Non-invasive continuous arterial pressure monitoring with Nexfin does not sufficiently replace invasive measurements in critically ill patients.

BACKGROUND: In this study, we tested the reliability of a non-invasive finger-cuff-based continuous arterial blood pressure monitoring device (Nexfin, BMEYE, Amsterdam, NL) in critically ill surgical patients. METHODS: Invasive intra-arterial and non-invasive arterial pressure measurements from 25 patients during a 4-h period were compared at five time points. Correlation and linear regression analysis were used and mean bias, precision [sd of bias] and limits of agreement (LOA) [bias (2.0 sd)] were calculated using the Bland-Altman method. RESULTS: Eight data pairs were excluded because of error message from the non-invasive technique, and thus a total of 117 data pairs were analysed. Overall, correlation between mean arterial pressure (MAP) was r(2)=0.50. Bias, precision, and LOA between invasive and non-invasive MAP were 6 (12) and -18 to +30 mm Hg. In patients requiring norepinephrine (83 data pairs), correlation was r(2)=0.28 and bias, precision, and LOA were 6 (13) and -20 to +32 mm Hg, whereas in patients not receiving norepinephrine (34 data pairs) r(2) was 0.80 and mean bias, precision, and LOA were 6 (11) and -16 to +28 mm Hg. In patients with peripheral oedema (49 data pairs), r(2) was 0.40 and mean bias, precision and LOA were 7 (15) and -23 to +37 mm Hg. In patients without oedema (64 data pairs), r(2) was 0.66 and mean bias, precision, and LOA were 5 (9) and -13 to +23 mm Hg. CONCLUSIONS: Non-invasive blood pressure monitoring with Nexfin does not seem to be sufficiently accurate to replace intra-arterial invasive blood pressure measurements in critically ill patients.

[Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry]. / Anästhesiologisches Management bei operativen Eingriffen am Thorax ­ eine Auswertung aus dem Deutschen Thoraxregister.

BACKGROUND: While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions. MATERIAL AND METHODS: The German Thoracic Registry recorded 4614 patients in 5 institutions between 2016 and 2019. Hospitals with a minimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, a matching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ2-test. RESULTS: The study enrolled patients with a median age of 65.6 years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (group A = 77.5%, group B = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of a vasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). A central venous catheter was established in 30.1% of all patients in group A, 39.8% in group B and 73.3% in group C. Patients in group A received an arterial catheter less frequently (71.7%) when compared to groups B (96.4%) and C (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, group B 61.6%, group C 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or a single infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to a general ward underwent less invasive thoracic procedures (group A). When the extent of resection was greater (group B and group C) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function. CONCLUSION: Our data indicate that less invasive thoracic operations are associated with a reduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

Comparison of PulsioFlex® uncalibrated pulse contour method and a modified Fick principle with transpulmonary thermodilution measurements in critically ill patients.

Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20-86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC-derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2 as mean±standard deviation. At baseline CITPTD was 3.7±0.7, CIPC 3.8±0.7 and CIFICK 5.2±1.8. After 4 hours, CITPTD was 3.5±0.6, CIPC 3.8±1.2 and CIFICK 4.8±1.7. Mean bias for PC at baseline was -0.1 (limits of agreement [LOA] -1.4 to 1.2) and -0.4 (LOA -2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of -1.5 (LOA -4.8 to 1.8, PE 74%) at baseline and -1.5 (LOA -4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA±57°) for PC and 16° (radial LOA±51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.

Severe sepsis caused by a linezolid-resistant Enterococcus faecium in a 10-year-old girl after multiple trauma.

While infections caused by Enterococcus faecium resistant to vancomycin (VRE) are increasing, linezolid-resistant strains are still rare. We present the case of a 10-year-old girl with severe sepsis caused by a linezolid-resistant E. faecium (Van-B VRE) after multiple trauma and right-sided hemipelvectomy. The off-label use of a targeted antimicrobial therapy with daptomycin (350 mg/day; approximately 8 mg/kg) for 17 days resulted in rapid normalization of infection parameters and improved clinical status. No side effects were observed and the patient was successfully discharged from the intensive care unit.