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Le Gall A, Vallée F, Joachim J, Hong A, Matéo J, Mebazaa A, Gayat E. Estimation of cardiac output variations induced by hemodynamic interventions using multi-beat analysis of arterial waveform: a comparative off-line study with transesophageal Doppler method during non-cardiac surgery. J Clin Monit Comput 2022; 36:501-510. [PMID: 33687601 PMCID: PMC9123019 DOI: 10.1007/s10877-021-00679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
Multi-beat analysis (MBA) of the radial arterial pressure (AP) waveform is a new method that may improve cardiac output (CO) estimation via modelling of the confounding arterial wave reflection. We evaluated the precision and accuracy using the trending ability of the MBA method to estimate absolute CO and variations (ΔCO) during hemodynamic challenges. We reviewed the hemodynamic challenges (fluid challenge or vasopressors) performed when intra-operative hypotension occurred during non-cardiac surgery. The CO was calculated offline using transesophageal Doppler (TED) waveform (COTED) or via application of the MBA algorithm onto the AP waveform (COMBA) before and after hemodynamic challenges. We evaluated the precision and the accuracy according to the Bland & Altman method. We also assessed the trending ability of the MBA by evaluating the percentage of concordance with 15% exclusion zone between ΔCOMBA and ΔCOTED. A non-inferiority margin was set at 87.5%. Among the 58 patients included, 23 (40%) received at least 1 fluid challenge, and 46 (81%) received at least 1 bolus of vasopressors. Before treatment, the COTED was 5.3 (IQR [4.1-8.1]) l min-1, and the COMBA was 4.1 (IQR [3-5.4]) l min-1. The agreement between COTED and COMBA was poor with a 70% percentage error. The bias and lower and upper limits of agreement between COTED and COMBA were 0.9 (CI95 = 0.82 to 1.07) l min-1, -2.8 (CI95 = -2.71 to-2.96) l min-1 and 4.7 (CI95 = 4.61 to 4.86) l min-1, respectively. After hemodynamic challenge, the percentage of concordance (PC) with 15% exclusion zone for ΔCO was 93 (CI97.5 = 90 to 97)%. In this retrospective offline analysis, the accuracy, limits of agreements and percentage error between TED and MBA for the absolute estimation of CO were poor, but the MBA could adequately track induced CO variations measured by TED. The MBA needs further evaluation in prospective studies to confirm those results in clinical practice conditions.
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Affiliation(s)
- Arthur Le Gall
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France.
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France.
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France.
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France.
| | - Fabrice Vallée
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
| | - Jona Joachim
- Inria Paris-Saclay, 01, avenue Honoré d'Estienne d'Orves, 91120, Palaiseau, France
- LMS, École Polytechnique, 91128, Palaiseau Cedex, France
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alex Hong
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
| | - Joaquim Matéo
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
| | - Alexandre Mebazaa
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
| | - Etienne Gayat
- Anesthesiology and Intensive Care Department, Lariboisière - Saint Louis - Fernand Widal University Hospitals, University of Paris, 02 rue Ambroise Paré, 75010, Paris, France
- UMR-S 942, INSERM, 02 rue Ambroise Paré, 75010, Paris, France
- Université de Paris, 85 boulevard Saint-Germain, 75006, Paris, France
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Best practice & research clinical anaesthesiology: Advances in haemodynamic monitoring for the perioperative patient: Perioperative cardiac output monitoring. Best Pract Res Clin Anaesthesiol 2019; 33:139-153. [PMID: 31582094 DOI: 10.1016/j.bpa.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. Even established, invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution have still an evidence-based place in the perioperative setting, albeit only in special patient populations. Accumulating evidence suggests to use continuous haemodynamic monitoring, especially flow-based variables such as stroke volume or cardiac output to prevent occult hypoperfusion and, consequently, decrease morbidity and mortality perioperatively. However, there is still a substantial gap between evidence provided by randomised trials and the implementation of haemodynamic monitoring in daily clinical routine. Given the fact that perioperative morbidity and mortality are higher than anticipated and anaesthesiologists are in charge to deal with this problem, the recent advances in minimally invasive and non-invasive monitoring technologies may facilitate more widespread use in the operating theatre, as in addition to costs, the degree of invasiveness of any monitoring tool determines the frequency of its application, at least perioperatively. This review covers the currently available invasive, non-invasive and minimally invasive techniques and devices and addresses their indications and limitations.
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Eisenried A, Klarwein R, Ihmsen H, Wehrfritz A, Tandler R, Heim C, Fechner J. Accuracy and Trending Ability of the Fourth-Generation FloTrac/EV1000 System in Patients With Severe Aortic Valve Stenosis Before and After Surgical Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:1230-1236. [DOI: 10.1053/j.jvca.2018.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Indexed: 11/11/2022]
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Bender M, Stein M, Uhl E, Reinges MHT. Serum Cortisol as an Early Biomarker of Cardiopulmonary Parameters Within the First 24 Hours After Aneurysmal Subarachnoid Hemorrhage in Intensive Care Unit Patients. J Intensive Care Med 2019; 35:1173-1179. [PMID: 30913956 DOI: 10.1177/0885066619837910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cardiopulmonary complications/stress are well-known phenomena in patients after aneurysmal subarachnoid hemorrhage (aSAH) and might be associated with an elevated serum troponin I (TNI) level. Since the glucocorticoid hormone cortisol is released during stress situations, the present study was conducted to investigate the influence of serum cortisol (SC) on cardiac and pulmonary parameters in patients after aSAH within the first 24 hours of intensive care unit (ICU) treatment. PATIENTS AND METHODS We retrospectively analyzed a cohort of 104 patients with aSAH admitted to our emergency department between January 2008 and April 2017. Blood samples were taken to determine SC and TNI. Demographics, initial Glasgow Coma Scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) score, and Fisher grade were evaluated retrospectively. Mean norepinephrine application rate (NAR) in µg/kg/min and mean inspiratory oxygen fraction (OF) within the first 24 hours were defined as cardiopulmonary parameters. RESULTS An elevated SC value was found in 44 (42%) patients, and 27 (26%) patients showed an increased TNI value. In patients with initially increased SC value, a significant higher NAR (P = .04) was needed. Furthermore, patients with initially elevated TNI value had a lower GCS score (P = .0013) and a higher WFNS score (P = .003) on admission and required a higher NAR (P = .02) as well as OF (P = .0008) within the first 24 hours of ICU treatment. CONCLUSIONS In the current study, initially elevated SC values were associated with a higher need of NAR within the first 24 hours of ICU treatment after aSAH. Moreover, patients with initially elevated TNI values required an increased NAR and a higher OF so that these biomarkers could be useful to improve ICU treatment.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - M Stein
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - E Uhl
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - M H T Reinges
- Department of Neurosurgery, Bremen-Mitte Hospital, Bremen, Germany
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Evaluation of cardiac output variations with the peripheral pulse pressure to mean arterial pressure ratio. J Clin Monit Comput 2018; 33:581-587. [PMID: 30361823 DOI: 10.1007/s10877-018-0210-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Abstract
Cardiac output (CO) optimisation during surgery reduces post-operative morbidity. Various methods based on pulse pressure analysis have been developed to overcome difficulties to measure accurate CO variations in standard anaesthetic settings. Several of these methods include, among other parameters, the ratio of pulse pressure to mean arterial pressure (PP/MAP). The aim of this study was to evaluate whether the ratio of radial pulse pressure to mean arterial pressure (ΔPPrad/MAP) could track CO variations (ΔCO) induced by various therapeutic interventions such as fluid infusions and vasopressors boluses [phenylephrine (PE), norepinephrine (NA) or ephedrine (EP)] in the operating room. Trans-oesophageal Doppler signal and pressure waveforms were recorded in patients undergoing neurosurgery. CO and PPrad/MAP were recorded before and after fluid challenges, PE, NA and EP bolus infusions as medically required during their anaesthesia. One hundred and three patients (mean age: 52 ± 12 years old, 38 men) have been included with a total of 636 sets of measurement. During fluids challenges (n = 188), a positive correlation was found between ΔPPrad/MAP and ΔCO (r = 0.22, p = 0.003). After PE (n = 256) and NA (n = 121) boluses, ΔPPrad/MAP positively tracked ΔCO (r = 0.53 and 0.41 respectively, p < 0.001). By contrast, there was no relation between ΔPPrad/MAP and ΔCO after EP boluses (r = 0.10, p = 0.39). ΔPPrad/MAP tracked ΔCO variations during PE and NA vasopressor challenges. However, after positive fluid challenge or EP boluses, ΔPPrad/MAP was not as performant to track ΔCO which could make the use of this ratio difficult in current clinical practice.
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Suresh MR, Chung KK, Schiller AM, Holley AB, Howard JT, Convertino VA. Unmasking the Hypovolemic Shock Continuum: The Compensatory Reserve. J Intensive Care Med 2018; 34:696-706. [PMID: 30068251 DOI: 10.1177/0885066618790537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypovolemic shock exists as a spectrum, with its early stages characterized by subtle pathophysiologic tissue insults and its late stages defined by multi-system organ dysfunction. The importance of timely detection of shock is well known, as early interventions improve mortality, while delays render these same interventions ineffective. However, detection is limited by the monitors, parameters, and vital signs that are traditionally used in the intensive care unit (ICU). Many parameters change minimally during the early stages, and when they finally become abnormal, hypovolemic shock has already occurred. The compensatory reserve (CR) is a parameter that represents a new paradigm for assessing physiologic status, as it comprises the sum total of compensatory mechanisms that maintain adequate perfusion to vital organs during hypovolemia. When these mechanisms are overwhelmed, hemodynamic instability and circulatory collapse will follow. Previous studies involving CR measurements demonstrated their utility in detecting central blood volume loss before hemodynamic parameters and vital signs changed. Measurements of the CR have also been used in clinical studies involving patients with traumatic injuries or bleeding, and the results from these studies have been promising. Moreover, these measurements can be made at the bedside, and they provide a real-time assessment of hemodynamic stability. Given the need for rapid diagnostics when treating critically ill patients, CR measurements would complement parameters that are currently being used. Consequently, the purpose of this article is to introduce a conceptual framework where the CR represents a new approach to monitoring critically ill patients. Within this framework, we present evidence to support the notion that the use of the CR could potentially improve the outcomes of ICU patients by alerting intensivists to impending hypovolemic shock before its onset.
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Affiliation(s)
- Mithun R Suresh
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Kevin K Chung
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alicia M Schiller
- 4 Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Aaron B Holley
- 2 Department of Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,3 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeffrey T Howard
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Victor A Convertino
- 1 Battlefield Health & Trauma Center for Human Integrative Physiology, US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
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Hur M, Yoo S, Choi JY, Park SK, Jung DE, Kim WH, Kim JT, Bahk JH. Positive end-expiratory pressure-induced increase in external jugular venous pressure does not predict fluid responsiveness in laparoscopic prostatectomy. J Anesth 2018; 32:316-325. [DOI: 10.1007/s00540-018-2475-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 02/22/2018] [Indexed: 01/31/2023]
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Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2018; 84:37-49. [PMID: 29019796 DOI: 10.1097/ta.0000000000001719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE Systematic Review, level II.
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9
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Lin SY, Chou AH, Tsai YF, Chang SW, Yang MW, Ting PC, Chen CY. Evaluation of the use of the fourth version FloTrac system in cardiac output measurement before and after cardiopulmonary bypass. J Clin Monit Comput 2017; 32:807-815. [PMID: 29039063 DOI: 10.1007/s10877-017-0071-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/06/2017] [Indexed: 12/27/2022]
Abstract
The FloTrac system is a system for cardiac output (CO) measurement that is less invasive than the pulmonary artery catheter (PAC). The purposes of this study were to (1) compare the level of agreement and trending abilities of CO values measured using the fourth version of the FloTrac system (CCO-FloTrac) and PAC-originated continuous thermodilution (CCO-PAC) and (2) analyze the inadequate CO-discriminating ability of the FloTrac system before and after cardiopulmonary bypass (CPB). Fifty patients were included. After exclusion, 32 patients undergoing cardiac surgery with CPB were analyzed. All patients were monitored with a PAC and radial artery catheter connected to the FloTrac system. CO was assessed at 10 timing points during the surgery. In the Bland-Altman analysis, the percentage errors (bias, the limits of agreement) of the CCO-FloTrac were 61.82% (0.16, - 2.15 to 2.47 L min) and 51.80% (0.48, - 1.97 to 2.94 L min) before and after CPB, respectively, compared with CCO-PAC. The concordance rates in the four-quadrant plot were 64.10 and 62.16% and the angular concordance rates (angular mean bias, the radial limits of agreement) in the polar-plot analysis were 30.00% (17.62°, - 70.69° to 105.93°) and 38.63% (- 10.04°, - 96.73° to 76.30°) before and after CPB, respectively. The area under the receiver operating characteristic curve for CCO-FloTrac was 0.56, 0.52, 0.52, and 0.72 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% CO changes (ΔCO) of CCO-PAC before CPB, respectively, and 0.59, 0.55, 0.49, and 0.46 for all, ≥ ± 5, ≥ ± 10, and ≥ ± 15% ΔCO of CCO-PAC after CPB, respectively. When CO < 4 L/min was considered inadequate, the Cohen κ coefficient was 0.355 and 0.373 before and after CPB, respectively. The accuracy, trending ability, and inadequate CO-discriminating ability of the fourth version of the FloTrac system in CO monitoring are not statistically acceptable in cardiac surgery.
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Affiliation(s)
- Sheng-Yi Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Su-Wei Chang
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Min-Wen Yang
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Pei-Chi Ting
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
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Kim DH, Yoo JY, Lee SY, Kim YJ, Lee SR, Park SY. Effects of pulse pressure alterations on cardiac output measurements derived from analysis of arterial pressure waveform. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.3.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dae-hee Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ji Young Yoo
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Yeo Jin Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Se Ryeon Lee
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sung-Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
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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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12
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Agreement in hemodynamic monitoring during orthotopic liver transplantation: a comparison of FloTrac/Vigileo at two monitoring sites with pulmonary artery catheter thermodilution. J Clin Monit Comput 2016. [PMID: 26884378 DOI: 10.1007/s10877-016-9840-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To study agreement in cardiac index (CI), systemic vascular resistance index (Systemic VRI) and stroke volume variation (SV variation) between the FloTrac/Vigileo at radial and femoral arterial cannulation sites, and pulmonary artery catheter (PAC) thermodilution, in patients undergoing orthotopic liver transplantation. A prospective observational study of 25 adult patients with liver failure. Radial and femoral arteries were cannulated with standardised FloTrac/Vigileo arterial transducer kits and a PAC was inserted. CI, SV variation and Systemic VRI were measured four times (30 min after induction of anesthesia, 30 min after portal vein clamping, 30 min after graft reperfusion, 30 min after commencement of bile duct anastomosis). The bias, precision, limits of agreement (LOA) and percentage errors were calculated using Bland-Altman statistics to compare measurements from radial and femoral arterial cannulation sites and PAC thermodilution. Neither radial nor femoral CI achieved acceptable agreement with PAC CI [radial to PAC bias (SD) 1.17 (1.49) L/min/m2, percentage error 64.40 %], [femoral to PAC bias (SD) -0.71 (1.81) L/min/m2, percentage error 74.20 %]. Agreement between radial and femoral sites for CI [mean difference (SD) -0.43 (1.51) L/min/m2, percentage error 70.40 %] and Systemic VRI [mean difference (SD) 0.03 (4.17) LOA ±8.17 mmHg min m2/L] were also unacceptable. Agreement in SV variation between radial and femoral measurement sites approached a clinically acceptable threshold [mean difference (SD) 0.68 (2.44) %), LOA ±4.78 %]. FloTrac/Vigileo CI cannot substitute for PAC thermodilution CI, regardless of measurement site. SV variation measurements may be interchangeable between radial and femoral sites for determining fluid responsiveness.
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13
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Lee M, Weinberg L, Pearce B, Scurrah N, Story DA, Pillai P, McCall PR, P McNicol L, Peyton PJ. Agreement in hemodynamic monitoring during orthotopic liver transplantation: a comparison of FloTrac/Vigileo at two monitoring sites with pulmonary artery catheter thermodilution. J Clin Monit Comput 2016; 31:343-351. [PMID: 26884378 DOI: 10.1007/s10877-016-9840-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/08/2016] [Indexed: 10/22/2022]
Abstract
To study agreement in cardiac index (CI), systemic vascular resistance index (Systemic VRI) and stroke volume variation (SV variation) between the FloTrac/Vigileo at radial and femoral arterial cannulation sites, and pulmonary artery catheter (PAC) thermodilution, in patients undergoing orthotopic liver transplantation. A prospective observational study of 25 adult patients with liver failure. Radial and femoral arteries were cannulated with standardised FloTrac/Vigileo arterial transducer kits and a PAC was inserted. CI, SV variation and Systemic VRI were measured four times (30 min after induction of anesthesia, 30 min after portal vein clamping, 30 min after graft reperfusion, 30 min after commencement of bile duct anastomosis). The bias, precision, limits of agreement (LOA) and percentage errors were calculated using Bland-Altman statistics to compare measurements from radial and femoral arterial cannulation sites and PAC thermodilution. Neither radial nor femoral CI achieved acceptable agreement with PAC CI [radial to PAC bias (SD) 1.17 (1.49) L/min/m2, percentage error 64.40 %], [femoral to PAC bias (SD) -0.71 (1.81) L/min/m2, percentage error 74.20 %]. Agreement between radial and femoral sites for CI [mean difference (SD) -0.43 (1.51) L/min/m2, percentage error 70.40 %] and Systemic VRI [mean difference (SD) 0.03 (4.17) LOA ±8.17 mmHg min m2/L] were also unacceptable. Agreement in SV variation between radial and femoral measurement sites approached a clinically acceptable threshold [mean difference (SD) 0.68 (2.44) %), LOA ±4.78 %]. FloTrac/Vigileo CI cannot substitute for PAC thermodilution CI, regardless of measurement site. SV variation measurements may be interchangeable between radial and femoral sites for determining fluid responsiveness.
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Affiliation(s)
- Matthew Lee
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Nicholas Scurrah
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - David A Story
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Larry P McNicol
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Philip J Peyton
- Department of Anaesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
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Johnson A, Mohajer-Esfahani M. Exploring hemodynamics: a review of current and emerging noninvasive monitoring techniques. Crit Care Nurs Clin North Am 2016; 26:357-75. [PMID: 25169689 DOI: 10.1016/j.ccell.2014.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The lack of randomized controlled trials suggesting improved outcomes with pulmonary artery catheter use and pressure-based hemodynamic monitoring has led to a decrease in pulmonary artery catheter use. However, an increasing amount of literature supporting stroke volume optimization (SVO) has caused a paradigm shift from pressure-based to flow-based techniques. This article discusses emerging flow-based techniques, supporting evidence, and considerations for use in critical care for methods such as Doppler, pulse contour, bioimpedance, bioreactance, and exhaled carbon dioxide. Regardless of the device chosen, the SVO algorithm approach should be considered, and volume challenges should be guided by dynamic assessments of fluid responsiveness.
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Affiliation(s)
- Alexander Johnson
- Critical Care, Central DuPage Hospital, Cadence Health, 25 North Winfield Road, Winfield, IL 60190, USA.
| | - Mehr Mohajer-Esfahani
- Critical Care, Central DuPage Hospital, Cadence Health, 25 North Winfield Road, Winfield, IL 60190, USA
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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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Chin JH, Kim WJ, Choi JH, Han YA, Kim SO, Choi WJ. Unreliable Tracking Ability of the Third-Generation FloTrac/Vigileo™ System for Changes in Stroke Volume after Fluid Administration in Patients with High Systemic Vascular Resistance during Laparoscopic Surgery. PLoS One 2015; 10:e0142125. [PMID: 26529592 PMCID: PMC4631474 DOI: 10.1371/journal.pone.0142125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/16/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The FloTrac/Vigileo™ system does not thoroughly reflect variable arterial tones, due to a lack of external calibration. The ability of this system to measure stroke volume and track its changes after fluid administration has not been fully evaluated in patients with the high systemic vascular resistance that can develop during laparoscopic surgery. METHODS In 42 patients undergoing laparoscopic prostatectomy, the stroke volume derived by the third-generation FloTrac/Vigileo™ system (SV-Vigileo), the stroke volume measured using transesophageal echocardiography (SV-TEE) as a reference method, and total systemic vascular resistance were evaluated before and after 500 ml fluid administration during pneumoperitoneum combined with the Trendelenburg position. RESULTS Total systemic vascular resistance was 2159.4 ± 523.5 dyn·s/cm5 before fluid administration. The SV-Vigileo was significantly higher than the SV-TEE both before (68.8 ± 15.9 vs. 57.0 ± 11.0 ml, P < 0.001) and after (73.0 ± 14.8 vs. 64.9 ± 12.2 ml, P = 0.003) fluid administration. During pneumoperitoneum combined with the Trendelenburg position, Bland-Altman analysis for repeated measures showed a 53.8% of percentage error between the SV-Vigileo and the SV-TEE. Four-quadrant plot (69.2% of a concordance rate) and polar plot analysis (20.6° of a mean polar angle, 16.4° of the SD of a polar angle, and ±51.5° of a radial sector containing 95% of the data points) did not indicate a good trending ability of the FloTrac/Vigileo™ system. CONCLUSIONS The third-generation FloTrac/Vigileo™ system may not be useful in patients undergoing laparoscopic surgery, based on unreliable performance in measuring the stroke volume and in tracking changes in the stroke volume after fluid administration during pneumoperitoneum combined with the Trendelenburg position.
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Affiliation(s)
- Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wook-Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Yun A. Han
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Jong Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- * E-mail:
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Comparison of an advanced minimally invasive cardiac output monitoring with a continuous invasive cardiac output monitoring during lung transplantation. J Clin Monit Comput 2015. [PMID: 26223864 DOI: 10.1007/s10877-015-9741-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The aim of this study was to compare a continuous non-calibrated left heart cardiac index (CI) measurement by arterial waveform analysis (FloTrac(®)/Vigileo(®)) with a continuous calibrated right heart CI measurement by pulmonary artery thermodilution (CCOmbo-PAC(®)/Vigilance II(®)) for hemodynamic monitoring during lung transplantation. CI was measured simultaneously by both techniques in 13 consecutive lung transplants (n = 4 single-lung transplants, n = 9 sequential double-lung transplants) at distinct time points perioperatively. Linear regression analysis and Bland-Altman analysis with percentage error calculation were used for statistical comparison of CI measurements by both techniques. In this study the FloTrac(®) system underestimated the CI in comparison with the continuous pulmonary arterial thermodilution (p < 0.000). For all measurement pairs we calculated a bias of -0.55 l/min/m(2) with limits of agreement between -2.31 and 1.21 l/min/m(2) and a percentage error of 55 %. The overall correlations before clamping a branch oft the pulmonary artery (percentage error 41 %) and during the clamping periods of a branch oft the pulmonary artery (percentage error 66 %) failed to reached the required percentage error of less than 30 %. We found good agreement of both CI measurements techniques only during the measurement point "15 min after starting the second one-lung ventilation period" (percentage error 30 %). No agreement was found during all other measurement points. This pilot study shows for the first time that the CI of the FloTrac(®) system is not comparable with the continuous pulmonary-artery thermodilution during lung transplantation including the time periods without clamping a branch of the pulmonary artery. Arterial waveform and continuous pulmonary artery thermodilution are, therefore, not interchangeable during these complex operations.
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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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Kutter APN, Bettschart-Wolfensberger R, Schwarzwald CC, Portier KG, Ringer SK. Evaluation of the non-calibrated pulse contour cardiac output monitor FloTrac/Vigileo against thermodilution in standing horses. Vet Anaesth Analg 2015; 43:153-62. [PMID: 26095722 DOI: 10.1111/vaa.12281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/10/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the non-calibrated, minimally invasive cardiac output (CO) monitor FloTrac/Vigileo (FloTrac) against thermodilution (TD) CO in standing horses. STUDY DESIGN Prospective, experimental trial. ANIMALS Nine adult horses weighing a median (range) of 535 (470-602) kg. METHODS Catheters were placed in the right atrium, pulmonary artery and carotid artery under local anaesthesia. CO was measured 147 times by TD and FloTrac and indexed to body weight. Changes in CO were achieved with romifidine or xylazine and dobutamine constant rate infusions. Bland-Altman analysis, concordance and polar plot analysis were used to assess agreement and ability to track changes in CO. RESULTS Mean ± standard deviation COTD of 48 ± 16 mL kg(-1) minute(-1) (range: 19-93 mL kg(-1) minute(-1) ) and mean COF loTrac of 9 ± 3 mL kg(-1) minute(-1) (range: 5-21 mL kg(-1) minute(-1) ) were measured. Low agreement with a large mean bias of 39 mL kg(-1) minute(-1) and wide limits of agreement of 8-70 mL kg(-1) minute(-1) were found. The percentage error of 108% and precision of TD of ± 18% resulted in an estimated precision of FloTrac of ± 106%. Comparison of changes in COF loTrac with changes in COTD gave a concordance rate of 52% in the four-quadrant plot, and a mean polar angle of -11° with radial limits of agreement of ± 61 ° in the polar plot. Mean arterial pressure (MAP) and COF loTrac were positively correlated (r = 0.5, p < 0.0001). No correlation of MAP with COTD was observed. CONCLUSIONS AND CLINICAL RELEVANCE The FloTrac system, originally designed for use in humans, neither measured absolute CO in standing horses accurately nor tracked relative changes in CO measured by TD correctly. The false dependence of COF loTrac on arterial blood pressure further discourages the use of this technique in horses.
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Affiliation(s)
- Annette P N Kutter
- Section of Anaesthesiology, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Colin C Schwarzwald
- Clinic for Equine Internal Medicine, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Karine G Portier
- Section of Anaesthesiology, VetAgro Sup (Veterinary Campus), University of Lyon, Marcy L'Étoile, France.,INSERM (Institut National de la Santé et de la Recherche Médicale), UMR-1060, CarMeN (Cardiovasculaire, Métabolisme, Diabétologie et Nutrition), Lyon, France
| | - Simone K Ringer
- Section of Anaesthesiology, Equine Department, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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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, Vaquer S, Anguel N, Jozwiak M, Cipriani F, Richard C, Teboul JL. Comparison of pulse contour analysis by Pulsioflex and Vigileo to measure and track changes of cardiac output in critically ill patients. Br J Anaesth 2015; 114:235-43. [DOI: 10.1093/bja/aeu375] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Maeda T, Yoshitani K, Inatomi Y, Ohnishi Y. Inaccuracy of the FloTrac/Vigileo™ System in Patients With Low Cardiac Index. J Cardiothorac Vasc Anesth 2014; 28:1521-6. [DOI: 10.1053/j.jvca.2014.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Indexed: 11/11/2022]
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Rex S. Continuous measurement of cardiac output using pulse-contour analysis: truly beat-to-beat? J Clin Monit Comput 2014; 29:319-21. [DOI: 10.1007/s10877-014-9640-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 11/25/2022]
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Feldheiser A, Hunsicker O, Krebbel H, Weimann K, Kaufner L, Wernecke KD, Spies C. Oesophageal Doppler and calibrated pulse contour analysis are not interchangeable within a goal-directed haemodynamic algorithm in major gynaecological surgery †. Br J Anaesth 2014; 113:822-31. [DOI: 10.1093/bja/aeu241] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Suehiro K, Tanaka K, Matsuura T, Funao T, Yamada T, Mori T, Nishikawa K. The Vigileo-FloTracTM System: Arterial Waveform Analysis for Measuring Cardiac Output and Predicting Fluid Responsiveness: A Clinical Review. J Cardiothorac Vasc Anesth 2014; 28:1361-74. [DOI: 10.1053/j.jvca.2014.02.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Indexed: 02/03/2023]
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Mehta Y, Arora D. Newer methods of cardiac output monitoring. World J Cardiol 2014; 6:1022-1029. [PMID: 25276302 PMCID: PMC4176793 DOI: 10.4330/wjc.v6.i9.1022] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/11/2014] [Accepted: 07/15/2014] [Indexed: 02/07/2023] Open
Abstract
Cardiac output (CO) is the volume of blood ejected by each ventricle per minute and is the product of stroke volume and heart rate. CO can thus be manipulated by alteration in heart rate or rhythm, preload, contractility and afterload. Moreover it gives important information about tissue perfusion and oxygen delivery. CO can be measured by various methods and thermodilution method using pulmonary artery catheter (PAC) is till date considered as gold standard method. Complications associated with PAC led to development of newer methods which are minimally or non-invasive. Newer methods fulfil other properties like continuous and reproducible reading, cost effective, reliable during various physiological states and have fast response time. These methods are validated against the gold standard with good level agreement. In this review we have discussed various newer methods of CO monitoring and their effectiveness in clinical use.
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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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Greenfield N, Balk RA. Evaluating the adequacy of fluid resuscitation in patients with septic shock: controversies and future directions. Hosp Pract (1995) 2014; 40:147-57. [PMID: 22615089 DOI: 10.3810/hp.2012.04.980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fluid resuscitation is a cornerstone in the treatment of severe sepsis and septic shock. However, there is little evidence to guide clinicians in its administration. Current guidelines recommend targeting fluid therapy based on measurements of cardiac filling pressures, such as central venous pressure. Static pressures are poor predictors of a patient's response to fluid. Such response can be better predicted by measuring changes in hemodynamic parameters caused by positive pressure ventilation or maneuvers designed to simulate increased preload. These changes can be measured by analysis of arterial waveforms, echocardiography or Doppler, or with emerging noninvasive technologies. This article reviews the current role of fluid replacement strategies and the use of monitoring systems in the overall resuscitation of patients with severe sepsis and septic shock.
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Affiliation(s)
- Neal Greenfield
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Rush Medical College, Chicago, IL
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Abstract
PURPOSE OF REVIEW Advanced hemodynamic monitoring is indispensable for adequate management of patients undergoing major surgery. This article will summarize minimally invasive hemodynamic monitoring technologies and their potential use in thoracic anesthesia. RECENT FINDINGS According to their inherent principle, currently available technologies can be classified into four groups: bioimpedance and bioreactance, applied Fick's principle, pulse wave analysis and Doppler. All devices measure stroke volume and cardiac output. Functional hemodynamic variables and volumetric parameters have been integrated in some devices. Two major indications can be identified: the 'hemodynamically unstable' patient and the patient 'at risk' for hemodynamic instability. Although there is evidence for the first indication, pre-emptive hemodynamic therapy or perioperative hemodynamic optimization for the patient 'at risk' is still an issue of ongoing debate. There is a growing body of evidence that this approach can positively influence patients' outcome with less postoperative complications in selected patient groups. SUMMARY Many different minimally invasive hemodynamic monitoring devices have been developed and clinically introduced in the last years. They offer the advantage of being less invasive and easier to use. However, these techniques have several limitations and data are scarce in patients undergoing thoracic anesthesia, preventing their widespread use so far.
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Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy. ACTA ACUST UNITED AC 2014; 52:77-84. [DOI: 10.1016/j.aat.2014.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/08/2014] [Indexed: 11/23/2022]
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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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Metzelder SM, Coburn M, Stoppe C, Fries M, Simon TP, Reinges MHT, Höllig A, Rossaint R, Marx G, Rex S. Accuracy and precision of calibrated arterial pulse contour analysis in patients with subarachnoid hemorrhage requiring high-dose vasopressor therapy: a prospective observational clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R25. [PMID: 24499533 PMCID: PMC4057342 DOI: 10.1186/cc13715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 01/30/2014] [Indexed: 12/13/2022]
Abstract
Introduction Calibrated arterial pulse contour analysis has become an established method for the continuous monitoring of cardiac output (PCCO). However, data on its validity in hemodynamically instable patients beyond the setting of cardiac surgery are scarce. We performed the present study to assess the validity and precision of PCCO-measurements using the PiCCO™-device compared to transpulmonary thermodilution derived cardiac output (TPCO) as the reference technique in neurosurgical patients requiring high-dose vasopressor-therapy. Methods A total of 20 patients (16 females and 4 males) were included in this prospective observational clinical trial. All of them suffered from subarachnoid hemorrhage (Hunt&Hess grade I-V) due to rupture of a cerebral arterial aneurysm and underwent high-dose vasopressor therapy for the prevention/treatment of delayed cerebral ischemia (DCI). Simultaneous CO measurements by bolus TPCO and PCCO were obtained at baseline as well as 2 h, 6 h, 12 h, 24 h, 48 h and 72 h after inclusion. Results PCCO- and TPCO-measurements were obtained at baseline as well as 2 h, 6 h, 12 h, 24 h, 48 h and 72 h after inclusion. Patients received vasoactive support with (mean ± standard deviation, SD) 0.57 ± 0.49 μg · kg-1 · min-1 norepinephrine resulting in a mean arterial pressure of 103 ± 13 mmHg and a systemic vascular resistance of 943 ± 248 dyn · s · cm-5. 136 CO-data pairs were analyzed. TPCO ranged from 5.2 to 14.3 l · min-1 (mean ± SD 8.5 ± 2.0 l · min-1) and PCCO ranged from 5.0 to 14.4 l · min-1 (mean ± SD 8.6 ± 2.0 l · min-1). Bias and limits of agreement (1.96 SD of the bias) were −0.03 ± 0.82 l · min-1 and 1.62 l · min-1, resulting in an overall percentage error of 18.8%. The precision of PCCO-measurements was 17.8%. Insufficient trending ability was indicated by concordance rates of 74% (exclusion zone of 15% (1.29 l · min-1)) and 67% (without exclusion zone), as well as by polar plot analysis. Conclusions In neurosurgical patients requiring extensive vasoactive support, CO values obtained by calibrated PCCO showed clinically and statistically acceptable agreement with TPCO-measurements, but the results from concordance and polar plot analysis indicate an unreliable trending ability.
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Slagt C, Malagon I, Groeneveld ABJ. Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation. Br J Anaesth 2014; 112:626-37. [PMID: 24431387 DOI: 10.1093/bja/aet429] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
UNLABELLED The FloTrac/Vigileo™, introduced in 2005, uses arterial pressure waveform analysis to calculate cardiac output (CO) and stroke volume variation (SVV) without external calibration. The aim of this systematic review is to evaluate the performance of the system. Sixty-five full manuscripts on validation of CO measurements in humans, published in English, were retrieved; these included 2234 patients and 44,592 observations. RESULTS have been analysed according to underlying patient conditions, that is, general critical illness and surgery as normodynamic conditions, cardiac and (post)cardiac surgery as hypodynamic conditions, and liver surgery and sepsis as hyperdynamic conditions, and subsequently released software versions. Eight studies compared SVV with other dynamic indices. CO, bias, precision, %error, correlation, and concordance differed among underlying conditions, subsequent software versions, and their interactions, suggesting increasing accuracy and precision, particularly in hypo- and normodynamic conditions. The bias and the trending capacity remain dependent on (changes in) vascular tone with most recent software. The SVV only moderately agreed with other dynamic indices, although it was helpful in predicting fluid responsiveness in 85% of studies addressing this. Since its introduction, the performance of uncalibrated FloTrac/Vigileo™ has improved particularly in hypo- and normodynamic conditions. A %error at or below 30% with most recent software allows sufficiently accurate and precise CO measurements and trending for routine clinical use in normo- and hypodynamic conditions, in the absence of large changes in vascular tone. The SVV may usefully supplement these measurements.
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Affiliation(s)
- C Slagt
- Department of Anaesthesiology and Intensive Care, Zaans Medical Centre, Koningin Julianaplein 58, 1502 DV Zaandam, The Netherlands
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Tsai YF, Liu FC, Yu HP. FloTrac/Vigileo system monitoring in acute-care surgery: current and future trends. Expert Rev Med Devices 2014; 10:717-28. [DOI: 10.1586/17434440.2013.844464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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A comparison of noninvasive bioreactance with oesophageal Doppler estimation of stroke volume during open abdominal surgery: an observational study. Eur J Anaesthesiol 2013; 30:501-8. [PMID: 23549128 DOI: 10.1097/eja.0b013e3283603250] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT The anaesthetist must maintain tissue perfusion by ensuring optimal perioperative fluid balance. This can be achieved using less invasive cardiac output monitors such as oesophageal Doppler monitoring (ODM). Other less invasive cardiac output monitors using bio-impedence technology (noninvasive cardiac output monitoring, NICOM) may have a role in monitoring the circulation and informing fluid management decisions. OBJECTIVE To compare estimates of stroke volume from ODM with those from NICOM, a noninvasive monitor using bioreactance, a modification of transthoracic bio-impedence. DESIGN An observational study. SETTING Manchester Royal Infirmary, UK. Data collected in 2011 and 2012. PARTICIPANTS Twenty-two patients scheduled for major, open abdominal surgery. Reasons for noninclusion: atrial fibrillation; heart failure; oesophageal disease; lack of capacity; and known sensitivity to colloid. INTERVENTION All patients had oesophageal Doppler cardiac output monitoring as a standard element of anaesthesia care. We placed NICOM Bioreactance electrodes and recorded stroke volume estimates from both devices. Fluid challenges were given by the anaesthetist and the haemodynamic responses were recorded. MAIN OUTCOME MEASURE Stroke volume during surgery. The Bland-Altman method was used to compare bias and limits of agreement for stroke volume and cardiac output. Fluid responders were defined as patients who increased stroke volume by at least 10% after fluid loading. The precision of each device was calculated during periods of haemodynamic stability. RESULTS We made 788 acceptable measurements of cardiac output. The bias was -6.9 ml and the limits of agreement were -22.9 to 36.8 ml. The percentage error was 57%. Average precision for both the ODM and NICOM were similar, 8.5% (SD 5.4%) and 8.7% (SD 3.2%). The concordance for the stroke volume change following fluid challenge was 90.5%. Both devices produced unacceptable readings with electrical diathermy. CONCLUSION Simultaneous stroke volume estimations made by noninvasive Bioreactance (NICOM) and oesophageal Doppler showed bias and limits of agreement that are not clinically acceptable. The measurements made by these two devices cannot be regarded as interchangeable.
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Suehiro K, Tanaka K, Funao T, Matsuura T, Mori T, Nishikawa K. Systemic vascular resistance has an impact on the reliability of the Vigileo-FloTrac system in measuring cardiac output and tracking cardiac output changes. Br J Anaesth 2013; 111:170-7. [DOI: 10.1093/bja/aet022] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Monge García MI, Romero MG, Cano AG, Rhodes A, Grounds RM, Cecconi M. Impact of arterial load on the agreement between pulse pressure analysis and esophageal Doppler. Crit Care 2013; 17:R113. [PMID: 23787086 PMCID: PMC4056096 DOI: 10.1186/cc12785] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 06/20/2013] [Indexed: 12/03/2022] Open
Abstract
Introduction The reliability of pulse pressure analysis to estimate cardiac output is known to be affected by arterial load changes. However, the contribution of each aspect of arterial load could be substantially different. In this study, we evaluated the agreement of eight non-commercial algorithms of pulse pressure analysis for estimating cardiac output (PPCO) with esophageal Doppler cardiac output (EDCO) during acute changes of arterial load. In addition, we aimed to determine the optimal arterial load parameter that could detect a clinically significant difference between PPCO and the EDCO. Methods We included mechanically ventilated patients monitored with a prototype esophageal Doppler (CardioQ-Combi™, Deltex Medical, Chichester, UK) and an indwelling arterial catheter who received a fluid challenge or in whom the vasoactive medication was introduced or modified. Initial calibration of PPCO was made with the baseline value of EDCO. We evaluated several aspects of arterial load: total systemic vascular resistance (TSVR = mean arterial pressure [MAP]/EDCO * 80), net arterial compliance (C = EDCO-derived stroke volume/pulse pressure), and effective arterial elastance (Ea = 0.9 * systolic blood pressure/EDCO-derived stroke volume). We compared CO values with Bland-Altman analysis, four-quadrant plot and a modified polar plot (with least significant change analysis). Results A total of 16,964-paired measurements in 53 patients were performed (median 271; interquartile range: 180-415). Agreement of all PPCO algorithms with EDCO was significantly affected by changes in arterial load, although the impact was more pronounced during changes in vasopressor therapy. When looking at different parameters of arterial load, the predictive abilities of Ea and C were superior to TSVR and MAP changes to detect a PPCO-EDCO discrepancy ≥ 10% in all PPCO algorithms. An absolute Ea change > 8.9 ± 1.7% was associated with a PPCO-EDCO discrepancy ≥ 10% in most algorithms. Conclusions Changes in arterial load profoundly affected the agreement of PPCO and EDCO, although the contribution of each aspect of arterial load to the PPCO-EDCO discrepancies was significantly different. Changes in Ea and C mainly determined PPCO-EDCO discrepancy.
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Kardiogener Schock. Herz 2013; 38:173-86; quiz 187-8. [DOI: 10.1007/s00059-013-3770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cardiac output monitoring in septic shock: evaluation of the third-generation Flotrac-Vigileo®. J Clin Monit Comput 2013; 27:273-9. [DOI: 10.1007/s10877-013-9431-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/10/2013] [Indexed: 02/03/2023]
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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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Kim HY, Choi YJ, Yu HN, Yoon SZ. Optimal carbon dioxide insufflation pressure during robot-assisted thyroidectomy in patients with various benign and malignant thyroid diseases. World J Surg Oncol 2012; 10:202. [PMID: 23017080 PMCID: PMC3506561 DOI: 10.1186/1477-7819-10-202] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 09/13/2012] [Indexed: 11/10/2022] Open
Abstract
Background Currently, data are not available concerning a safe insufflation pressure that provides a proper view of the surgical field without adverse metabolic and hemodynamic changes in humans undergoing the robot-assisted thyroidectomy bilateral axillo-breast approach (BABA) using the da Vinci robotic surgical system. The purpose of this study was to determine the optimal carbon dioxide (CO2) insufflation pressure in patients with various benign and malignant thyroid diseases when using the da Vinci robotic surgical system. Methods A total of 32 patients underwent thyroid surgery at 6 (n = 15), 9 (n = 15), and 12 (n = 2) mmHg. The partial pressure of carbon dioxide (PaCO2), pH, cardiac output, heart rate, and mean arterial pressure were measured at baseline, 30 min and 1, 1.5, and 2 hours after CO2 insufflation, and 30 min after desufflation. Results CO2 insufflation of 12 mmHg caused severe facial subcutaneous emphysema, hypercarbia, and acidosis during robot-assisted thyroidectomy with BABA. The study was stopped before completion for the patients’ safety in accordance with the study protocol. Applying 6- or 9- mmHg of CO2 insufflation pressure caused increases in PaCO2 and decreases in arterial pH. However, vital signs were stable and pH and PaCO2 were within the physiologic range during the surgery in the 6- and 9-mmHg groups. Conclusions We propose that a CO2 insufflation pressure under 10 mmHg in robot-assisted thyroidectomy with BABA is the optimal insufflation pressure for patient safety.
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Affiliation(s)
- Hoon Yub Kim
- Department of Surgery, College of Medicine, Korea University, Seoul, South Korea
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Bouwman R, Boer C. I. Minimal invasive cardiac output monitoring: get the dose of fluid right. Br J Anaesth 2012; 109:299-302. [DOI: 10.1093/bja/aes277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Muller JC, Kennard JW, Browne JS, Fecher AM, Hayward TZ. Hemodynamic monitoring in the intensive care unit. Nutr Clin Pract 2012; 27:340-51. [PMID: 22593102 DOI: 10.1177/0884533612443562] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients in the intensive care unit are often critically ill with inadequate tissue perfusion and oxygenation. This inadequate delivery of substrates at the cellular level is a common definition of shock. Hemodynamic monitoring is the observation of cardiovascular physiology. The purpose of hemodynamic monitoring is to identify abnormal physiology and intervene before complications, including organ failure and death, occur. The most common types of invasive hemodynamic monitors are central venous catheters, pulmonary artery catheters, and arterial pulse-wave analysis. Ultrasonography is a noninvasive alternative being used in intensive care units for hemodynamic measurements and assessments.
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Affiliation(s)
- Joseph C Muller
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Mutoh T, Ishikawa T, Kobayashi S, Suzuki A, Yasui N. Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after subarachnoid hemorrhage. Surg Neurol Int 2012; 3:99. [PMID: 23061015 PMCID: PMC3463836 DOI: 10.4103/2152-7806.100195] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 07/13/2012] [Indexed: 11/30/2022] Open
Abstract
Background: Monitoring of cardiac output (CO) is important for promising safe approach to goal-directed hemodynamic therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), but is often precluded by the invasiveness and complexity of ongoing monitoring modalities. We examined the clinical utility of less-invasive management using an uncalibrated arterial pressure waveform-derived cardiac output (APCO) monitor with refined algorithm (Third-generation FloTrac/Vigileo, Edwards, Irvine, CA, USA) during hyperdynamic therapy for post-SAH DCI, compared with transpulmonary thermodilution (PiCCO, Pulsion, Munich, Germany) as a reference technique. Methods: Forty-five patients who underwent surgical clipping within 24 h of SAH onset and subsequently developed clinical deterioration attributable to DCI were investigated. Validation of the APCO-derived cardiac index (CI) during dobutamine-induced hyperdynamic therapy was compared with a reference CI analyzed by transpulmonary thermodilution in 20 patients. In a subsequent trial of 48 cases, the overall clinical results from patients managed with each device were compared. Results: The APCO underestimated CI with an overall bias ± SD of 0.33 ± 0.26 L/min/m2 compared with transpulmonary thermodilution, resulting in an error of 14.9%. The trends of CI for both techniques at each dobutamine dose were similar (r2= 0.77; P < 0.0001). No statistically significant differences were observed between the device groups for frequencies of neurological improvement, cerebral infarction, cardiopulmonary complications, or functional outcomes at 3 months. Conclusions: These data suggest that the refined APCO tends to underestimate CI compared with reference transpulmonary thermodilution during hyperdynamic therapy with dobutamine for reversing DCI, but may be acceptable in this select category of patients to obtain comparable clinical results.
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Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, 6-10 Senshu-Kubota-Machi, Akita, Japan
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Abstract
Cardiogenic shock is most commonly a complication of acute myocardial infarction. The ischemic loss of functional myocardium triggers distinct cardiovascular responses which can deteriorate to global pump failure with a mortality rate of more than 50%. Causes of cardiogenic shock beyond myocardial ischemia are very diverse. Decisive management with rapid evaluation, identification of the underlying disease and urgent initiation of supportive measures as well as definitive therapy is of prognostic value. Causal treatment of the cardiac disease is crucial but has to be weighed against the specific surgical circumstances of perioperative patients, particularly concerning anticoagulation, platelet inhibition and bleeding risks. Hemodynamic stabilization is achieved by pharmacological support of myocardial function, control of arrhythmia and volume load. Prevention and intensive care of shock-related multiorgan failure is of pivotal importance in the successful management of cardiogenic shock.
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Affiliation(s)
- S Rasche
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinik Dresden, Deutschland.
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Mahjoub Y, Lakhdari M, Lorne E, Ammenouche N, Levrard M, Airapetian N, Seydi AA, Tinturier F, Dupont H. Assessment of an uncalibrated pressure waveform device's ability to track cardiac output changes due to norepinephrine dose adjustments in patients with septic shock: a comparison with Doppler echocardiography. ACTA ACUST UNITED AC 2012; 31:677-81. [PMID: 22776771 DOI: 10.1016/j.annfar.2012.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 05/14/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The FloTrac Vigileo (FTV) estimates cardiac output (CO) on the basis of an uncalibrated arterial pressure waveform. To assess the ability of the third-generation of FTV (v.3.02) to track changes in CO following norepinephrine dose adjustment in patients with septic shock, we performed a comparative study using Doppler echocardiography (DE). STUDY DESIGN Prospective observational study. PATIENTS We prospectively included 20 mechanically ventilated patients receiving norepinephrine and monitored with the FTV. Five minutes after each change in norepinephrine dose (decided by the attending physician), CO was measured simultaneously with the FTV (CO(FTV)) and DE (CO(DE)). The changes in CO were compared. ROC curves were built to assess the ability of FTV to detect significant changes in CO(DE) of at least 15%. RESULTS Ninety pairs of CO variations measurements were made. The intertechnique correlation coefficient for changes in CO of at least 15% was r=0.59; P=0.0009. The AUC of a ROC curve built to test the FTV's ability to detect a CO(DE) increase of 15% or more was 0.783 (±0.083) (P=0.005). A CO(FTV) threshold value of 15% had a sensitivity of 54% (25-81) and a specificity of 87% (77-94). For a CO(DE) decrease of 15% or more, the ROC curve had an AUC of 0.616 (±0.075) (P=0.12) and a CO(FTV) threshold value of 13% yielded a sensitivity of 53% (27-79) and a specificity of 72% (60-82). CONCLUSIONS The FTV was unable to accurately track changes in CO following norepinephrine dose adjustments in critically ill patients with septic shock.
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Affiliation(s)
- Y Mahjoub
- Unité de réanimation polyvalente, pôle d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex, France.
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Olsen E, Andersen PH, Pfau T. Accuracy and precision of equine gait event detection during walking with limb and trunk mounted inertial sensors. SENSORS (BASEL, SWITZERLAND) 2012; 12:8145-56. [PMID: 22969392 PMCID: PMC3436021 DOI: 10.3390/s120608145] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/04/2012] [Accepted: 06/07/2012] [Indexed: 11/16/2022]
Abstract
The increased variations of temporal gait events when pathology is present are good candidate features for objective diagnostic tests. We hypothesised that the gait events hoof-on/off and stance can be detected accurately and precisely using features from trunk and distal limb-mounted Inertial Measurement Units (IMUs). Four IMUs were mounted on the distal limb and five IMUs were attached to the skin over the dorsal spinous processes at the withers, fourth lumbar vertebrae and sacrum as well as left and right tuber coxae. IMU data were synchronised to a force plate array and a motion capture system. Accuracy (bias) and precision (SD of bias) was calculated to compare force plate and IMU timings for gait events. Data were collected from seven horses. One hundred and twenty three (123) front limb steps were analysed; hoof-on was detected with a bias (SD) of -7 (23) ms, hoof-off with 0.7 (37) ms and front limb stance with -0.02 (37) ms. A total of 119 hind limb steps were analysed; hoof-on was found with a bias (SD) of -4 (25) ms, hoof-off with 6 (21) ms and hind limb stance with 0.2 (28) ms. IMUs mounted on the distal limbs and sacrum can detect gait events accurately and precisely.
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Affiliation(s)
- Emil Olsen
- Department of Large Animal Sciences, Faculty of Health and Medical Science, University of Copenhagen, Hojbakkegaard Alle 5, 2630 Taastrup, Denmark; E-Mail:
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, North Mymms, Hawkshead Road, North Mymms, Herts AL9 7TA, UK; E-Mail:
| | - Pia Haubro Andersen
- Department of Large Animal Sciences, Faculty of Health and Medical Science, University of Copenhagen, Hojbakkegaard Alle 5, 2630 Taastrup, Denmark; E-Mail:
| | - Thilo Pfau
- Department of Veterinary Clinical Sciences, The Royal Veterinary College, North Mymms, Hawkshead Road, North Mymms, Herts AL9 7TA, UK; E-Mail:
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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: 195] [Impact Index Per Article: 16.3] [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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Abstract
PURPOSE OF REVIEW In this review, we describe the basic principles of arterial waveform analysis (AWA) to assess cardiac output (CO) and cardiac preload. The validity of commercially based hemodynamic monitoring systems is discussed, together with their clinical applications and limitations. RECENT FINDINGS Currently, three devices (the FloTrac system, PiCCO monitor, and LiDCO system) are available for measurement of AWA-based CO. In addition, dynamic preload parameters such as stroke volume variation (SVV) and pulse pressure variation (PPV) are determined, which may be useful to predict fluid responsiveness in mechanically ventilated patients. SUMMARY AWA provides a less invasive and easy-to-use alternative for CO measurement. The validity of AWA devices has been verified in a variety of patients and circumstances, but their performance is compromised in the presence of hemodynamic instability, cardiac arrhythmias, or other factors disturbing the arterial pressure waveform. The definitive role of dynamic preload parameters like SVV and PPV is a matter of research. Large trials in which the value of early goal-directed therapy using this technology is studied in relation to outcome are urgently needed.
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Su B, Tsai Y, Chen C, Yu H, Yang M, Lee W, Lin C. Cardiac Output Derived From Arterial Pressure Waveform Analysis in Patients Undergoing Liver Transplantation: Validity of a Third-Generation Device. Transplant Proc 2012; 44:424-8. [DOI: 10.1016/j.transproceed.2011.12.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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