[Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]. / Aktuelle Aspekte der intensivmedizinischen Versorgung bei Schädel-Hirn-Trauma ­ Teil 1.

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.

[Intraoperative clinical application of hemodynamic monitoring in noncardiac surgery patients]. / Intraoperative klinische Anwendung von hämodynamischem Monitoring bei nichtkardiochirurgischen Patient:innen.

The current S1 guidelines on the intraoperative clinical application of hemodynamic monitoring in patients scheduled for noncardiac surgery are presented based on a case report under the aspect of an optimized intraoperative anesthesiological management. The S1 guidelines were developed with the aim of identifying the questions on the intraoperative hemodynamic monitoring and management which are important for the routine daily clinical practice, to discuss them in a guideline group and to answer them based on the current state of scientific knowledge. The guidelines were written under the auspices of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and published by the AWMF in 2023 under the register number 001/049.

The Use of Pressure Recording Analytical Method in Patients Undergoing Endovascular Repair for Abdominal Aortic Aneurysm: The Impact on Clinical Decisions for the Appropriate Postoperative Setting and Cost-effective Analysis.

OBJECTIVE: To analyze the use of the Pressure Recording Analytical Method (PRAM), an hemodynamic monitoring system, in evaluating intraoperative and postoperative hemodynamic instability in patients undergoing endovascular repair for abdominal aortic aneurysm, and to evaluate if the decision to refer patients to a ordinary ward or to a Cardiac Step-Down Unit (CSDU) after the intervention on the basis of intraoperative hemodynamic monitoring could be more cost-effective. MATERIALS AND METHODS: After preoperative clinical evaluation, 44 patients were divided in this non-randomised study into two groups according to their postoperative destination: Group 1-ward (N=22) and Group 2-CSDU (N=22). All patients underwent monitoring with PRAM during the intervention and in the 24 postoperative hours, measuring several indices of myocardial contractility and other hemodynamic variables. RESULTS: According to the variability of two parameters, Stroke Volume Variation and Pulse Pressure Variation, patients were classified as stable or unstable. Unstable patients showed a significant alteration in several hemodynamic indices, in comparison to stable ones. According to the intraoperative monitoring, eight high risk patients could have been sent to an ordinary ward due to their stability, with a reduction in the improper use of CSDU and, consequently, in costs. CONCLUSIONS: Hemodynamic monitoring with PRAM can be useful in these patients, both for intraoperative management and for the choice of the more appropriate postoperative setting, possibly reducing the improper use of CSDU for hemodynamically stable patients who are judged to be at high risk preoperatively, and re-evaluating low surgical risk patients with an unstable intraoperative pattern, with a possible reduction in costs.

Effect of Hemodynamic Monitoring Systems on Short-Term Outcomes after Living Donor Liver Transplantation.

Background and Objectives: To evaluate the effects of the pulse index continuous cardiac output and MostCare Pressure Recording Analytical Method hemodynamic monitoring systems on short-term graft and patient outcomes during living donor liver transplantation in adult patients. Materials and Methods: Overall, 163 adult patients who underwent living donor liver transplantation between January 2018 and March 2022 and met the study inclusion criteria were divided into two groups based on the hemodynamic monitoring systems used during surgery: the MostCare Pressure Recording Analytical Method group (n = 73) and the pulse index continuous cardiac output group (n = 90). The groups were compared with respect to preoperative clinicodemographic features (age, sex, body mass index, graft-to-recipient weight ratio, and Model for End-stage Liver Disease score), intraoperative clinical characteristics, and postoperative biochemical parameters (aspartate aminotransferase, alanine aminotransferase, total bilirubin, direct bilirubin, prothrombin time, international normalized ratio, and platelet count). Results: There were no significant between-group differences with respect to recipient age, sex, body mass index, graft-to-recipient weight ratio, Child, Model for End-stage Liver Disease score, ejection fraction, systolic pulmonary artery pressure, surgery time, anhepatic phase, cold ischemia time, warm ischemia time, erythrocyte suspension use, human albumin use, crystalloid use, urine output, hospital stay, and intensive care unit stay. However, there was a significant difference in fresh frozen plasma use (p < 0.001) and platelet use (p = 0.037). Conclusions: The clinical and biochemical outcomes are not significantly different between pulse index continuous cardiac output and MostCare Pressure Recording Analytical Method as hemodynamic monitoring systems in living donor liver transplantation. However, the MostCare Pressure Recording Analytical Method is more economical and minimally invasive.

Non-invasive prediction of massive transfusion during surgery using intraoperative hemodynamic monitoring data.

OBJECTIVE: Failure to receive prompt blood transfusion leads to severe complications if massive bleeding occurs during surgery. For the timely preparation of blood products, predicting the possibility of massive transfusion (MT) is essential to decrease morbidity and mortality. This study aimed to develop a model for predicting MT 10 min in advance using non-invasive bio-signal waveforms that change in real-time. METHODS: In this retrospective study, we developed a deep learning-based algorithm (DLA) to predict intraoperative MT within 10 min. MT was defined as the transfusion of 3 or more units of red blood cells within an hour. The datasets consisted of 18,135 patients who underwent surgery at Seoul National University Hospital (SNUH) for model development and internal validation and 621 patients who underwent surgery at the Boramae Medical Center (BMC) for external validation. We constructed the DLA by using features extracted from plethysmography (collected at 500 Hz) and hematocrit measured during surgery. RESULTS: Among 18,135 patients in SNUH and 621 patients in BMC, 265 patients (1.46%) and 14 patients (2.25%) received MT during surgery, respectively. The area under the receiver operating characteristic curve (AUROC) of DLA predicting intraoperative MT before 10 min was 0.962 (95% confidence interval [CI], 0.948-0.974) in internal validation and 0.922 (95% CI, 0.882-0.959) in external validation, respectively. CONCLUSION: The DLA can successfully predict intraoperative MT using non-invasive bio-signal waveforms.

Invasive Implanted Hemodynamic Monitoring in Patients With Complex Congenital Heart Disease: State-of-the-Art Review.

As the number of patients with congenital heart disease (CHD) continues to increase, the burden of heart failure (HF) in this population requires innovative strategies to individualize management. Given the success of implanted invasive hemodynamic monitoring (IHM) with the CardioMEMSTM HF system in adults with acquired HF, this is often suggested for use in patients with CHD, though published data are limited to case reports and case series. Therefore, this review summarizes the available published reports on the use of IHM in patients with complex CHD, describes novel applications, and highlights future directions for study. In patients with CHD, IHM has been used across the lifespan, from age 3 years to adulthood, with minimal device-related complications reported. IHM uses include (1) prevention of HF hospitalizations; (2) reassessment of hemodynamics after titration of medical therapy without repeated cardiac catheterization; (3) serial monitoring of at-risk patients for pulmonary hypertension to optimize timing of heart transplant referral; (4) and hemodynamic assessment with exercise (5) or after ventricular assist device placement. IHM has the potential to reduce the number of cardiac catheterizations in anatomically complex patients and, in patients with Fontan circulation, IHM pressures may have prognostic implications. In conclusion, though further studies are needed, as patients with CHD age and HF is more prevalent, this tool may assist CHD physicians in caring for this complex patient population.

Pilot Study to Optimize Goal-directed Hemodynamic Management During Pancreatectomy.

INTRODUCTION: Intraoperative goal-directed hemodynamic therapy (GDHT) is a cornerstone of enhanced recovery protocols. We hypothesized that use of an advanced noninvasive intraoperative hemodynamic monitoring system to guide GDHT may decrease intraoperative hypotension (IOH) and improve perfusion during pancreatic resection. METHODS: The monitor uses machine learning to produce the Hypotension Prediction Index to predict hypotensive episodes. A clinical decision-making algorithm uses the Hypotension Prediction Index and hemodynamic data to guide intraoperative fluid versus pressor management. Pre-implementation (PRE), patients were placed on the monitor and managed per usual. Post-implementation (POST), anesthesia teams were educated on the algorithm and asked to use the GDHT guidelines. Hemodynamic data points were collected every 20 s (8942 PRE and 26,638 POST measurements). We compared IOH (mean arterial pressure <65 mmHg), cardiac index >2, and stroke volume variation <12 between the two groups. RESULTS: 10 patients were in the PRE and 24 in the POST groups. In the POST group, there were fewer minimally invasive resections (4.2% versus 30.0%, P = 0.07), more pancreaticoduodenectomies (75.0% versus 20.0%, P < 0.01), and longer operative times (329.0 + 108.2 min versus 225.1 + 92.8 min, P = 0.01). After implementation, hemodynamic parameters improved. There was a 33.3% reduction in IOH (5.2% ± 0.1% versus 7.8% ± 0.3%, P < 0.01, a 31.6% increase in cardiac index >2.0 (83.7% + 0.2% versus 63.6% + 0.5%, P < 0.01), and a 37.6% increase in stroke volume variation <12 (73.2% + 0.3% versus 53.2% + 0.5%, P < 0.01). CONCLUSIONS: Advanced intraoperative hemodynamic monitoring to predict IOH combined with a clinical decision-making tree for GDHT may improve intraoperative hemodynamic parameters during pancreatectomy. This warrants further investigation in larger studies.

[Tissue perfusion monitoring in children with acute circulatory dysfunction: narrative review]. / Monitorización de la perfusión tisular en el niño con disfunción circulatoria aguda: revisión narrativa.

Sepsis is one of the main causes of admission to Intensive Care Units (ICU). The hemodynamic objectives usually sought during the resuscitation of the patient in septic shock correspond to macrohemodynamic parameters (heart rate, blood pressure, central venous pressure). However, persistent alterations in microcirculation, despite the restoration of macrohemodynamic parameters, can cause organ failure. This dissociation between the macrocirculation and microcirculation originates the need to evaluate organ tissue perfusion, the most commonly used being urinary output, lactatemia, central venous oxygen saturation (ScvO2), and veno-arterial pCO2 gap. Because peripheral tissues, such as the skin, are sensitive to disturbances in perfusion, noninvasive monitoring of peripheral circulation, such as skin temperature gradient, capillary refill time, mottling score, and peripheral perfusion index may be helpful as early markers of the existence of systemic hemodynamic alterations. Peripheral circulation monitoring techniques are relatively easy to interpret and can be used directly at the patient's bedside. This approach can be quickly applied in the intra- or extra-ICU setting. The objective of this narrative review is to analyze the various existing tissue perfusion markers and to update the evidence that allows guiding hemodynamic support in a more individualized therapy for each patient.

Cost-effectiveness of remote haemodynamic monitoring by an implantable pulmonary artery pressure monitoring sensor (CardioMEMS-HF system) in chronic heart failure in the Netherlands.

AIMS: Remote haemodynamic monitoring with an implantable pulmonary artery (PA) sensor has been shown to reduce heart failure (HF) hospitalizations and improve quality of life. Cost-effectiveness analyses studying the value of remote haemodynamic monitoring in a European healthcare system with a contemporary standard care group are lacking. METHODS AND RESULTS: A Markov model was developed to estimate the cost-effectiveness of PA-guided therapy compared to the standard of care based upon patient-level data of the MONITOR-HF trial performed in the Netherlands in patients with chronic HF (New York Heart Association class III and at least one previous HF hospitalization). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained from the Dutch societal perspective with a lifetime horizon which encompasses a wide variety of costs including costs of hospitalizations, monitoring time, telephone contacts, laboratory assessments, and drug changes in both treatment groups. In the base-case analysis, PA-guided therapy increased costs compared to standard of care by €12 121. The QALYs per patient for PA-guided therapy and standard of care was 4.07 and 3.481, respectively, reflecting a gain of 0.58 QALYs. The resulting incremental cost-effectiveness ratio was €20 753 per QALY, which is below the Dutch willingness-to-pay threshold of €50 000 per QALY gained for HF. CONCLUSIONS: The current cost-effectiveness study suggests that remote haemodynamic monitoring with PA-guided therapy on top of standard care is likely to be cost-effective for patients with symptomatic moderate-to-severe HF in the Netherlands.

Hemodynamic Bedside Monitoring Instrument with Pressure and Optical Sensors: Validation and Modality Comparison.

Results from two independent clinical validation studies for measuring hemodynamics at the patient's bedside using a compact finger probe are reported. Technology comprises a barometric pressure sensor, and in one implementation, additionally, an optical sensor for photoplethysmography (PPG) is developed, which can be used to measure blood pressure and analyze rhythm, including the continuous detection of atrial fibrillation. The capabilities of the technology are shown in several form factors, including a miniaturized version resembling a common pulse oximeter to which the technology could be integrated in. Several main results are presented: i) the miniature finger probe meets the accuracy requirements of non-invasive blood pressure instrument validation standard, ii) atrial fibrillation can be detected during the blood pressure measurement and in a continuous recording, iii) a unique comparison between optical and pressure sensing mechanisms is provided, which shows that the origin of both modalities can be explained using a pressure-volume model and that recordings are close to identical between the sensors. The benefits and limitations of both modalities in hemodynamic monitoring are further discussed.

Non-Invasive Hemodynamic Monitoring System Integrating Spectrometry, Photoplethysmography, and Arterial Pressure Measurement Capabilities.

Minimally invasive and non-invasive hemodynamic monitoring technologies have recently gained more attention, driven by technological advances and the inherent risk of complications in invasive techniques. In this article, an experimental non-invasive system is presented that effectively combines the capabilities of spectrometry, photoplethysmography (PPG), and arterial pressure measurement. Both time- and wavelength-resolved optical signals from the fingertip are measured under external pressure, which gradually increased above the level of systolic blood pressure. The optical channels measured at 434-731 nm divided into three groups separated by a group of channels with wavelengths approximately between 590 and 630 nm. This group of channels, labeled transition band, is characterized by abrupt changes resulting from a decrease in the absorption coefficient of whole blood. External pressure levels of maximum pulsation showed that shorter wavelengths (<590 nm) probe superficial low-pressure blood vessels, whereas longer wavelengths (>630 nm) probe high-pressure arteries. The results on perfusion indices and DC component level changes showed clear differences between the optical channels, further highlighting the importance of wavelength selection in optical hemodynamic monitoring systems. Altogether, the results demonstrated that the integrated system presented has the potential to extract new hemodynamic information simultaneously from macrocirculation to microcirculation.

Haemodynamic monitoring during noncardiac surgery: past, present, and future.

During surgery, various haemodynamic variables are monitored and optimised to maintain organ perfusion pressure and oxygen delivery - and to eventually improve outcomes. Important haemodynamic variables that provide an understanding of most pathophysiologic haemodynamic conditions during surgery include heart rate, arterial pressure, central venous pressure, pulse pressure variation/stroke volume variation, stroke volume, and cardiac output. A basic physiologic and pathophysiologic understanding of these haemodynamic variables and the corresponding monitoring methods is essential. We therefore revisit the pathophysiologic rationale for intraoperative monitoring of haemodynamic variables, describe the history, current use, and future technological developments of monitoring methods, and finally briefly summarise the evidence that haemodynamic management can improve patient-centred outcomes.

Assessing the impact of haemodynamic monitoring with CardioMEMS on heart failure patients: a cost-benefit analysis.

AIMS: The objective of this study was to perform a cost-benefit analysis of the CardioMEMS HF System (Abbott Laboratories, Abbott Park, IL, USA) in a heart failure (HF) clinic in Spain by evaluating the real-time remote monitoring of pulmonary artery pressures, which has been shown to reduce HF-related hospitalizations and improve the quality of life for selected HF patients. Particularly, the study aimed to determine the value of CardioMEMS in Southern Europe, where healthcare costs are significantly lower and its effectiveness remains uncertain. METHODS AND RESULTS: This single-centre study enrolled all consecutive HF patients (N = 43) who had been implanted with a pulmonary artery pressure sensor (CardioMEMS HF System); 48.8% were females, aged 75.5 ± 7.0 years, with both reduced and preserved left ventricular ejection fraction; 67.4% of them were in New York Heart Association Class III. The number of HF hospitalizations in the year before and the year after the sensor implantation was compared. Quality-adjusted life years gained based on a literature review of previous studies were calculated. The rate of HF hospitalizations was significantly lower at 1 year compared with the year before CardioMEMS implantation (0.25 vs. 1.10 events/patient-year, hazard ratio 0.22, P = 0.001). At the end of the first year, the usual management outperformed the CardioMEMS HF System. By the end of the second year, the CardioMEMS system is estimated to reduce costs compared with usual management (net benefits of €346). CONCLUSIONS: Based on the results, we suggest that remote monitoring of pulmonary artery pressure with the CardioMEMS HF System represents a midterm and long-term efficient strategy in a healthcare setting in Southern Europe.

Echocardiographic haemodynamic monitoring in the context of HeartMate 3™ therapy: a systematic review.

AIMS: While echocardiography remains essential within haemodynamic monitoring of durable mechanical circulatory support, previous echocardiographic guidelines are missing scientific evidence for the novel HeartMate 3™ (HM3) system. Accordingly, this review aims to summarize available echocardiographic evidence including HM3. METHODS AND RESULTS: This systematic review adhered to the PRISMA 2020 guidelines. Searches were conducted during August 2023 across PubMed, Embase, and Google Scholar using specific echocardiographic terms combined with system identifiers. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies and Critical Appraisal Instrument (PCAI) for cross-sectional studies. Nine studies met the inclusion criteria, of which eight cohort studies and one cross-sectional study. Aortic regurgitation (AR) prevalence at approximately 12 months of support exhibited heterogenicity (33.5% (Δ 33%)) in a limited number of studies (n = 3). Several studies (n = 5) demonstrated an increasing prevalence and severity of AR during HM3 support, generating moderate to high level of evidence. One AR study showed a higher cumulative incidence of death and heart failure (HF) readmission compared with those without significant AR, hazard ratio 3.42 (95% CI 1.48-8.76). A second study showed that a worsening AR group had significantly lower survival-free from HF readmission (59% vs. 89%, P = 0.023) with a hazard ratio of 5.18 (95% CI 1.07-25.0), while a third study did not reveal any differences in cardiac-related hospitalizations in the 12 months follow-up or non-cardiac-related hospitalization. Mitral regurgitation (MR) prevalence at approximately 12 months of support exhibited good consistency 15.0% (Δ 0.8%) in both included studies, which did not reveal any significant pattern of changing prevalence over time. Tricuspid regurgitation (TR) prevalence at approximately 12 months of support exhibited fair consistency 28.5% (Δ 8.3%) in a limited number of studies (n = 2); both studies showed a statistically un-confirmed trend of increased TR prevalence over time. The evidence of general prevalence of right ventricular dysfunction (RVD) was insufficient due to lack of studies. CONCLUSIONS: There are few methodologically consistent studies with focus on long-term haemodynamic effects. Aortic regurgitation still seems to be a prevalent and potentially significant finding. The available evidence concerning right heart function is limited despite clinical relevance and potential prognostic value. Potential interventricular and haemodynamic interplay are identified as a white field for future research.

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Prehospital invasive arterial blood pressure monitoring in critically ill patients attended by a UK helicopter emergency medical service- a retrospective observational review of practice.

BACKGROUND: Accurate haemodynamic monitoring in the prehospital setting is essential. Non-invasive blood pressure measurement is susceptible to vibration and motion artefact, especially at extremes of hypotension and hypertension: invasive arterial blood pressure (IABP) monitoring is a potential solution. This study describes the largest series to date of cases of IABP monitoring being initiated prehospital. METHODS: This retrospective observational study was conducted at East Anglian Air Ambulance (EAAA), a UK helicopter emergency medical service (HEMS). It included all patients attended by EAAA who underwent arterial catheterisation and initiation of IABP monitoring between 1st February 2015 and 20th April 2023. The following data were retrieved for all patients: sex; age; aetiology (medical cardiac arrest, other medical emergency, trauma); site of arterial cannulation; operator role (doctor/paramedic); time of insertion and, where applicable, times of pre-hospital emergency anaesthesia, and return of spontaneous circulation following cardiac arrest. Descriptive analyses were performed to characterise the sample. RESULTS: 13,556 patients were attended: IABP monitoring was initiated in 1083 (8.0%) cases, with a median age 59 years, of which 70.8% were male. 546 cases were of medical cardiac arrest: in 22.4% of these IABP monitoring was initiated during cardiopulmonary resuscitation. 322 were trauma cases, and the remaining 215 were medical emergencies. The patients were critically unwell: 981 required intubation, of which 789 underwent prehospital emergency anaesthesia; 609 received vasoactive medication. In 424 cases IABP monitoring was instituted en route to hospital. CONCLUSION: This study describes over 1000 cases of prehospital arterial catheterisation and IABP monitoring in a UK HEMS system and has demonstrated feasibility at scale. The high-fidelity of invasive arterial blood pressure monitoring with the additional benefit of arterial blood gas analysis presents an attractive translation of in-hospital critical care to the prehospital setting.