect increased extravascular lung water in critically ill patients. Crit Ultrasound J 2017; 9:13. [PMID: 28612302 PMCID: PMC5469722 DOI: 10.1186/s13089-017-0068-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 06/02/2017] [Indexed: 12/16/2022] Open
Abstract
Background The quantification of B-lines at lung ultrasonography is a valid tool to estimate the extravascular lung water (EVLW) in patients after major cardiac surgery. However, there is still uncertainty about the correlation between B-lines and EVLW in a general population of critically ill. Aim To evaluate a simplified lung ultrasonographic assessment as a tool to estimate the EVLW in critically ill patients admitted to a polyvalent intensive care unit (ICU). Methods Nineteen consecutive critically ill patients requiring mechanical ventilation and hemodynamic monitoring were enrolled. Lung ultrasonography and the thermodilution methodology (PiCCO system) were performed by two independent operators. The positive scan at lung ultrasound was defined by visualization of at least 3 B-lines. We then compared the number of chest areas positive for B-lines with the EVLW index obtained by the invasive procedure. Results A significant correlation was found between the number of lung quadrants positive for B-lines and EVLW indexed using both actual body weight (rho = 0.612 p = 0.0053) and predicted body weight (rho = 0.493 p = 0.032). Presence of more than 3 positive lung quadrants showed a good performance in identifying an EVLW index value >10 ml/kg of actual body weight(area under the ROC 0.894; 95% CI 0.668–0.987 p < 0.0001). Presence of of more than 4 positive lung quadrants indentified an EVLW index value >10 ml/kg of predicted body weight (area under the ROC 0.8; 95% CI 0.556–0.945 p = 0.0048). Conclusion A simplified lung ultrasound approach can by used as a reliable noninvasive bedside tool to predict EVLW in emergency and critically ill patients.
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Affiliation(s)
- Antonio Anile
- Intensive Care Unit, Ospedale Vittorio Emanuele, AOU Policlinico-Vittorio Emanuele, Catania, Italy
| | - Jole Russo
- Department of Anesthesia and Intensive Care, Ospedale Vittorio Emanuele, ASP Caltanissetta, Gela, Italy
| | - Giacomo Castiglione
- Intensive Care Unit, Ospedale Vittorio Emanuele, AOU Policlinico-Vittorio Emanuele, Catania, Italy.
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
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Monitorage hémodynamique par échocardiographie des patients en état de choc. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Monitorage hémodynamique en 2017 : place de l’échocardiographie transœsophagienne. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Beitz A, Berbara H, Mair S, Henschel B, Lahmer T, Rasch S, Schmid R, Huber W. Consistency of cardiac function index and global ejection fraction with global end-diastolic volume in patients with femoral central venous access for transpulmonary thermodilution: a prospective observational study. J Clin Monit Comput 2016; 31:599-605. [PMID: 27103253 DOI: 10.1007/s10877-016-9880-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 04/12/2016] [Indexed: 12/20/2022]
Abstract
Global ejection fraction (GEF) and cardiac function index (CFI) are transpulmonary thermodilution (TPTD)-derived indices of the systolic function. Their validity relies on an accurate determination of the global end-diastolic volume (GEDV). Due to an overestimation of GEDV using a femoral central venous catheter (CVC) a correction formula for indexed GEDV (GEDVI) has been implemented in the latest PiCCO™-algorithm. However, a recent study demonstrated that correction for femoral CVC does not pertain to pulmonary vascular permeability index PVPI, which is calculated of extravascular lung water EVLW and GEDV. Therefore, it was the aim of our study to evaluate, if GEF and CFI are corrected for femoral CVC. In ten adult ICU-patients with PiCCO™-monitoring, ten triplicate TPTDs were performed within 30 h. 95 complete data sets were analyzed, if a GEDV corrected for CVC site was applied to derive CFI and GEF. Therefore, we compared displayed values CFIdisplayed and GEFdisplayed to CFIcalculated and GEFcalculated, which were calculated from displayed GEDV, cardiac output and stroke volume. GEDVcalculated derived from division of GEDVI by predicted body surface area did not substantially differ from GEDVdisplayed (1448 ± 414 ml vs. 1447 ± 416 ml), which suggests a correction of GEDV for CVC site. However, CFIdisplayed was significantly lower than CFIcalculated (3.8 ± 1.6/min vs. 5.1 ± 1. 8/min: p < 0.001), suggesting that CFIdisplayed is based on an uncorrected GEDV. By contrast, GEFcalculated (23.1 ± 8.7 %) was not substantially different from GEFdisplayed (22.4 ± 8.6 %). Although GEDV and GEF are corrected for femoral CVC site, this does not apply to CFI. However, all indices derived from GEDV should be calculated consistently.
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Affiliation(s)
- Analena Beitz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Helena Berbara
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Benedikt Henschel
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Sebastian Rasch
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Roland Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Street 22, 81675, Munich, Germany.
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High Serum sTREM-1 Correlates With Myocardial Dysfunction and Predicts Prognosis in Septic Patients. Am J Med Sci 2016; 351:555-62. [PMID: 27238916 DOI: 10.1016/j.amjms.2016.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 12/25/2015] [Accepted: 01/12/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This study aimed to evaluate the predictive and prognostic value of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in patients with myocardial dysfunction induced by severe sepsis and septic shock. MATERIALS AND METHODS A total of 84 patients with severe sepsis and septic shock were enrolled between May 2013 and December 2014.The patients were monitored by pulse indicator continuous cardiac output system and divided into myocardial depression group (cardiac function index [CFI] < 4.1/minute, n = 37) and nonmyocardial depression group (CFI ≥ 4.1/minute, n = 47 ). Additionally, the patients were divided into survival group (n = 40) and nonsurvival group (n = 44) based on 28-day mortality. Hemodynamic parameters and serum sTREM-1, B-type natriuretic peptide (BNP) and cardiac troponin I (cTnI) levels were collected on days 1, 3 and 5 after admission to intensive care unit. RESULTS (1) The serum values of sTREM-1, BNP and cTnI in myocardial depression group were higher than those in nonmyocardial depression group (P < 0.01); and CFI, cardiac index, stroke volume, global ejection fraction and left ventricular contractility index (dpmax) in myocardial depression group were lower than those in nonmyocardial depression group on day 1 (P < 0.05); (2) serum sTREM-1 negatively correlated with left ventricular ejection fraction, CFI, cardiac index, global ejection fraction and dpmax, and it positively correlated with BNP and cTnI (P < 0.01); (3) the area under the receiver operating characteristics curve for sTREM-1 in the prediction of myocardial depression was 0.671 with a sensitivity of 83.8% and a specificity of 46.8% when cutoff point was 174.5ng/mL, the power of predicting septic depression for sTREM-1 was lower than that of BNP; logistic regression analysis showed that serum sTREM-1 was not an independent predictor of septic myocardial depression; the area under the receiver operating characteristics curve was 0.773 for sTREM-1 in predicting outcome with a sensitivity of 86.4% and a specificity of 80% when cutoff point was 182.3ng/mL, the power of predicting prognosis for sTREM-1 was superior to those of BNP and cTnI; (4) there was a decrease trend for sTREM-1 levels and an increasing trend for CFI in the survival group (P < 0.05). CONCLUSIONS Myocardial dysfunction is common in patients with severe sepsis and septic shock and high serum levels of sTREM-1 correlates with myocardial dysfunction to some extent but is not an independent predictor, which more importantly showed prognostic value for septic shock outcome.
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Giraud R, Siegenthaler N, Merlani P, Bendjelid K. Reproducibility of transpulmonary thermodilution cardiac output measurements in clinical practice: a systematic review. J Clin Monit Comput 2016; 31:43-51. [PMID: 26753534 DOI: 10.1007/s10877-016-9823-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/03/2016] [Indexed: 01/31/2023]
Abstract
Measuring cardiac output (CO) is an integral part of the diagnostic and therapeutic strategy in critically ill patients. During the last decade, the single transpulmonary thermodilution (TPTD) technique was implemented in clinical practice. The purpose of this paper was to systematically review and critically assess the existing data concerning the reproducibility of CO measured using TPTD (COTPTD). A total of 16 studies were identified to potentially be included in our study because these studies had the required information that allowed for calculating the reproducibility of COTPTD measurements. 14 adult studies and 2 pediatric studies were analyzed. In total, 3432 averaged CO values in the adult population and 78 averaged CO values in the pediatric population were analyzed. The overall reproducibility of COTPTD measurements was 6.1 ± 2.0 % in the adult studies and 3.9 ± 2.9 % in the pediatric studies. An average of 3 boluses was necessary for obtaining a mean CO value. Achieving more than 3 boluses did not improve reproducibility; however, achieving less than 3 boluses significantly affects the reproducibility of this technique. The present results emphasize that TPTD is a highly reproducible technique for monitoring CO in critically ill patients, especially in the pediatric population. Our findings suggest that obtaining a mean of 3 measurements for determining CO values is recommended.
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Affiliation(s)
- Raphaël Giraud
- Intensive Care Service, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland. .,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland. .,Geneva Hemodynamic Research Group, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland.
| | - Nils Siegenthaler
- Intensive Care Service, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland.,Geneva Hemodynamic Research Group, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland
| | - Paolo Merlani
- Intensive Care Service, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland.,Intensive Care Unit, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Karim Bendjelid
- Intensive Care Service, Geneva University Hospitals, 4 Rue Gabrielle Perret-Gentil, 1211, Geneva 14, Switzerland.,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland.,Geneva Hemodynamic Research Group, University of Geneva, Rue Michel-Servet 1, 1206, Geneva, Switzerland
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Kutter APN, Mosing M, Hartnack S, Raszplewicz J, Renggli M, Mauch JY, Hofer CK. The influence of acute pulmonary hypertension on cardiac output measurements: calibrated pulse contour analysis, transpulmonary and pulmonary artery thermodilution against a modified Fick method in an animal model. Anesth Analg 2015; 121:99-107. [PMID: 25742632 DOI: 10.1213/ane.0000000000000655] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In critically ill patients with significant pulmonary hypertension (PH), close perioperative cardiovascular monitoring is mandatory, considering the increased morbidity and mortality in this patient group. Although the pulmonary artery catheter is still the standard for the diagnosis of PH, its use to monitor cardiac output (CO) in patients with PH is decreasing as a result of increased morbidity and possible influence of tricuspid regurgitation on the measurements. However, continuous CO measurement methods have never been evaluated under PH regarding their agreement and trending ability. In this study, we evaluated the influence of acute PH and different CO states on transpulmonary thermodilution (TPTD) and calibrated pulse contour analysis (PiCCO; both assessed with PiCCO plus™), intermittent pulmonary artery thermodilution (PATD), and continuous thermodilution (CCO) compared with a modified Fick method (FICK) in an animal model. METHODS Nine healthy pigs were studied under anesthesia. PH of 25 and 40 mm Hg (by administration of the thromboxane analog U46619), CO decreases, and CO increases were induced to test the different CO measurement techniques over a broad range of hemodynamic situations. Before each step, a new baseline data set was collected. CO values were compared using Bland-Altman analysis; trending abilities were assessed via concordance and polar plot analysis. The influence of pulmonary pressure on CO measurements was analyzed using linear mixed models. RESULTS A mean bias of -0.26 L/min with prediction intervals of -0.88 to 1.4 L/min was measured between TPTD and FICK. Their concordance rate was 100% (94%-100% confidence interval), and the mean polar angle -3° with radial limits of agreement of ±28° indicated good trending abilities. PATD compared with FICK also showed good trending ability. Comparisons of PiCCO and CCO versus FICK revealed low agreement and poor trending results with concordance rates of 84% (71%-93%) and 88% (74%-95%), mean polar angles from -17° and -19°, and radial limits of agreement of ±45° and 40°. Pulmonary pressures influenced only the difference between FICK and PiCCO, as assessed by linear mixed models. CONCLUSIONS TPTD compared with FICK was able to track all changes induced during the study period, including those by PH. It yielded better agreement than PATD both compared with FICK. PiCCO and CCO were not mapping all changes correctly, and when used clinically in unstable patients, regular controls with intermittent techniques are required. Acute pharmacologically induced PH did influence the difference between FICK and PiCCO.
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Affiliation(s)
- Annette P N Kutter
- From the Section of Anesthesiology, Equine Department and Section of Epidemiology, Vetsuisse Faculty of the University of Zurich, Zurich, Switzerland; Department of Anesthesiology, Kantonsspital Luzern, Luzern, Switzerland; and Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland
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Yu T, Li Q, Liu L, Guo F, Longhini F, Yang Y, Qiu H. Different effects of propofol and dexmedetomidine on preload dependency in endotoxemic shock with norepinephrine infusion. J Surg Res 2015; 198:185-91. [PMID: 26081003 DOI: 10.1016/j.jss.2015.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 03/24/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND To clarify whether propofol (PROP) and dexmedetomidine (DEX) differentially affect preload dependency in an endotoxemic model based on evaluations of the systemic vascular system and cardiac function. METHODS Animals were prepared under PiCCO monitoring (BL), and endotoxemic shock was induced using an intravenous bolus of lipopolysaccharide (055:B5) in 16 New Zealand ketamine-anesthetized rabbits. After fluid resuscitation and norepinephrine infusion (SD0), the animals were randomized to PROP (n = 8) or DEX (n = 8) sedation at two incremental doses (SD1 and SD2). The mean arterial pressure and the central venous pressure were monitored. Pulse pressure variation (PPV) was assessed to evaluate preload dependency. Global end-diastolic volume, vascular resistance, mean systemic filling pressure, and cardiac function index were assessed at each time point. RESULTS PPV progressively and significantly increased with increasing infusion rates of PROP (SD1 versus SD0, P < 0.01; SD2 versus SD0, P < 0.001; and SD2 versus SD1, P = 0.024) but not DEX. PPV was higher at SD1 and SD2 in the PROP group than in the DEX group (P < 0.001). PROP increased the heart rate without affecting cardiac contractility or vascular resistance. In contrast, DEX decreased heart contractility and increased vascular resistance at the highest dose. However, neither drug affected mean arterial pressure, central venous pressure, mean systemic filling pressure, global end-diastolic volume, or venous return. CONCLUSIONS PROP more effectively increased PPV than DEX in an endotoxemic shock model after fluid resuscitation during norepinephrine infusion. DEX, but not PROP, at the highest dose influenced vascular resistance and heart contractility.
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Affiliation(s)
- Tao Yu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Qing Li
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Ling Liu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Federico Longhini
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China; Anesthesia and Intensive Care, Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Medicine, Nanjing, China.
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Laight NS, Levin AI. Transcardiopulmonary Thermodilution-Calibrated Arterial Waveform Analysis: A Primer for Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2015; 29:1051-64. [PMID: 26279223 DOI: 10.1053/j.jvca.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Nicola S Laight
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa
| | - Andrew I Levin
- Department of Anesthesiology and Critical Care, University of Stellenbosch, Tygerberg Hospital, Cape Town, South Africa.
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Monnet X, Teboul JL. Devant un état de choc : pourquoi je fais un monitoring cardiovasculaire. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1041-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Yatin Mehta
- Chairman, Medanta Institute of Critical Care and Anesthesia, Medanta The Medicity, Sector 38, Gurgaon (NCR), Haryana, India
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Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Impact of transpulmonary thermodilution-based cardiac contractility and extravascular lung water measurements on clinical outcome of patients with Takotsubo cardiomyopathy after subarachnoid hemorrhage: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:482. [PMID: 25113260 PMCID: PMC4243958 DOI: 10.1186/s13054-014-0482-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 07/25/2014] [Indexed: 12/20/2022]
Abstract
Introduction Takotsubo cardiomyopathy (TCM) is a life-threatening systemic consequence early after subarachnoid hemorrhage (SAH), but precise hemodynamics and related outcomes have not been studied. The purpose of this study was to investigate TCM-induced cardiac function by transpulmonary thermodilution and its impact on clinical outcome of SAH. Methods We retrospectively analyzed 46 consecutive postoperative SAH patients who developed TCM. Patients were divided into two groups of echocardiographic left ventricular ejection fraction (LVEF) <40% (TCM with left ventricular (LV) dysfunction) and LVEF ≥40% (TCM without LV dysfunction). Cardiac function index (CFI) and extravascular lung water index (ELWI) were monitored by transpulmonary thermodilution in parallel with serial measurements of echocardiographic parameters and blood biochemical markers. Results Transpulmonary thermodilution-derived CFI was significantly correlated with LVEF (r = 0.82, P < 0.0001). The CFI between days 0 and 7 was significantly lower in patients with LV dysfunction (LVEF <40%) than in patients with LVEF ≥40% (P < 0.05). CFI had a better ability than cardiac output to detect cardiac dysfunction (LVEF <40%) (area under the curve = 0.85 ± 0.02; P < 0.001). A CFI value <4.2 min−1 had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%. CFI <4.2 min−1 was associated with delayed cerebral ischemia (DCI) (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.33 to 2.86; P = 0.004) and poor 3-month functional outcome on a modified Rankin Scale of 4 to 6 (OR = 1.87, 95% CI = 1.06 to 3.29; P = 0.02). An extravascular lung water index (ELWI) >14 ml/kg after day 4 increased the risk of poor functional outcome at 3-month follow-up (OR = 2.10, 95% CI = 1.11 to 3.97; P = 0.04). Conclusions Prolonged cardiac dysfunction and pulmonary edema increased the risk of DCI and poor 3-month functional outcome in postoperative SAH patients with TCM. Serial measurements of CFI and ELWI by transpulmonary thermodilution may provide an easy bedside method of detecting early changes in cardiopulmonary function to direct proper post-SAH treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0482-4) contains supplementary material, which is available to authorized users.
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Evaluation of cardiac function index as measured by transpulmonary thermodilution as an indicator of left ventricular ejection fraction in cardiogenic shock. BIOMED RESEARCH INTERNATIONAL 2014; 2014:598029. [PMID: 25013790 PMCID: PMC4071812 DOI: 10.1155/2014/598029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/07/2014] [Accepted: 05/19/2014] [Indexed: 01/28/2023]
Abstract
Introduction. The PiCCO transpulmonary thermodilution technique provides two indices of cardiac systolic function, the cardiac function index (CFI) and the global ejection fraction (GEF). Both appear to be correlated with left ventricular ejection fraction (LVEF) measured by echocardiography in patients with circulatory failure, especially in septic shock. The aim of the present study was to test the reliability of CFI as an indicator of LVEF in patients with cardiogenic shock. Methods. In thirty-five patients with cardiogenic shock, we performed (i) simultaneous measurements of echocardiography LVEF and cardiac function index assessed by transpulmonary thermodilution (n = 72) and (ii) transpulmonary thermodilution before/after increasing inotropic agents (n = 18). Results. Mean LVEF was 31% (+/−11.7), CFI 3/min (+/−1), and GEF 14.2% (+/−6). CFI and GEF were both positively correlated with LVEF (P < 0.0001, r2 = 0.27). CFI and GEF were significantly increased with inotropic infusion (resp., P = 0.005, P = 0.007). A cardiac function index <3.47/min predicted a left ventricular ejection fraction ≤35% (sensitivity 81.1% and specificity 63%). In patients with right ventricular dysfunction, CFI was not correlated with LVEF. Conclusion. CFI is correlated with LVEF provided that patient does not present severe right ventricular dysfunction. Thus, the PiCCO transpulmonary thermodilution technique is useful for the monitoring of inotropic therapy during cardiogenic shock.
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Ruhparwar A, Piontek P, Ungerer M, Ghodsizad A, Partovi S, Foroughi J, Szabo G, Farag M, Karck M, Spinks GM, Kim SJ. Electrically contractile polymers augment right ventricular output in the heart. Artif Organs 2014; 38:1034-9. [PMID: 24689769 DOI: 10.1111/aor.12300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Research into the development of artificial heart muscle has been limited to assembly of stem cell-derived cardiomyocytes seeded around a matrix, while nonbiological approaches to tissue engineering have rarely been explored. The aim of the study was to apply electrically contractile polymer-based actuators as cardiomyoplasty for positive inotropic support of the right ventricle. Complex trilayer polypyrrole (PPy) bending polymers for high-speed applications were generated. Bending motion occurred directly as a result of electrochemically driven charging and discharging of the PPy layers. In a rat model (n = 5), strips of polymers (3 × 20 mm) were attached and wrapped around the right ventricle (RV). RV pressure was continuously monitored invasively by direct RV cannulation. Electrical activation occurred simultaneously with either diastole (in order to evaluate the polymer's stand-alone contraction capacity; group 1) or systole (group 2). In group 1, the pressure generation capacity of the polymers was measured by determining the area under the pressure curve (area under curve, AUC). In group 2, the RV pressure AUC was measured in complexes directly preceding those with polymer contraction and compared to RV pressure complexes with simultaneous polymer contraction. In group 1, the AUC generated by polymer contraction was 2768 ± 875 U. In group 2, concomitant polymer contraction significantly increased AUC compared with complexes without polymer support (5987 ± 1334 U vs. 4318 ± 691 U, P ≤ 0.01). Electrically contractile polymers are able to significantly augment right ventricular contraction. This approach may open new perspectives for myocardial tissue engineering, possibly in combination with fetal or embryonic stem cell-derived cardiomyocytes.
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Affiliation(s)
- Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany
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Trof RJ, Danad I, Groeneveld AJ. Global end-diastolic volume increases to maintain fluid responsiveness in sepsis-induced systolic dysfunction. BMC Anesthesiol 2013; 13:12. [PMID: 23799933 PMCID: PMC3698117 DOI: 10.1186/1471-2253-13-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 06/19/2013] [Indexed: 12/11/2022] Open
Abstract
Background Sepsis-induced cardiac dysfunction may limit fluid responsiveness and the mechanism thereof remains unclear. Since cardiac function may affect the relative value of cardiac filling pressures, such as the recommended central venous pressure (CVP), versus filling volumes in guiding fluid loading, we studied these parameters as determinants of fluid responsiveness, according to cardiac function. Methods A delta CVP-guided, 90 min colloid fluid loading protocol was performed in 16 mechanically ventilated patients with sepsis-induced hypotension and three 30 min consecutive fluid loading steps of about 450 mL per patient were evaluated. Global end-diastolic volume index (GEDVI), cardiac index (CI) and global ejection fraction (GEF) were assessed from transpulmonary dilution. Baseline and changes in CVP and GEDVI were compared among responding (CI increase ≥10% and ≥15%) and non-responding fluid loading steps, in patient with low (<20%, n = 9) and near-normal (≥20%) GEF (n = 7) at baseline. Results A low GEF was in line with other indices of impaired cardiac (left ventricular) function, prior to and after fluid loading. Of 48 fluid loading steps, 9 (of 27) were responding when GEF <20% and 6 (of 21) when GEF ≥20. Prior to fluid loading, CVP did not differ between responding and non-responding steps and levels attained were 23 higher in the latter, regardless of GEF (P = 0.004). Prior to fluid loading, GEDVI (and CI) was higher in responding (1007 ± 306 mL/m2) than non-responding steps (870 ± 236 mL/m2) when GEF was low (P = 0.002), but did not differ when GEF was near-normal. Increases in GEDVI were associated with increases in CI and fluid responsiveness, regardless of GEF (P < 0.001). Conclusions As estimated from transpulmonary dilution, about half of patients with sepsis-induced hypotension have systolic cardiac dysfunction. During dysfunction, cardiac dilation with a relatively high baseline GEDVI maintains fluid responsiveness by further dilatation (increase in GEDVI rather than of CVP) as in patients without dysfunction. Absence of fluid responsiveness during systolic cardiac dysfunction may be caused by diastolic dysfunction and/or right ventricular dysfunction.
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Affiliation(s)
- Ronald J Trof
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands ; Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Ibrahim Danad
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - Ab Johan Groeneveld
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands ; Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
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The influence of haemodialysis on haemodynamic measurements using transpulmonary thermodilution in patients with septic shock. Eur J Anaesthesiol 2013; 30:16-20. [DOI: 10.1097/eja.0b013e328358543a] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Effects of norepinephrine on mean systemic pressure and venous return in human septic shock*. Crit Care Med 2012; 40:3146-53. [DOI: 10.1097/ccm.0b013e318260c6c3] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Circulatory characteristics of normovolemia and normotension therapy after subarachnoid hemorrhage, focusing on pulmonary edema. Acta Neurochir (Wien) 2012; 154:2195-202. [PMID: 22972633 DOI: 10.1007/s00701-012-1491-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE Cardiopulmonary complications are common after subarachnoid hemorrhage (SAH), and include pulmonary edema (PE). The purpose of this study was to investigate circulatory characteristics of normovolemia and normotension therapy after SAH using pulse contour analysis, and to reveal the mechanisms of PE after SAH. METHODS Pulse contour analysis was performed from day 3 until day 12 after the onset of SAH in 49 patients. RESULTS Global end-diastolic volume index (GEDI) was normal, although net water balance was estimated to be negative and central venous pressure (CVP) was low in all patients. Seven patients (14 %) suffered from pulmonary edema. Cardiac function index (CFI) and global ejection fraction (GEF) were lower in patients with pulmonary edema (PE group) than in patients without PE (non-PE group) throughout the study period (CFI, P≤0.0119; GEF, P≤0.0348). The PE group showed higher GEDI from days 7 to 10, and higher extravascular lung water index (ELWI) throughout the entire study period compared to the non-PE group (GEDI, P≤0.0094; ELWI, P≤0.0077). CONCLUSIONS The appropriate preload was kept despite negative net water balance and low CVP. PE after SAH was biphasic, with cardiogenic PE caused by low cardiac contractility immediately after SAH, and hydrostatic PE caused by low cardiac contractility and hypervolemia on and after day 7 of SAH. Pulse contour analysis was useful to monitor this unique circulatory change and effective for detecting cardiopulmonary complications after SAH.
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Sakka SG, Reuter DA, Perel A. The transpulmonary thermodilution technique. J Clin Monit Comput 2012; 26:347-53. [DOI: 10.1007/s10877-012-9378-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 06/21/2012] [Indexed: 12/12/2022]
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Abstract
Advanced hemodynamic monitoring is necessary for many patients with acute brain and/or spinal cord injury. Optimizing cerebral and systemic physiology requires multi-organ system function monitoring. Hemodynamic manipulations are cardinal among interventions to regulate cerebral perfusion pressure and cerebral blood flow. The pulmonary artery catheter is not any more the sole tool available; less invasive and potentially more accurate methodologies have been developed and employed in the operating room and among diverse critically ill populations. These include transpulmonary thermodilution, arterial pressure pulse contour, and waveform analysis and bedside critical care ultrasound. A thorough understanding of hemodynamics and of the available monitoring modalities is an essential skill for the neurointensivist.
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Ochagavía A, Zapata L, Carrillo A, Rodríguez A, Guerrero M, Ayuela JM. [Evaluation of contractility and postloading in the intensive care unit]. Med Intensiva 2012; 36:365-74. [PMID: 22482957 DOI: 10.1016/j.medin.2012.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 02/19/2012] [Indexed: 11/26/2022]
Abstract
Cardiovascular failure is a common disorder in critical care medicine. When admitted to the ICU, patients with hemodynamic deterioration should be examined rapidly to correctly assess the main determinants of cardiovascular function (preload, afterload and contractility). This review examines the assessment of contractility and afterload involving the combined use of several hemodynamic monitors, which allows different approaches to the same problem, with a view to improving the efficiency of management and treatment in critically ill patients.
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Affiliation(s)
- A Ochagavía
- Servicio de Medicina Intensiva, Hospital de Sabadell, CIBER Enfermedades Respiratorias, Institut Universitari Parc Tauli, UAB, Sabadell, Barcelona, España.
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Ballestero Y, Urbano J, López-Herce J, Solana MJ, Botrán M, Vinciguerra D, Bellón JM. Pulmonary arterial thermodilution, femoral arterial thermodilution and bioreactance cardiac output monitoring in a pediatric hemorrhagic hypovolemic shock model. Resuscitation 2012; 83:125-9. [DOI: 10.1016/j.resuscitation.2011.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 10/18/2022]
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Cardiac Output Measurements in Septic Patients: Comparing the Accuracy of USCOM to PiCCO. Crit Care Res Pract 2011; 2012:270631. [PMID: 22191019 PMCID: PMC3235433 DOI: 10.1155/2012/270631] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 10/10/2011] [Indexed: 01/20/2023] Open
Abstract
USCOM is an ultrasound-based method which has been accepted for noninvasive hemodynamic monitoring in various clinical conditions (USCOM, Ultrasonic cardiac output monitoring). The present study aimed at comparing the accuracy of the USCOM device with that of the thermodilution technique in patients with septicemia. We conducted a prospective observational study in a medical but noncardiological ICU of a university hospital. Septic adult patients (median age 55 years, median SAPS-II-Score 43 points) on mechanical ventilation and catecholamine support were monitored with USCOM and PiCCO (n = 70). Seventy paired left-sided CO measurements (transaortic access = COUS-A) were obtained. The mean COUS-A were 6.55 l/min (±2.19) versus COPiCCO 6.5 l/min (±2.18). The correlation coefficient was r = 0.89. Comparison by Bland-Altman analysis revealed a bias of −0.36 l/min (±0.99 l/min) leading to a mean percentage error of 29%. USCOM is a feasible and rapid method to evaluate CO in septic patients. USCOM does reliably represent CO values as compared to the reference technique based on thermodilution (PiCCO). It seems to be appropriate in situations where CO measurements are most pertinent to patient management.
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Thermodilution-derived indices for assessment of left and right ventricular cardiac function in normal and impaired cardiac function. Crit Care Med 2011; 39:2106-12. [PMID: 21572331 DOI: 10.1097/ccm.0b013e31821cb9ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether thermodilution-derived parameters of right and left ventricular cardiac function (right ventricular ejection fraction, global ejection fraction, cardiac function index) are able to track changes of cardiac contractile function and whether they are influenced by substantial preload reduction. DESIGN Prospective animal study. SETTING University-affiliated animal research laboratory. SUBJECTS Domestic pigs. INTERVENTIONS Sixteen domestic pigs were studied. Right ventricular ejection fraction, global ejection fraction, and cardiac function index were compared to direct measurement of left ventricular rate of maximum systolic pressure rise and the left ventricular rate of maximum systolic pressure rise corrected to preload. Measurements were done with normal cardiac function during normo- and hypovolemia. Thereafter, cardiac function was impaired by continuous infusion of verapamil and measurements were repeated during normo- and hypovolemia (withdrawal of blood 20 mL kg body weight). MEASUREMENTS AND MAIN RESULTS With normal cardiac function, hypovolemia led to a significant decrease of right ventricular ejection fraction from 36.7% ± 6.6% to 29.8% ± 5.8% (p < .001), global ejection fraction from 40.5% ± 6.2% to 33.6% ± 7.6% (p < .001), and the left ventricular rate of maximum systolic pressure rise from 2104 ± 390 mm Hg sec to 1297 ± 438 mm Hg sec (p < .001). Cardiac function index (8.92 ± 2.20 min to 7.93 ± 1.54 min) and the left ventricular rate of maximum systolic pressure rise corrected to preload (18.2 ± 4.7 mm Hg sec mL to 15.2 ± 4.3 mm Hg sec mL) did not change significantly. Infusion of verapamil led to a significant reduction of right ventricular ejection fraction, global ejection fraction, cardiac function index, the left ventricular rate of maximum systolic pressure rise, and the left ventricular rate of maximum systolic pressure rise corrected to preload (p < .001). Now, hypovolemia led to a significant decrease of right ventricular ejection fraction (29.1% ± 4.6% to 24.9% ± 5.9%; p < .001), global ejection fraction (37.1% ± 4.7% to 31.9% ± 3.9%; p < .05), cardiac function index (7.58 ± 1.02 to 6.27 ± 1.19 min; p < .05), and the left ventricular rate of maximum systolic pressure rise (733 ± 141 mm Hg sec to 426 ± 108 mm Hg sec; p < .05). Only the left ventricular rate of maximum systolic pressure rise corrected to preload did not change significantly (6.7 ± 1.3 mm Hg sec mL to 4.6 ± 1 mm Hg sec mL; p > .05). CONCLUSIONS Right ventricular ejection fraction, global ejection fraction, and cardiac function index enable detection of changes in load-independent, intrinsic cardiac contractility. Importantly, they also reflect changes of contractile function caused by substantial decrease of preload, emphasizing the importance of assessing both cardiac contractile function in coherence with cardiac preload to differentiate between reduced intrinsic contractility and hypovolemia.
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Globalization of ejection fraction: the pulmonary artery catheter has been outsourced. Crit Care Med 2011; 39:2192. [PMID: 21849834 DOI: 10.1097/ccm.0b013e31821f02d4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Assessing the left ventricular systolic function at the bedside: the role of transpulmonary thermodilution-derived indices. Anesthesiol Res Pract 2011; 2011:927421. [PMID: 21808645 PMCID: PMC3145351 DOI: 10.1155/2011/927421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/19/2011] [Accepted: 06/07/2011] [Indexed: 01/20/2023] Open
Abstract
Evaluating the systolic function of the left ventricle (LV) is important in the hemodynamic management of the critically ill patients with circulatory failure. Echocardiography is considered the standard monitor for estimating the LV function at the bedside in the intensive care unit. However, it requires a trained operator and is not a real-time monitoring tool. For monitoring of the systolic function, the pulmonary artery catheter has been the gold standard for a long time. However, now there are alternatives to this device, with transpulmonary thermodilution being one of them. This paper provides an overview of the usefulness of the transpulmonary thermodilution-derived indices for assessing systolic function at the bedside.
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Belda FJ, Aguilar G, Jover JL, Ferrando C, Postigo S, Aznárez B. [Clinical validation of minimally invasive evaluation of systolic function]. ACTA ACUST UNITED AC 2011; 57:559-64. [PMID: 21155336 DOI: 10.1016/s0034-9356(10)70282-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulse contour continuous cardiac output (PiCCO) monitoring by means of transpulmonary thermodilution provides 2 indices of systolic function: the cardiac function index and the global ejection fraction. Our aim was to compare these 2 PiCCO indices to the left-ventricular ejection fraction obtained by transthoracic echocardiography. MATERIAL AND METHODS This was a prospective clinical study of 35 adult patients in the critical care unit of a university hospital. Each patient provided his or her own control data. Patients with marked changes in regional segment contractility or nonsinus rhythm were excluded. We collected patient variables, reason for admission to the critical care unit, the Acute Physiology and Chronic Health Evaluation II score, the reason for hemodynamic monitoring, and the infusion of vasoactive drugs at the time of the procedure. RESULTS Statistically significant correlations were found between the left-ventricular ejection fraction and the global ejection fraction (r=0.79, P<.001) and the cardiac function index (r=0.66, P<.001). The mean (SD) difference between the left-ventricular ejection fraction and the global ejection fraction and the cardiac function index were 1.05% (10.2%) (range, 19.0% to 29.1%) and 0.001% (12.4%) (range, -24.3% to 24.3%), respectively. For predicting a left-ventricular ejection fraction of less than 40%, the area under the curve was 0.879 for the global ejection fraction and 0.805 for the cardiac function index of A global ejection fraction less than 13.5% and a cardiac function index less than 3.15 min(-1) predicted a left-ventricular ejection fraction less than 40% with sensitivities of 97% and 96% and specificities of 85% and 77%, respectively. CONCLUSIONS In patients without marked changes in regional segment contractility, the global ejection fraction and the cardiac function index calculated by the PiCCO monitor offer a reliable and simple way to assess left-ventricular systolic function. Low values for these indicators suggest the need for echocardiographic assessment of left- and right-ventricular function.
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Affiliation(s)
- F J Belda
- Hospital Clínico Universitario, Valencia
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Lavrentieva A, Palmieri T. Determination of cardiovascular parameters in burn patients using arterial waveform analysis: A review. Burns 2011; 37:196-202. [DOI: 10.1016/j.burns.2010.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/09/2010] [Accepted: 09/28/2010] [Indexed: 11/16/2022]
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Trof RJ, Danad I, Reilingh MWL, Breukers RMBGE, Groeneveld ABJ. Cardiac filling volumes versus pressures for predicting fluid responsiveness after cardiovascular surgery: the role of systolic cardiac function. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R73. [PMID: 21352541 PMCID: PMC3222006 DOI: 10.1186/cc10062] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 02/01/2011] [Accepted: 02/25/2011] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Static cardiac filling volumes have been suggested to better predict fluid responsiveness than filling pressures, but this may not apply to hearts with systolic dysfunction and dilatation. We evaluated the relative value of cardiac filling volume and pressures for predicting and monitoring fluid responsiveness, according to systolic cardiac function, estimated by global ejection fraction (GEF, normal 25 to 35%) from transpulmonary thermodilution. METHODS We studied hypovolemic, mechanically ventilated patients after coronary (n = 18) or major vascular (n = 14) surgery in the intensive care unit. We evaluated 96 colloid fluid loading events (200 to 600 mL given in three consecutive 30-minute intervals, guided by increases in filling pressures), divided into groups of responding events (fluid responsiveness) and non-responding events, in patients with low GEF (<20%) or near-normal GEF (≥ 20%). Patients were monitored by transpulmonary dilution and central venous (n = 9)/pulmonary artery (n = 23) catheters to obtain cardiac index (CI), global end-diastolic volume index (GEDVI), central venous (CVP) and pulmonary artery occlusion pressure (PAOP). RESULTS Fluid responsiveness occurred in 8 (≥ 15% increase in CI) and 17 (≥ 10% increase in CI) of 36 fluid loading events when GEF was <20%, and 7 (≥ 15% increase in CI) and 17 (≥ 10% increase in CI) of 60 fluid loading events when GEF was ≥ 20%. Whereas a low baseline GEDVI predicted fluid responsiveness particularly when GEF was ≥ 20% (P = 0.002 or lower), a low PAOP was of predictive value particularly when GEF was <20% (P = 0.004 or lower). The baseline CVP was lower in responding events regardless of GEF. Changes in CVP and PAOP paralleled changes in CI particularly when GEF was <20%, whereas changes in GEDVI paralleled CI regardless of GEF. CONCLUSIONS Regardless of GEF, CVP may be useful for predicting fluid responsiveness in patients after coronary and major vascular surgery provided that positive end-expiratory pressure is low. When GEF is low (<20%), PAOP is more useful than GEDVI for predicting fluid responsiveness, but when GEF is near-normal (≥20%) GEDVI is more useful than PAOP. This favors predicting and monitoring fluid responsiveness by pulmonary artery catheter-derived filling pressures in surgical patients with systolic left ventricular dysfunction and by transpulmonary thermodilution-derived GEDVI when systolic left ventricular function is relatively normal.
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Affiliation(s)
- Ronald J Trof
- Vrije Universiteit Medical Centre, Department of Intensive Care, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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