Two Methods of Hemodynamic and Volume Status Assessment in Critically Ill Patients: A Study of Disagreement.

INTRODUCTION: The invasive nature and potential complications associated with pulmonary artery (PA) catheters (PACs) have prompted the pursuit of less invasive monitoring options. Before implementing new hemodynamic monitoring technologies, it is important to determine the interchangeability of these modalities. This study examines monitoring concordance between the PAC and the arterial waveform analysis (AWA) hemodynamic monitoring system. METHODS: Critically ill patients undergoing hemodynamic monitoring with PAC were simultaneously equipped with the FloTrac AWA system (both from Edwards Lifesciences, Irvine, California). Data were concomitantly obtained for hemodynamic variables. Bland-Altman methodology was used to assess CO measurement bias and κ coefficent to show discrepancies in intravascular volume. RESULTS: Significant measurement bias was observed in both CO and intravascular volume status between the 2 techniques (mean bias, -1.055 ± 0.263 liter/min, r = 0.481). There was near-complete lack of agreement regarding the need for intravenous volume administration (κ = 0.019) or the need for vasoactive agent administration (κ = 0.015). CONCLUSIONS: The lack of concordance between PAC and AWA in critically ill surgical patients undergoing active resuscitation raises doubts regarding the interchangeability and relative accuracy of these modalities in clinical use. Lack of awareness of these limitations can lead to errors in clinical decision making when managing critically ill patients.

Thoracostomy tubes: A comprehensive review of complications and related topics.

Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.

Obesity in trauma patients: correlations of body mass index with outcomes, injury patterns, and complications.

Current understanding of the effects of obesity on trauma patients is incomplete. We hypothesized that among older trauma patients, obese patients differ from nonobese patients in injury patterns, complications, and mortality. Patients older than 45 years old presenting to a Level I trauma center were included in this retrospective database analysis (n = 461). Body mass index (BMI) groups were defined as underweight less than 18.5 kg/m(2), normal 18.5 to 24.9 kg/m(2), overweight 25.0 to 29.9 kg/m(2), or obese greater than 30 kg/m(2). Injury patterns, complications, and outcomes were analyzed using univariate analyses, multivariate logistic regression, and Kaplan-Meier survival analysis. Higher BMI is associated with a higher incidence of torso injury and proximal upper extremity injuries in blunt trauma (n = 410). All other injury patterns and complications (except anemia) were similar between BMI groups. The underweight (BMI less than 18.5 kg/m(2)) group had significantly lower 90-day survival than other groups (P < 0.05). BMI is not a predictor of morbidity or mortality in multivariate analysis. Among older blunt trauma patients, increasing BMI is associated with higher rates of torso and proximal upper extremity injuries. Our study suggests that obesity is not an independent risk factor for complications or mortality after trauma in older patients. Conversely, underweight trauma patients had a lower 90-day survival.

Atrial fibrillation after esophagectomy: an indicator of postoperative morbidity.

PURPOSE: The relevance of new-onset atrial fibrillation (AF) after esophagectomy remains poorly defined. This study's primary goal is to better define the incidence, clinical patterns, and outcomes associated with the development of AF after esophagectomy. METHODS: The study is a retrospective review of patients undergoing esophagectomy at a single academic center between May 1996 and December 2007. Patients with new-onset AF were evaluated by univariate and multivariate analyses for risk factors associated with AF onset and outcomes. RESULTS: New-onset AF was noted in 32 of 156 (20.5%) patients after esophagectomy. Most (16/32, 50%) developed AF within 48 h, and 28 of 32 (87.5%) developed new AF within 72 h of surgery. Pulmonary complications were more frequent in patients with AF than those without AF (59.4% vs. 15.3%, P < 0.01) and usually immediately preceded or occurred concurrently with AF. Anastomotic leaks were significantly more common in patients with AF than those without (28.1% vs. 6.45%, P < 0.01) and were identified, on average, 4.2 days after the onset of AF. In the multivariate analysis, anastomotic leaks, pulmonary complications, and number of complications were significantly associated with AF. Although 60-day survival was worse for patients developing AF (P < 0.01), multivariate analysis suggests that non-AF complications were the independent predictor of mortality. CONCLUSION: New-onset AF after esophagectomy is associated with anastomotic leaks, pulmonary complications, and decreased 60-day survival. Although pulmonary complications typically occurred coincident with the onset of AF, anastomotic leaks were usually diagnosed 4 days after AF onset. New postesophagectomy AF should prompt vigilance for the presence of other concurrent complications.