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Yoshii R, Sawa T, Kawajiri H, Amaya F, Tanaka KA, Ogawa S. A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study. Sci Rep 2022; 12:17269. [PMID: 36241854 PMCID: PMC9568545 DOI: 10.1038/s41598-022-22119-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/10/2022] [Indexed: 01/06/2023] Open
Abstract
Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63-0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93-0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83-1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.
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Affiliation(s)
- Ryogo Yoshii
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- grid.272458.e0000 0001 0667 4960Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Fumimasa Amaya
- grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
| | - Kenichi A. Tanaka
- grid.266902.90000 0001 2179 3618Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma, USA
| | - Satoru Ogawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan ,grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
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Teixeira-Neto FJ, Valverde A. Clinical Application of the Fluid Challenge Approach in Goal-Directed Fluid Therapy: What Can We Learn From Human Studies? Front Vet Sci 2021; 8:701377. [PMID: 34414228 PMCID: PMC8368984 DOI: 10.3389/fvets.2021.701377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Resuscitative fluid therapy aims to increase stroke volume (SV) and cardiac output (CO) and restore/improve tissue oxygen delivery in patients with circulatory failure. In individualized goal-directed fluid therapy (GDFT), fluids are titrated based on the assessment of responsiveness status (i.e., the ability of an individual to increase SV and CO in response to volume expansion). Fluid administration may increase venous return, SV and CO, but these effects may not be predictable in the clinical setting. The fluid challenge (FC) approach, which consists on the intravenous administration of small aliquots of fluids, over a relatively short period of time, to test if a patient has a preload reserve (i.e., the relative position on the Frank-Starling curve), has been used to guide fluid administration in critically ill humans. In responders to volume expansion (defined as individuals where SV or CO increases ≥10–15% from pre FC values), FC administration is repeated until the individual no longer presents a preload reserve (i.e., until increases in SV or CO are <10–15% from values preceding each FC) or until other signs of shock are resolved (e.g., hypotension). Even with the most recent technological developments, reliable and practical measurement of the response variable (SV or CO changes induced by a FC) has posed a challenge in GDFT. Among the methods used to evaluate fluid responsiveness in the human medical field, measurement of aortic flow velocity time integral by point-of-care echocardiography has been implemented as a surrogate of SV changes induced by a FC and seems a promising non-invasive tool to guide FC administration in animals with signs of circulatory failure. This narrative review discusses the development of GDFT based on the FC approach and the response variables used to assess fluid responsiveness status in humans and animals, aiming to open new perspectives on the application of this concept to the veterinary field.
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Affiliation(s)
- Francisco José Teixeira-Neto
- Departmento de Cirurgia Veterinária e Reprodução Animal, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista, Botucatu, Brazil
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Rozental O, Thalappillil R, White RS, Tam CW. To Swan or Not to Swan: Indications, Alternatives, and Future Directions. J Cardiothorac Vasc Anesth 2020; 35:600-615. [PMID: 32859489 DOI: 10.1053/j.jvca.2020.07.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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4
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Cardiac output estimation by pulse wave analysis using the pressure recording analytical method and intermittent pulmonary artery thermodilution. Eur J Anaesthesiol 2020; 37:920-925. [DOI: 10.1097/eja.0000000000001227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Grensemann J. Cardiac Output Monitoring by Pulse Contour Analysis, the Technical Basics of Less-Invasive Techniques. Front Med (Lausanne) 2018; 5:64. [PMID: 29560351 PMCID: PMC5845549 DOI: 10.3389/fmed.2018.00064] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/20/2018] [Indexed: 12/20/2022] Open
Abstract
Routine use of cardiac output (CO) monitoring became available with the introduction of the pulmonary artery catheter into clinical practice. Since then, several systems have been developed that allow for a less-invasive CO monitoring. The so-called “non-calibrated pulse contour systems” (PCS) estimate CO based on pulse contour analysis of the arterial waveform, as determined by means of an arterial catheter without additional calibration. The transformation of the arterial waveform signal as a pressure measurement to a CO as a volume per time parameter requires a concise knowledge of the dynamic characteristics of the arterial vasculature. These characteristics cannot be measured non-invasively and must be estimated. Of the four commercially available systems, three use internal databases or nomograms based on patients’ demographic parameters and one uses a complex calculation to derive the necessary parameters from small oscillations of the arterial waveform that change with altered arterial dynamic characteristics. The operator must ensure that the arterial waveform is neither over- nor under-dampened. A fast-flush test of the catheter–transducer system allows for the evaluation of the dynamic response characteristics of the system and its dampening characteristics. Limitations to PCS must be acknowledged, i.e., in intra-aortic balloon-pump therapy or in states of low- or high-systemic vascular resistance where the accuracy is limited. Nevertheless, it has been shown that a perioperative algorithm-based use of PCS may reduce complications. When considering the method of operation and the limitations, the PCS are a helpful component in the armamentarium of the critical care physician.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Romagnoli S, Franchi F, Ricci Z, Scolletta S, Payen D. The Pressure Recording Analytical Method (PRAM): Technical Concepts and Literature Review. J Cardiothorac Vasc Anesth 2017; 31:1460-1470. [DOI: 10.1053/j.jvca.2016.09.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 12/22/2022]
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7
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Noninvasive iPhone Measurement of Left Ventricular Ejection Fraction Using Intrinsic Frequency Methodology*. Crit Care Med 2017; 45:1115-1120. [DOI: 10.1097/ccm.0000000000002459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 31:291-308. [PMID: 27671216 DOI: 10.1053/j.jvca.2016.05.029] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Evgeny V Fominskiy
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Cardiac Surgery, Research Institute of Circulation Pathology, Novosibirsk, Russia
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9
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Comparison Between Doppler-Echocardiography and Uncalibrated Pulse Contour Method for Cardiac Output Measurement. Crit Care Med 2016; 44:1370-9. [DOI: 10.1097/ccm.0000000000001663] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Urbano J, López J, González R, Fernández SN, Solana MJ, Toledo B, Carrillo Á, López-Herce J. Comparison between pressure-recording analytical method (PRAM) and femoral arterial thermodilution method (FATD) cardiac output monitoring in an infant animal model of cardiac arrest. Intensive Care Med Exp 2016; 4:13. [PMID: 27256288 PMCID: PMC4891310 DOI: 10.1186/s40635-016-0087-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/26/2016] [Indexed: 02/06/2023] Open
Abstract
Background The pressure-recording analytical method is a new semi-invasive method for cardiac output measurement (PRAM). There are no studies comparing this technique with femoral artery thermodilution (FATD) in an infant animal model. Methods A prospective study was performed using 25 immature Maryland pigs weighing 9.5 kg. Fifty-eight simultaneous measurements of cardiac index (CI) were made by FATD and PRAM at baseline and after return of spontaneous circulation. Differences, correlation, and concordance between both methods were analyzed. The ability of PRAM to track changes in CI was explored with a polar plot. Results Mean CI measurements were 4.5 L/min/m2 (95 % CI, 4.2–4.8 L/min/m2; coefficient of variation, 27 %) by FATD and 4.0 L/min/m2 (95 % CI, 3.6–4.3 L/min/m2; coefficient for variation, 37 %) by PRAM (difference, 0.5 L/min/m2; 95 % CI for the difference, 0.1–1.0 L/min/m2; p = 0.003; n = 58). No correlation between both methods was observed (r = 0.170, p = 0.20). Limits of agreement were −2.9 to 4.0 L/min/m2 (−69.9 to 84.9 %). Percentage error was 80.6 %. Only 26.1 % of data points lied within an absolute deviation of ±30° from the polar axis. Conclusions No correlation nor concordance between both methods was observed. Limits of agreement and percentage of error were high and clinically not acceptable. No concurrence between both methods in CI changes was observed. PRAM is not a useful method for measurement of the CI in this pediatric model of cardiac arrest.
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Affiliation(s)
- Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Jorge López
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Sarah N Fernández
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Blanca Toledo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Ángel Carrillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain.,Universidad Complutense, Madrid, Spain.,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Instituto de investigación sanitaria del hospital Gregorio Marañón (IiSGM), Madrid, Spain. .,Universidad Complutense, Madrid, Spain. .,Research Network on Maternal and Child Health and Development II (REDSAMID II), Spanish Health Institute Carlos III, Madrid, Spain.
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Hendy A, Bubenek Ş. Pulse waveform hemodynamic monitoring devices: recent advances and the place in goal-directed therapy in cardiac surgical patients. Rom J Anaesth Intensive Care 2016; 23:55-65. [PMID: 28913477 DOI: 10.21454/rjaic.7518.231.wvf] [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] [Indexed: 11/27/2022] Open
Abstract
Hemodynamic monitoring has evolved and improved greatly during the past decades as the medical approach has shifted from a static to a functional approach. The technological advances have led to innovating calibrated or not, but minimally invasive and noninvasive devices based on arterial pressure waveform (APW) analysis. This systematic clinical review outlines the physiologic rationale behind these recent technologies. We describe the strengths and the limitations of each method in terms of accuracy and precision of measuring the flow parameters (stroke volume, cardiac output) and dynamic parameters which predict the fluid responsiveness. We also analyzed the place of the APW monitoring devices in goal-directed therapy (GDT) protocols in cardiac surgical patients. According to the data from the three GDT-randomized control trials performed in cardiac surgery (using two types of APW techniques PiCCO and FloTrac/Vigileo), these devices did not demonstrate that they played a role in decreasing mortality, but only decreasing the ventilation time and the ICU and hospital length of stay.
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Affiliation(s)
- Adham Hendy
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Şerban Bubenek
- Carol Davila University of Medicine and Pharmacy, Bucharest, 1 Department of Cardiovascular Anaesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
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12
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Minimally invasive or noninvasive cardiac output measurement: an update. J Anesth 2016; 30:461-80. [DOI: 10.1007/s00540-016-2154-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 02/17/2016] [Indexed: 12/15/2022]
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13
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Menger J, Mora B, Skhirtladze K, Fischer A, Jan Ankersmit H, Dworschak M. Accuracy of Continuous Cardiac Output Measurement With the LiDCOplus System During Intra-Aortic Counterpulsation After Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 30:592-8. [PMID: 26718662 DOI: 10.1053/j.jvca.2015.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the effect of intra-aortic counterpulsation on precision, accuracy, and concordance of continuous pulse contour cardiac output determined using LiDCOplus (LiDCO Group, London). DESIGN Prospective trial. SETTING University hospital critical care unit. PARTICIPANTS Patients with intra-aortic balloon pump support in the 1:1 mode after elective or urgent cardiac surgery. INTERVENTIONS Lithium dilution calibrated pulse contour cardiac output was compared with pulmonary artery bolus thermodilution cardiac output during hemodynamically stable conditions in the course of standardized postoperative management. MEASUREMENTS AND MAIN RESULTS Fifty-one paired measurements demonstrated good correlation between the 2 methods (r = 0.88, p<0.001). Mean bias was -0.14±0.81 L/min, limits of agreement 1.48 to -1.77 L/min, and percentage error 28%. Concordance between the 2 techniques regarding directional changes>±10% cardiac output was 100% (p = 0.008). Trending ability was moderate when paired cardiac output changes were assessed using linear regression, 4-quadrant table, and polar plots. When changes <±10% of the reference cardiac output were excluded, 90% of the data pairs still lay within the 30° radial limits. Optimal timing of the balloon pump was indispensable for proper determination of pulse contour cardiac output. CONCLUSIONS Because of the LiDCOplus-specific algorithm in determining stroke volume from the arterial pulse waveform, which differs from other devices, accuracy and precision of continuous pulse contour cardiac output only are affected insignificantly by intra-aortic counterpulsation. The authors nevertheless caution that the device should be recalibrated after major hemodynamic alterations or otherwise inexplicable changes of the pulse contour cardiac output to improve trending.
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Affiliation(s)
- Johannes Menger
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine
| | - Bruno Mora
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine
| | - Keso Skhirtladze
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine
| | - Arabella Fischer
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine
| | - Hendrik Jan Ankersmit
- Department of Surgery, and Christian Doppler Laboratory for Cardiac and Thoracic Diseases, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine.
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14
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Sakka SG. Hemodynamic Monitoring in the Critically Ill Patient - Current Status and Perspective. Front Med (Lausanne) 2015; 2:44. [PMID: 26284244 PMCID: PMC4522558 DOI: 10.3389/fmed.2015.00044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/26/2015] [Indexed: 01/20/2023] Open
Abstract
In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient's outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations.
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Affiliation(s)
- Samir G Sakka
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Center Cologne Merheim, University Witten/Herdecke , Cologne , Germany
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15
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Abstract
Although use of the classic pulmonary artery catheter has declined, several techniques have emerged to estimate cardiac output. Arterial pressure waveform analysis computes cardiac output from the arterial pressure curve. The method of estimating cardiac output for these devices depends on whether they need to be calibrated by an independent measure of cardiac output. Some newer devices have been developed to estimate cardiac output from an arterial curve obtained noninvasively with photoplethysmography, allowing a noninvasive beat-by-beat estimation of cardiac output. This article describes the different devices that perform pressure waveform analysis.
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Affiliation(s)
- Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France; EA4533, Paris-Sud University, 63 rue Gabriel Péri, F-94270 Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France; EA4533, Paris-Sud University, 63 rue Gabriel Péri, F-94270 Le Kremlin-Bicêtre, France
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16
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Hamzaoui O, Monnet X, Teboul JL. Evolving concepts of hemodynamic monitoring for critically ill patients. Indian J Crit Care Med 2015; 19:220-6. [PMID: 25878430 PMCID: PMC4397629 DOI: 10.4103/0972-5229.154556] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The last decades have been characterized by a continuous evolution of hemodynamic monitoring techniques from intermittent toward continuous and real-time measurements and from an invasive towards a less invasive approach. The latter approach uses ultrasounds and pulse contour analysis techniques that have been developed over the last 15 years. During the same period, the concept of prediction of fluid responsiveness has also been developed and dynamic indices such as pulse pressure variation, stroke volume variation, and the real-time response of cardiac output to passive leg raising or to end-expiration occlusion, can be easily obtained and displayed with the minimally invasive techniques. In this article, we review the main hemodynamic monitoring devices currently available with their respective advantages and drawbacks. We also present the current viewpoint on how to choose a hemodynamic monitoring device in the most severely ill patients and especially in patients with circulatory shock.
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Affiliation(s)
- Olfa Hamzaoui
- Intensive Care Unit, Antoine Beclere Hospital, Clamart, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicetre Hospital, Le Kremlin-Bicetre, France ; Paris-South University, Inserm U999, Le Kremlin-Bicetre, France
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Urbano J, López J, González R, Solana MJ, Fernández SN, Bellón JM, López-Herce J. Measurement of cardiac output in children by pressure-recording analytical method. Pediatr Cardiol 2015; 36:358-64. [PMID: 25179459 DOI: 10.1007/s00246-014-1014-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 08/22/2014] [Indexed: 12/13/2022]
Abstract
We evaluated two pressure-recording analytical method (PRAM) software versions (v.1 and v.2) to measure cardiac index (CI) in hemodynamically stable critically ill children and investigate factors that influence PRAM values. The working hypothesis was that PRAM CI measurements would stay within normal limits in hemodynamically stable patients. Ninety-five CI PRAM measurements were analyzed in 47 patients aged 1-168 months. Mean CI was 4.1 ± 1.4 L/min/m(2) (range 2.0-7.0). CI was outside limits defined as normal (3-5 L/min/m(2)) in 53.7% of measurements (47.8% with software v.1 and 69.2% with software v.2, p = 0.062). Moreover, 14.7% of measurements were below 2.5 L/min/m(2), and 13.6% were above 6 L/min/m(2). CI was significantly lower in patients with a clearly visible dicrotic notch than in those without (3.7 vs. 4.6 L/min/m(2), p = 0.004) and in children with a radial arterial catheter (3.5 L/min/m(2)) than in those with a brachial (4.4 L/min/m(2), p = 0.021) or femoral catheter (4.7 L/min/m(2), p = 0.005). By contrast, CI was significantly higher in children under 12 months (4.2 vs. 3.6 L/min/m(2), p = 0.034) and weighing under 10 kg (4.2 vs. 3.6 L/min/m(2), p = 0.026). No significant differences were observed between cardiac surgery patients and the rest of children. A high percentage of CI measurements registered by PRAM were outside normal limits in hemodynamically stable, critically ill children. CI measured by PRAM may be influenced by the age, weight, location of catheter, and presence of a dicrotic notch.
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Affiliation(s)
- Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria del, Hospital General Universitario Gregorio Marañón de Madrid, Madrid, Spain
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Esper SA, Pinsky MR. Arterial waveform analysis. Best Pract Res Clin Anaesthesiol 2014; 28:363-80. [PMID: 25480767 DOI: 10.1016/j.bpa.2014.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/19/2014] [Accepted: 08/27/2014] [Indexed: 01/20/2023]
Abstract
The bedside measurement of continuous arterial pressure values from waveform analysis has been routinely available via indwelling arterial catheterization for >50 years. Invasive blood pressure monitoring has been utilized in critically ill patients, in both the operating room and critical care units, to facilitate rapid diagnoses of cardiovascular insufficiency and monitor response to treatments aimed at correcting abnormalities before the consequences of either hypo- or hypertension are seen. Minimally invasive techniques to estimate cardiac output (CO) have gained increased appeal. This has led to the increased interest in arterial waveform analysis to provide this important information, as it is measured continuously in many operating rooms and intensive care units. Arterial waveform analysis also allows for the calculation of many so-called derived parameters intrinsically created by this pulse pressure profile. These include estimates of left ventricular stroke volume (SV), CO, vascular resistance, and during positive-pressure breathing, SV variation, and pulse pressure variation. This article focuses on the principles of arterial waveform analysis and their determinants, components of the arterial system, and arterial pulse contour. It will also address the advantage of measuring real-time CO by the arterial waveform and the benefits to measuring SV variation. Arterial waveform analysis has gained a large interest in the overall assessment and management of the critically ill and those at a risk of hemodynamic deterioration.
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Affiliation(s)
- Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Michael R Pinsky
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Semi-invasive measurement of cardiac output based on pulse contour: a review and analysis. Can J Anaesth 2014; 61:452-79. [PMID: 24643474 DOI: 10.1007/s12630-014-0135-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 02/18/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this review was to provide a meta-analysis of all five of the most popular systems for arterial pulse contour analysis compared with pulmonary artery thermodilution, the established reference method for measuring cardiac output (CO). The five investigated systems are FloTrac/Vigileo(®), PiCCO(®), LiDCO/PulseCO(®), PRAM/MostCare(®), and Modelflow. SOURCE In a comprehensive literature search through MEDLINE(®), Web of Knowledge (v.5.11), and Google Scholar, we identified prospective studies and reviews that compared the pulse contour approach with the reference method (n = 316). Data extracted from the 93 selected studies included range and mean cardiac output, bias, percentage error, software versions, and study population. We performed a pooled weighted analysis of their precision in determining CO in various patient groups and clinical settings. PRINCIPAL FINDINGS Results of the majority of studies indicate that the five investigated systems show acceptable accuracy during hemodynamically stable conditions. Forty-three studies provided adequate data for a pooled weighted analysis and resulted in a mean (SD) total pooled bias of -0.28 (1.25) L·min(-1), percentage error of 40%, and a correlation coefficient of r = 0.71. In hemodynamically unstable patients (n = 8), we found a higher percentage error (45%) and bias of -0.54 (1.64) L·min(-1). CONCLUSION During hemodynamic instability, CO measurement based on continuous arterial pulse contour analysis shows only limited agreement with intermittent bolus thermodilution. The calibrated systems seem to deliver more accurate measurements than the auto-calibrated or the non-calibrated systems. For reliable use of these semi-invasive systems, especially for critical therapeutic decisions during hemodynamic disorders, both a strategy for hemodynamic optimization and further technological improvements are necessary.
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Barile L, Landoni G, Pieri M, Ruggeri L, Maj G, Nigro Neto C, Pasin L, Cabrini L, Zangrillo A. Cardiac Index Assessment by the Pressure Recording Analytic Method in Critically Ill Unstable Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:1108-13. [DOI: 10.1053/j.jvca.2013.02.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Indexed: 11/11/2022]
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Romagnoli S, Ricci Z, Romano SM, Dimizio F, Bonicolini E, Quattrone D, De Gaudio R. FloTrac/VigileoTM (Third Generation) and MostCare®/PRAM Versus Echocardiography for Cardiac Output Estimation in Vascular Surgery. J Cardiothorac Vasc Anesth 2013; 27:1114-21. [DOI: 10.1053/j.jvca.2013.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Indexed: 01/22/2023]
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Ameloot K, Van De Vijver K, Broch O, Van Regenmortel N, De laet I, Schoonheydt K, Dits H, Bein B, Malbrain MLNG. Nexfin noninvasive continuous hemodynamic monitoring: validation against continuous pulse contour and intermittent transpulmonary thermodilution derived cardiac output in critically ill patients. ScientificWorldJournal 2013; 2013:519080. [PMID: 24319373 PMCID: PMC3844244 DOI: 10.1155/2013/519080] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Accepted: 09/15/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Nexfin (Bmeye, Amsterdam, Netherlands) is a noninvasive cardiac output (CO) monitor based on finger arterial pulse contour analysis. The aim of this study was to validate Nexfin CO (NexCO) against thermodilution (TDCO) and pulse contour CO (CCO) by PiCCO (Pulsion Medical Systems, Munich, Germany). PATIENTS AND METHODS In a mix of critically ill patients (n = 45), NexCO and CCO were measured continuously and recorded at 2-hour intervals during the 8-hour study period. TDCO was measured at 0-4-8 hrs. RESULTS NexCO showed a moderate to good (significant) correlation with TDCO (R (2) 0.68, P < 0.001) and CCO (R (2) 0.71, P < 0.001). Bland and Altman analysis comparing NexCO with TDCO revealed a bias (± limits of agreement, LA) of 0.4 ± 2.32 L/min (with 36% error) while analysis comparing NexCO with CCO showed a bias (±LA) of 0.2 ± 2.32 L/min (37% error). NexCO is able to follow changes in TDCO and CCO during the same time interval (level of concordance 89.3% and 81%). Finally, polar plot analysis showed that trending capabilities were acceptable when changes in NexCO (ΔNexCO) were compared to ΔTDCO and ΔCCO (resp., 89% and 88.9% of changes were within the level of 10% limits of agreement). CONCLUSION we found a moderate to good correlation between CO measurements obtained with Nexfin and PiCCO.
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Affiliation(s)
- Koen Ameloot
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Katrijn Van De Vijver
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Ole Broch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
| | - Niels Van Regenmortel
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Inneke De laet
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Karen Schoonheydt
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Hilde Dits
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
| | - Berthold Bein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
| | - Manu L. N. G. Malbrain
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerp, Belgium
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Donati A, Carsetti A, Tondi S, Scorcella C, Domizi R, Damiani E, Gabbanelli V, Münch C, Adrario E, Pelaia P, Cecconi M. Thermodilution vs pressure recording analytical method in hemodynamic stabilized patients. J Crit Care 2013; 29:260-4. [PMID: 24332994 DOI: 10.1016/j.jcrc.2013.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/02/2013] [Accepted: 11/04/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE Many mini-invasive devices to monitor cardiac output (CO) have been introduced and, among them, the pressure recording analytical method (PRAM). The aim of this study was to assess the agreement of PRAM with the intermittent transpulmonary thermodilution and continuous pulmonary thermodilution in measuring CO in hemodynamically stabilized patients. MATERIALS AND METHODS This is a prospective clinical study in a mixed medical-surgical intensive care unit (ICU) and in a postcardiac surgical ICU. Forty-eight patients were enrolled: 32 patients to the medical-surgical ICU monitored with PiCCO (Pulsion Medical System AG, Munich, Germany) and 16 were cardiac patients monitored with Vigilance (Edwards Lifesciences, Irvine, CA). RESULTS A total of 112 measurements were made. Ninety-six comparisons of paired CO measurements were made in patients hospitalized in medical-surgical ICU; 16, in cardiac surgical patients. The mean Vigilance-CO was 4.49 ± 0.99 L/min (range, 2.80-5.90 L/min), and the mean PRAM-CO was 4.27 ± 0.88 L/min (range, 2.85-6.19 L/min). The correlation coefficient between Vigilance-CO and PRAM-CO was 0.83 (95% confidence interval, 0.57-0.94; P < .001). The bias was 0.22 ± 0.55 L/min with limits of agreement between 0.87 and 1.30 L/min. The percentage error was 25%. Mean TP-CO was 6.78 ± 2.04 L/min (range, 4.12-11.27 L/min), and the mean PRAM-CO was 6.11 ± 2.18 L/min (range, 2.82-10.90 L/min). The correlation coefficient between PiCCO-CO and PRAM-CO was 0.91 (95% confidence interval, 0.83-0.96; P < .0001). The bias was 0.67 ± 0.89 L/min with limits of agreement -1.07 and 2.41 L/min. The coefficient of variation for PiCCO was 4% ± 2%, and the coefficient of variation for PRAM was 10% ± 8%. The percentage error was 28%. CONCLUSIONS The PRAM system showed good agreement with pulmonary artery catheter and PiCCO in hemodynamically stabilized patients.
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Affiliation(s)
- Abele Donati
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy.
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Stefania Tondi
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Elisa Damiani
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Vincenzo Gabbanelli
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Christopher Münch
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Cardiological Sciences, AOU Ospedali Riuniti, via Conca, 60126, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Paolo Pelaia
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/A, 60126, Ancona, Italy
| | - Maurizio Cecconi
- Department of General Intensive Care, St George's Healthcare NHS Trust, SW17 0QT London, UK; St George's Medical School, SW17 0QT London, UK
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Xie X, Willemink MJ, Zhao Y, de Jong PA, van Ooijen PMA, Oudkerk M, Greuter MJW, Vliegenthart R. Inter- and intrascanner variability of pulmonary nodule volumetry on low-dose 64-row CT: an anthropomorphic phantom study. Br J Radiol 2013; 86:20130160. [PMID: 23884758 DOI: 10.1259/bjr.20130160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess inter- and intrascanner variability in volumetry of solid pulmonary nodules in an anthropomorphic thoracic phantom using low-dose CT. METHODS Five spherical solid artificial nodules [diameters 3, 5, 8, 10 and 12 mm; CT density +100 Hounsfield units (HU)] were randomly placed inside an anthropomorphic thoracic phantom in different combinations. The phantom was examined on two 64-row multidetector CT (64-MDCT) systems (CT-A and CT-B) from different vendors with a low-dose protocol. Each CT examination was performed three times. The CT examinations were evaluated twice by independent blinded observers. Nodule volume was semi-automatically measured by dedicated software. Interscanner variability was evaluated by Bland-Altman analysis and expressed as 95% confidence interval (CI) of relative differences. Intrascanner variability was expressed as 95% CI of relative variation from the mean. RESULTS No significant difference in CT-derived volume was found between CT-A and CT-B, except for the 3-mm nodules (p<0.05). The 95% CI of interscanner variability was within ±41.6%, ±18.2% and ±4.9% for 3, 5 and ≥8 mm nodules, respectively. The 95% CI of intrascanner variability was within ±28.6%, ±13.4% and ±2.6% for 3, 5 and ≥8 mm nodules, respectively. CONCLUSION Different 64-MDCT scanners in low-dose settings yield good agreement in volumetry of artificial pulmonary nodules between 5 mm and 12 mm in diameter. Inter- and intrascanner variability decreases at a larger nodule size to a maximum of 4.9% for ≥8 mm nodules. ADVANCES IN KNOWLEDGE The commonly accepted cut-off of 25% to determine nodule growth has the potential to be reduced for ≥8 mm nodules. This offers the possibility of reducing the interval for repeated CT scans in lung cancer screenings.
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Affiliation(s)
- X Xie
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Saxena R, Durward A, Puppala NK, Murdoch IA, Tibby SM. Pressure recording analytical method for measuring cardiac output in critically ill children: a validation study. Br J Anaesth 2012. [PMID: 23183320 DOI: 10.1093/bja/aes420] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pressure recording analytical method (PRAM) is a novel, arterial pulse contour-based method for measuring cardiac output (CO). Validation studies of PRAM in children are few, and have not assessed both absolute accuracy and ability to track changes in CO across a broad case mix. We aimed to compare CO as measured by PRAM with that using a transpulmonary dilution method in a cohort of critically ill children. METHODS Forty-eight, mechanically ventilated children with a median (inter-quartile) weight of 10.7 (5.5-15) kg with arterial and central venous catheters in situ were studied. CO was measured simultaneously using PRAM and the comparator method, transpulmonary ultrasound dilution (UD). Measurements were repeated before and after therapeutic interventions that were intended to augment CO (e.g. fluid bolus). RESULTS In total, 210 paired measurements were compared. The mean (sd) CO was 1.9 (1.2) litre min(-1) with UD when compared with 1.92 (0.5) litre min(-1) using PRAM. The mean bias was 0.02 litre min(-1) with wide limits of agreement: ± 2.21 litre min(-1), giving a percentage error of 116%. The concordance between PRAM and UD for measuring changes in CO was also poor, with only 37% of measurements falling within the pre-defined polar plot limits of ±30°. CONCLUSIONS There is an unacceptably poor agreement between UD and PRAM. We do not recommend the use of PRAM for measuring CO in critically ill children with the current algorithm.
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Affiliation(s)
- R Saxena
- Paediatric Intensive Care Unit, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
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Marik PE. Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth 2012; 27:121-34. [PMID: 22609340 DOI: 10.1053/j.jvca.2012.03.022] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Biais M, Cottenceau V, Stecken L, Jean M, Ottolenghi L, Roullet S, Quinart A, Sztark F. Evaluation of stroke volume variations obtained with the pressure recording analytic method. Crit Care Med 2012; 40:1186-91. [PMID: 22425817 DOI: 10.1097/ccm.0b013e31823bc632] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate whether stroke volume variations obtained with the pressure recording analytic method can predict fluid responsiveness in mechanically ventilated patients with circulatory failure. DESIGN Prospective study. SETTING Surgical intensive care unit of a university hospital. PATIENTS Thirty-five mechanically ventilated patients with circulatory failure for whom the decision to give fluid was taken by the physician were included. Exclusion criteria were: Arrhythmia, tidal volume <8 mL/kg, left ventricular ejection fraction<50%, right ventricular dysfunction, and heart rate/respiratory rate ratio <3.6. INTERVENTIONS Fluid challenge with 500 mL of saline over 15 mins. MEASUREMENTS AND MAIN RESULTS Stroke volume variations and cardiac output obtained with a pressure recording analytic method, pulse pressure variations, and cardiac output estimated by echocardiography were recorded before and after volume expansion. Patients were defined as responders if stroke volume obtained using echocardiography increased by ≥15% after volume expansion. Nineteen patients responded to the fluid challenge. Median [interquartile range, 25% to 75%] stroke volume variation values at baseline were not different in responders and nonresponders (10% [8-16] vs. 14% [12-16]), whereas pulse pressure variations were significantly higher in responders (17% [13-19] vs. 7% [5-10]; p < .0001). A 12.6% stroke volume variations threshold discriminated between responders and nonresponders with a sensitivity of 63% (95% confidence interval 38% to 84%) and a specificity of 69% (95% confidence interval 41% to 89%). A 10% pulse pressure variation threshold discriminated between responders and nonresponders with a sensitivity of 89% (95% confidence interval 67% to 99%) and a specificity of 88% (95% confidence interval 62% to 98%). The area under the receiver operating characteristic curves was different between pulse pressure variations (0.95; 95% confidence interval 0.82-0.99) and stroke volume variations (0.60; 95% confidence interval 0.43-0.76); p < .0001). Volume expansion-induced changes in cardiac output measured using echocardiography or pressure recording analytic method were not correlated (r = 0.14; p > .05) and the concordance rate of the direction of change in cardiac output was 60%. CONCLUSION Stroke volume variations obtained with a pressure recording analytic method cannot predict fluid responsiveness in intensive care unit patients under mechanical ventilation. Cardiac output measured by this device is not able to track changes in cardiac output induced by volume expansion.
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Affiliation(s)
- Matthieu Biais
- Emergency Department, Centre Hospitalier Universitaire de Bordeaux, France.
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Zhang G, Mukkamala R. Continuous and minimally invasive cardiac output monitoring by long time interval analysis of a radial arterial pressure waveform: assessment using a large, public intensive care unit patient database. Br J Anaesth 2012; 109:339-44. [PMID: 22499767 DOI: 10.1093/bja/aes099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A potential practical approach for continuous and minimally invasive cardiac output (CO) monitoring in intensive care unit (ICU) patients is to mathematically analyse an arterial pressure (AP) waveform using an existing radial artery line ('pulse contour analysis'). We recently proposed a technique to estimate the relative CO change by unique long time interval analysis (LTIA) of an AP waveform. We aimed to test this technique in an ICU patient population and compare its accuracy relative to other techniques. METHODS We studied a public, electronic ICU patient database. We extracted 1482 pairs of radial AP waveforms and thermodilution CO measurements (via single bolus injections) from 169 patients. We applied the LTIA and previous pulse contour analysis techniques to the AP waveforms. We assessed the calibrated CO estimates against the thermodilution measurements. RESULTS The overall root-mean-squared-error of the LTIA technique was 18.8%. This total level of accuracy was not better than the previous techniques. However, the average magnitude of the thermodilution changes was only 12.3% (9.9 sd). When the magnitude of the thermodilution change exceeded 30%, 50%, and 70%, the median squared-error differences between the LTIA technique and the most accurate previous technique were -45 (-322:69 quartiles) (P=0.005), -128 (-704:23) (P=0.006), and -862 (-2871:306)%(2) (P=0.055), respectively. The LTIA technique was therefore superior in detecting clinically important CO changes. CONCLUSIONS The LTIA technique attained an overall accuracy that may be considered clinically acceptable after taking into account the known thermodilution error and became progressively more accurate than previous techniques with increasing CO changes.
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Affiliation(s)
- G Zhang
- Department of Electrical and Computer Engineering, Michigan State University, 2120 Engineering Building, East Lansing, MI 48824-1226, USA
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Scolletta S, Franchi F, Taccone FS, Donadello K, Biagioli B, Vincent JL. An Uncalibrated Pulse Contour Method to Measure Cardiac Output During Aortic Counterpulsation. Anesth Analg 2011; 113:1389-95. [DOI: 10.1213/ane.0b013e318230b2de] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Heringlake M, Paarmann H, Groesdonk H, Sedemund-Adib B, Hanke T, Heinze H, Schoen J. Reply from the authors. Br J Anaesth 2011. [DOI: 10.1093/bja/aer310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Scolletta S, Taccone F, Romagnoli S, Landoni G, Giomarelli P. Pressure recording analytical method to measure cardiac output after cardiac surgery: some practical considerations. Br J Anaesth 2011; 107:814-5; author's reply 815-6. [DOI: 10.1093/bja/aer319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Chikhani M, Moppett I. Minimally invasive cardiac output monitoring: what evidence do we need? Br J Anaesth 2011; 106:451-3. [DOI: 10.1093/bja/aer056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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