[Hemodynamic monitoring in the critically patient. Recomendations of the Cardiological Intensive Care and CPR Working Group of the Spanish Society of Intensive Care and Coronary Units]

Hemodynamic monitoring offers valuable information on cardiovascular performance in the critically ill, and has become a fundamental tool in the diagnostic approach and in the therapy guidance of those patients presenting with tissue hypoperfusion. From introduction of the pulmonary artery catheter to the latest less invasive technologies, hemodynamic monitoring has been surrounded by many questions regarding its usefulness and its ultimate impact on patient prognosis. The Cardiological Intensive Care and CPR Working Group (GTCIC-RCP) of the Spanish Society of Intensive Care and Coronary Units (SEMICYUC) has recently impulsed the development of an updating series in hemodynamic monitoring. Now, a final series of recommendations are presented in order to analyze essential issues in hemodynamics, with the purpose of becoming a useful tool for residents and critical care practitioners involved in the daily management of critically ill patients.

[Bronchoalveolar lavage for diagnosing pneumonia in mechanically ventilated patients]

OBJECTIVE

To evaluate the diagnostic role of bronchoalveolar lavage (BAL) in mechanically ventilated patients with suspected pneumonia and to describe the clinical outcome in the different kinds of pneumonia in critically ill patients.

DESIGN

Descriptive study.

SETTING

A 17-bed medical and surgical intensive care unit.

PATIENTS

Mechanically ventilated patients admitted to the ICU from November 2003 to March 2006 with suspected pneumonia who underwent bronchoscopy with BAL.

INTERVENTIONS

BAL was performed by fiberoptic bronchoscopy with three aliquots of 50 ml sterile normal saline. Recovered BAL fluid was pro-cessed for microbiologic analysis.

MAIN VARIABLES OF INTEREST

Age, APACHE II score within the first 24 hours of admission, time on mechanical ventilation, ICU length of stay, mortality, and isolated bacteria were analyzed.

RESULTS

A total of 96 cases of suspected pneumonia with BAL were recruited, including 4 groups: community associated pneumonia (CAP), 12 cases, early-onset ventilator-associated pneumonia (VAP), 26 cases, late-onset ventilator-associated pneumonia, 43 cases, and immunocompromised patients, 15 cases. BAL was positive (> 10000 ufc/ml) in 40 (41.7%) patients (2, 16, 17 and 5 patients with CAP, early-onset VAP, late-onset VAP and immunocompromised, respectively). Mortality was 33.3%, 26.9%, 25.6% and 73.3% in CAP, early-onset VAP, late-onset VAP and immunocompromised patients respectively.

CONCLUSIONS

The low incidence of positive BAL in the CAP group supports using BAL only for particularly severe, selected cases. Mortality was very high in the immunocompromised patients. In the light of our personal experience, BAL is most useful in the diagnosis of pneumonia in the group of patients with VAP.

[Minimally invasive hemodynamic monitoring with esophageal echoDoppler]

Hemodynamic monitoring is a key element in the care of the critical patients, providing an unquestionable aid in the attendance to diagnosis and the choice of the adequate treatment. Minimally invasive devices have been emerging over the past few years as an effective alternative to classic monitoring tools. The esophageal echoDoppler is among these. It makes it possible to obtain continuous and minimally invasive monitoring of the cardiac output in addition to other useful parameters by measuring the blood flow rate and the diameter of the thoracic descending aorta, which provides a sufficiently extensive view of the hemodynamic state of the patient and facilitates early detection of the changes produced by a sudden clinical derangement. Although several studies have demonstrated the usefulness of the esophageal Doppler in the surgical scene, there is scarce and dispersed evidence in the literature on its benefits in critical patients. Nevertheless, its advantages make it an attractive element to take into account within the diagnostic arsenal in the intensive care. The purpose of the following article is to describe how it works, its degree of validation with other monitoring methods and the role of esophageal echoDoppler as a minimally invasive monitoring tool for measuring cardiac output in the daily clinical practice, contributing with our own experience in the critical patient.