Advanced hemodynamic monitoring in intensive care medicine : A German web-based survey study.

BACKGROUND: Advanced hemodynamic monitoring is recommended in patients with complex circulatory shock. OBJECTIVES: To evaluate the current attitudes and beliefs among German intensivists, regarding advanced hemodynamic monitoring, the actual hemodynamic management in clinical practice, and the barriers to using it. MATERIALS AND METHODS: Web-based survey among members of the German Society of Medical Intensive Care and Emergency Medicine. RESULTS: Of 284 respondents, 249 (87%) agreed that further hemodynamic assessment is needed to determine the type of circulatory shock if no clear clinical diagnosis can be made. In all, 281 (99%) agreed that echocardiography is helpful for this purpose (transpulmonary thermodilution: 225 [79%]; pulmonary artery catheterization: 126 [45%]). More than 70% of respondents agreed that blood flow variables (cardiac output, stroke volume) should be measured in patients with hemodynamic instability. The parameters most respondents agreed should be assessed in a patient with hemodynamic instability were mean arterial pressure, cardiac output, and serum lactate. Echocardiography is available in 99% of ICUs (transpulmonary thermodilution: 91%; pulmonary artery catheter: 63%). The respondents stated that, in clinical practice, invasive arterial pressure measurements and serum lactate measurements are performed in more than 90% of patients with hemodynamic instability (cardiac output monitoring in about 50%; transpulmonary thermodilution in about 40%). The respondents did not feel strong barriers to the use of advanced hemodynamic monitoring in clinical practice. CONCLUSIONS: This survey study shows that German intensivists deem advanced hemodynamic assessment necessary for the differential diagnosis of circulatory shock and to guide therapy with fluids, vasopressors, and inotropes in ICU patients.

Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia.

BACKGROUND: We hypothesized that different phases of intraoperative hypotension should be differentiated because of different underlying causative mechanisms. We defined post-induction hypotension (PIH; i.e. arterial hypotension occurring during the first 20 min after anaesthesia induction) and early intraoperative hypotension (eIOH; i.e. arterial hypotension during the first 30 min of surgery). METHODS: In this retrospective study, we included 2037 adult patients who underwent general anaesthesia. Arterial hypotension was defined as a systolic arterial blood pressure (SAP) <90 mm Hg or a need for norepinephrine infusion at > 6 µg min -1 at least once during the phases of PIH and eIOH. Multivariate logistic regression analysis was used to test for association of clinical factors with PIH and eIOH. RESULTS: Independent variables significantly related to PIH were pre-induction SAP [odds ratio (OR) 0.97 (95% confidence interval 0.97-0.98)], age [OR 1.03 (1.02-1.04)], and emergency surgery [OR 1.75 (1.20-2.56); P <0.01 each]. Pre-induction SAP [OR 0.99 (0.98-0.99), P <0.01], age [OR 1.02 (1.02-1.03), P <0.01], emergency surgery [OR 1.83 (1.28-2.62), P <0.01], supplementary administration of spinal or epidural anaesthetic techniques [OR 3.57 (2.41-5.29), P <0.01], male sex [OR 1.41 (1.12-1.79), P <0.01], and ASA physical status IV [OR 2.18 (1.19-3.99), P =0.01] were significantly related to eIOH. CONCLUSIONS: We identified clinical factors associated with PIH and eIOH. The use of these factors to estimate the risk of PIH and eIOH might allow the avoidance or timely treatment of hypotensive episodes during general anaesthesia.