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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.
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Monitorización Hemodinámica , Trasplante de Hígado , Donadores Vivos , Humanos , Trasplante de Hígado/métodos , Masculino , Femenino , Donadores Vivos/estadística & datos numéricos , Persona de Mediana Edad , Adulto , Monitorización Hemodinámica/métodos , Monitorización Hemodinámica/estadística & datos numéricos , Gasto Cardíaco/fisiología , Hemodinámica/fisiología , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Background There is increasing utilization of cardiogenic shock treatment algorithms. The cornerstone of these algorithms is the use of invasive hemodynamic monitoring (IHM). We sought to compare the in-hospital outcomes in patients who received IHM versus no IHM in a real-world contemporary database. Methods and Results Patients with cardiogenic shock admitted during October 1, 2015 to December 31, 2018, were identified from the National Inpatient Sample. Among this group, we compared the outcomes among patients who received IHM versus no IHM. The primary end point was in-hospital mortality. Secondary end points included vascular complications, major bleeding, need for renal replacement therapy, length of stay, cost of hospitalization, and rate of utilization of left ventricular assist devices and heart transplantation. Propensity score matching was used for covariate adjustment. A total of 394 635 (IHM=62 565; no IHM=332 070) patients were included. After propensity score matching, 2 well-matched groups were compared (IHM=62 220; no IHM=62 220). The IHM group had lower in-hospital mortality (24.1% versus 30.6%, P<0.01), higher percentages of left ventricular assist devices (4.4% versus 1.3%, P<0.01) and heart transplantation (1.3% versus 0.7%, P<0.01) utilization, longer length of hospitalization and higher costs. There was no difference between the 2 groups in terms of vascular complications, major bleeding, and the need for renal replacement therapy. Conclusions Among patients with cardiogenic shock, the use of IHM is associated with a reduction in in-hospital mortality and increased utilization of advanced heart failure therapies. Due to the observational nature of the current study, the results should be considered hypothesis-generating, and future prospective studies confirming these findings are needed.
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Monitorización Hemodinámica , Mortalidad Hospitalaria , Choque Cardiogénico , Monitorización Hemodinámica/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Humanos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapiaAsunto(s)
Hemodinámica/fisiología , Oxígeno/análisis , Intercambio Gaseoso Pulmonar/fisiología , Anciano , Anciano de 80 o más Años , Catéteres Venosos Centrales/estadística & datos numéricos , Estudios de Cohortes , Femenino , Monitorización Hemodinámica/métodos , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Sustitutos del Plasma , Estudios Prospectivos , Respiración Artificial/métodos , Respiración Artificial/estadística & datos numéricosRESUMEN
BACKGROUND: The aim of this study was to compare the occurrence of postoperative complications in patients undergoing elective open abdominal surgery and receiving intraoperative goal-directed hemodynamic therapy or restrictive normovolemic therapy. METHODS: A total of 401 patients were randomized in the goal-directed hemodynamic therapy or restrictive normovolemic therapy groups. A cardiac output monitor was used in all goal-directed hemodynamic therapy patients and was left at the discretion of anesthetists in charge of patients in the restrictive normovolemic therapy group. The primary outcome was a composite morbidity endpoint (30-day mortality and complications grade 2-4 according to Dindo-Clavien classification). Secondary outcomes were the hospital duration of stay, the incidence of pulmonary, cardiovascular, and renal complications up to 30 days after surgery, and midterm survival. RESULTS: Intraoperatively, the goal-directed hemodynamic therapy group received higher intravenous fluid volumes (mean of 10.8 mL/kg/h and standard deviation of 4.0) compared with the restrictive normovolemic therapy group (mean of 7.2 mL/kg/h and standard deviation of 2.0; P < .001). On the first postoperative day, similar fluid volumes were infused in the 2 groups. The primary outcome occurred in 57.7% of goal-directed hemodynamic therapy and 53.0% of restrictive normovolemic therapy (relative risk, 1.09 [95% confidence interval, 0.91-1.30]), and there was no significant difference between groups for any secondary outcomes. CONCLUSION: Among patients undergoing major open abdominal surgery, the goal-directed hemodynamic therapy and the restrictive normovolemic therapy were associated with similar incidence of moderate-to-severe postoperative complications and hospital resource use.
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Monitorización Hemodinámica/estadística & datos numéricos , Laparotomía/estadística & datos numéricos , Anciano , Anestesia General , Femenino , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangreRESUMEN
Major hemodynamic changes are frequently noted during liver transplantation (LT). We evaluated the performance of electrical velocimetry (EV) as compared to that of TEE in SV optimization during liver transplantation. This was an observational study in 32 patients undergoing LT. We compared SV values measured simultaneously by EV (SVEV) and TEE (SVTEE) at baseline 30 min after induction, at the end of dissection phase, 30 min after anhepatic phase, 30 min after reperfusion. We also evaluated the reliability of EV to track changes In SV before and after 49 fluid challenges. Finally, the SV variation (SVV) and pulse pressure variation (PPV) were tested as predictors for volume responsiveness, defined as an increase in SV ≥ 10% after 250 ml of colloid. For 112 paired SV data, the overall correlation was 0.76 and bias (limits of agreement) 0.3 (- 29 to 29) ml percentage error 62%. The EV was able to track changes in SV with a concordance rate of 97%, and a sensitivity and specificity of 93% to detect a positive fluid challenge. The AUC values (with 95% confidence intervals) for SVV and PPV were 0.68 (0.52-0.83) and 0.72 (0.57-0.86), respectively, indicating low predictive capacity in these setting. The absolute values of SV derived from EV did not agree with SV derived from TEE. However, EV was able to track the direction of changes in SV during hemodynamic management of patients undergoing liver transplantation.Clinical trial registration: Clinicaltrials.gov Identifier: NCT03228329 prospectively Registered on 13-July-2017.
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Monitorización Hemodinámica/métodos , Trasplante de Hígado , Monitoreo Intraoperatorio/métodos , Resucitación , Reología/métodos , Adulto , Cardiografía de Impedancia/métodos , Cardiografía de Impedancia/estadística & datos numéricos , Ecocardiografía Transesofágica , Femenino , Fluidoterapia , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/estadística & datos numéricos , Estudios Prospectivos , Reología/estadística & datos numéricos , Volumen SistólicoAsunto(s)
Presión Sanguínea/fisiología , Procedimientos Quirúrgicos Cardíacos , Monitorización Hemodinámica/estadística & datos numéricos , Monitoreo Intraoperatorio/estadística & datos numéricos , Análisis de Varianza , Toma de Decisiones Asistida por Computador , Fluidoterapia , Humanos , Aplicaciones Móviles , Análisis de la Onda del Pulso/estadística & datos numéricos , Teléfono Inteligente , Volumen Sistólico/fisiologíaRESUMEN
Evaluation of a new Windkessel model based pulse contour method (WKflow) to calculate stroke volume in patients undergoing intra-aortic balloon pumping (IABP). Preload changes were induced by vena cava occlusions (VCO) in twelve patients undergoing cardiac surgery to vary stroke volume (SV), which was measured by left ventricular conductance volume method (SVlv) and WKflow (SVwf). Twelve VCO series were carried out during IABP assist at a 1:2 ratio and seven VCO series were performed with IABP switched off. Additionally, SVwf was evaluated during nine episodes of severe arrhythmia. VCO's produced marked changes in SV over 10-20 beats. 198 paired data sets of SVlv and SVwf were obtained. Bland-Altman analysis for the difference between SVlv and SVwf during IABP in 1:2 mode showed a bias (accuracy) of 1.04 ± 3.99 ml, precision 10.9% and limits of agreement (LOA) of - 6.94 to 9.02 ml. Without IABP bias was 0.48 ± 4.36 ml, precision 11.6% and LOA of - 8.24 to 9.20 ml. After one thermodilution calibration of SVwf per patient, during IABP the accuracy improved to 0.14 ± 3.07 ml, precision to 8.3% and LOA to - 6.00 to + 6.28 ml. Without IABP the accuracy improved to 0.01 ± 2.71 ml, precision to 7.5% and LOA to - 5.41 to + 5.43 ml. Changes in SVlv and SVwf were directionally concordant in response to VCO's and during severe arrhythmia. (R2 = 0.868). The SVwf and SVlv methods are interchangeable with respect to measuring absolute stroke volume as well as tracking changes in stroke volume. The precision of the non-calibrated WKflow method is about 10% which improved to 7.5% after one calibration per patient.
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Presión Arterial , Gasto Cardíaco , Monitorización Hemodinámica/métodos , Contrapulsador Intraaórtico , Anciano , Arritmias Cardíacas/fisiopatología , Simulación por Computador , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Modelos Cardiovasculares , Análisis de Regresión , Volumen Sistólico , Venas Cavas/fisiopatologíaRESUMEN
In this study, new and existing methods of estimating stroke volume, cardiac output and total peripheral resistance from analysis of the arterial blood pressure waveform were tested over a wide range of conditions. These pulse contour analysis methods (PCMs) were applied to data obtained in six swine during infusion of volume, phenylephrine, dobutamine, isoproterenol, esmolol and nitroglycerine as well as during progressive hemorrhage. Performance of PCMs was compared using true end-ejection pressures as well as estimated end-ejection pressures. There was considerable overlap in the accuracies of the PCMs when using true end-ejection measures. However, for perhaps the most clinically relevant condition, where radial artery pressure is the input, only Wesseling's Corrected Impedance method and the Kouchoukos Correction method achieved statistically superior results. We introduced a method of estimating end-ejection by determining when the systolic pressure dropped to a value equal to the sum of the end-diastolic pressure plus a fraction of the pulse pressure. The most accurate estimation of end-ejection was obtained when that fraction was set to 60% for the central arterial pressure and to 50% for the femoral and radial arterial pressures. When the estimated end-ejection measures were used for the PCMs that depend on end-ejection measures and when radial artery pressure was used as the input, only Wesseling's Corrected Impedance method and the modified Herd's method achieved statistically superior results. This study provides a systematic comparison of multiple PCMs' ability to estimate stroke volume, cardiac output, and total peripheral resistance and introduces a new method of estimating end-systole.
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Monitorización Hemodinámica/veterinaria , Sus scrofa/fisiología , Algoritmos , Animales , Presión Arterial , Presión Sanguínea , Gasto Cardíaco , Monitorización Hemodinámica/métodos , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Modelos Cardiovasculares , Análisis de la Onda del Pulso , Volumen Sistólico , Resistencia VascularRESUMEN
BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.
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Lesiones Traumáticas del Encéfalo/terapia , Hemorragia Cerebral/terapia , Hematoma Subdural/terapia , Mortalidad Hospitalaria , Hemorragia Subaracnoidea/terapia , Centros Médicos Académicos/estadística & datos numéricos , Adulto , Anciano , Asia/epidemiología , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/fisiopatología , Neoplasias Encefálicas/epidemiología , Neoplasias Encefálicas/fisiopatología , Neoplasias Encefálicas/terapia , Hemorragia Cerebral/epidemiología , Hemorragia Cerebral/fisiopatología , Cuidados Críticos , Manejo de la Enfermedad , Servicio de Urgencia en Hospital , Europa (Continente)/epidemiología , Femenino , Escala de Coma de Glasgow , Recursos en Salud , Paro Cardíaco/epidemiología , Paro Cardíaco/fisiopatología , Paro Cardíaco/terapia , Hematoma Subdural/epidemiología , Hematoma Subdural/fisiopatología , Monitorización Hemodinámica/estadística & datos numéricos , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos , Internacionalidad , Accidente Cerebrovascular Isquémico/epidemiología , Accidente Cerebrovascular Isquémico/fisiopatología , Accidente Cerebrovascular Isquémico/terapia , América Latina/epidemiología , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Medio Oriente/epidemiología , Análisis Multivariante , Monitorización Neurofisiológica/estadística & datos numéricos , América del Norte/epidemiología , Oceanía/epidemiología , Oportunidad Relativa , Cuidados Paliativos/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Comodidad del Paciente , Transferencia de Pacientes/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Reflejo Pupilar , Órdenes de ResucitaciónRESUMEN
OBJECTIVES: This study sought to evaluate the clinical characteristics and outcomes of Takotusbo cardiomyopathy cardiogenic shock (TC-CS) in comparison to those of acute myocardial infarction cardiogenic shock (AMI-CS) among patients hospitalized in the United States. We additionally sought to compare the incidence of multiorgan failure and use of supportive therapies as well as the trends over time, given the increasing awareness and diagnosis of TC. BACKGROUND: CS is a major complication of TC; however, there are limited data, especially as to how TC-CS compares to AMI-CS. METHODS: The National Inpatient Sample Database was used to identify adults hospitalized with CS in the setting of TC and AMI from 2007 to 2014. We required patients admitted with TC to have undergone coronary angiography without intervention. Clinical characteristics and in-hospital outcomes in TC-CS patients were compared with those in AMI-CS patients. Multivariate regression and propensity matching were used to adjust for potential confounding factors. RESULTS: Between 2007 and 2014, there were 374,152 admissions for CS due to either TC or AMI, of which 4,614 patients (1.2%) had TC-CS. TC-CS admission patients were more likely to be younger, white females with fewer comorbidities. Rates of respiratory failure and mechanical ventilation were higher in TC-CS, but cardiac arrest and acute kidney injury were lower. There were no differences between cohorts in use of intra-aortic balloon pumps. TC-CS admissions had lower in-hospital mortality (15% vs. 37%, respectively) and hospital costs (U.S. dollars: $135,397 ± $127,617 vs. $154,827 ± $186,035, respectively) and were discharged home more often (45% vs. 36%, respectively) compared to AMI-CS admissions (all: p < 0.001). After adjustments for potential confounders, TC-CS was associated with lower in-hospital mortality (odds ratio [OR]: 0.35; 95% confidence interval [CI]: 0.32 to 0.38; p < 0.001). Similar findings were observed in the propensity-matched cohort (OR: 0.32; 95% CI: 0.25 to 0.39; p < 0.001). CONCLUSIONS: There are key differences between the clinical characteristics and multiorgan failure patterns in TC-CS compared to those in AMI-CS. In-hospital mortality (15%) is lower in TC-CS.
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Mortalidad Hospitalaria , Infarto del Miocardio/terapia , Choque Cardiogénico/terapia , Cardiomiopatía de Takotsubo/terapia , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/terapia , Distribución por Edad , Anciano , Anciano de 80 o más Años , Angiografía Coronaria/estadística & datos numéricos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Femenino , Paro Cardíaco/epidemiología , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Incidencia , Contrapulsador Intraaórtico/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/epidemiología , Infarto del Miocardio/complicaciones , Puntaje de Propensión , Diálisis Renal/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/epidemiología , Insuficiencia Respiratoria/terapia , Distribución por Sexo , Choque Cardiogénico/epidemiología , Choque Cardiogénico/etiología , Cardiomiopatía de Takotsubo/complicaciones , Estados Unidos/epidemiologíaRESUMEN
PURPOSE OF REVIEW: Hemodynamic investigations are required in patients with shock to identify the type of shock, to select the most appropriate treatments and to assess the patient's response to the selected therapy. We discuss how to select the most appropriate hemodynamic monitoring techniques in patients with shock as well as the future of hemodynamic monitoring. RECENT FINDINGS: Over the last decades, the hemodynamic monitoring techniques have evolved from intermittent toward continuous and real-time measurements and from invasive toward less-invasive approaches. In patients with shock, current guidelines recommend the echocardiography as the preferred modality for the initial hemodynamic evaluation. In patients with shock nonresponsive to initial therapy and/or in the most complex patients, it is recommended to monitor the cardiac output and to use advanced hemodynamic monitoring techniques. They also provide other useful variables that are useful for managing the most complex cases. Uncalibrated and noninvasive cardiac output monitors are not reliable enough in the intensive care setting. SUMMARY: The use of echocardiography should be initially encouraged in patients with shock to identify the type of shock and to select the most appropriate therapy. The use of more invasive hemodynamic monitoring techniques should be discussed on an individualized basis.
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Gasto Cardíaco/fisiología , Cuidados Críticos , Enfermedad Crítica/terapia , Monitorización Hemodinámica/métodos , Choque/fisiopatología , Cuidados Críticos/métodos , Ecocardiografía , Monitorización Hemodinámica/estadística & datos numéricos , Hemodinámica , Humanos , Choque/terapiaRESUMEN
The purpose of this technological notes paper is to describe our institution's experience collecting peripheral venous pressure (PVP) waveforms using a standard peripheral intravenous catheter in an awake pediatric patient. PVP waveforms were collected from patients with hypertrophic pyloric stenosis. PVP measurements were obtained prospectively at two time points during the hospitalization: admission to emergency department and after bolus in emergency department. Data was collected from thirty-two patients. Interference in the PVP waveforms data collection was associated with the following: patient or device motion, system set-up error, type of IV catheter, and peripheral intravenous catheter location. PVP waveforms can be collected in an awake pediatric patient and adjuncts to decrease signal interference can be used to optimize data collection.
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Determinación de la Presión Sanguínea/estadística & datos numéricos , Presión Venosa/fisiología , Análisis de Ondículas , Cateterismo Periférico , Deshidratación/diagnóstico , Deshidratación/etiología , Deshidratación/terapia , Femenino , Fluidoterapia , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Lactante , Masculino , Proyectos Piloto , Estudios Prospectivos , Estenosis Hipertrófica del Piloro/complicaciones , Estenosis Hipertrófica del Piloro/fisiopatología , Vigilia/fisiologíaRESUMEN
This study assessed the ability of a continuous non-invasive blood pressure (BP) monitoring system to reduce intra-anesthetic hemodynamic fluctuation compared with intermittent BP cuff measurement. Forty patients undergoing total knee arthroplasty under general anesthesia were enrolled and randomly divided into two groups (Control and CS group). BP management was performed using the same protocol with BP measured by intermittent BP cuff in the Control and that by continuous non-invasive BP monitoring in the CS group. We assessed the accuracy and precision of the continuous non-invasive BP monitoring compared with BP cuff measurement using Bland-Altman, four-quadrant plot, and polar-plot analyses. Additionally, the occurrence of hypotension and hypertention during general anesthesia was compared between the two groups. The continuous non-invasive BP monitoring showed excellent accuracy of - 1.1 ± 8.1 mmHg during surgery and an acceptable trending ability with a concordance rate of 95.1% according to the four-quadrant plot analysis and an angular concordance rate of 86.7% by polar-plot analysis. Hypotension was less common in the CS group during induction of anesthesia (p = 0.002) and surgery (p = 0.008). Hypertension occurred more frequently in the Control group during emergence from anesthesia (p = 0.037). The duration of hemodynamic stability (systolic BP 80-110% of baseline) intraoperatively was longer in the CS group than in the Control group (87.7 vs. 61.9%; p < 0.001). Accuracy and trending ability of the continuous non-invasive BP monitoring was clinically acceptable, and lead to hemodynamic stability and reduction of intra-anesthetic hypotension and hypertension intraoperatively.
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Anestesia General/efectos adversos , Determinación de la Presión Sanguínea/métodos , Monitorización Hemodinámica/métodos , Monitoreo Intraoperatorio/métodos , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Rodilla , Determinación de la Presión Sanguínea/estadística & datos numéricos , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Hipertensión/etiología , Hipertensión/fisiopatología , Hipertensión/prevención & control , Hipotensión/etiología , Hipotensión/fisiopatología , Hipotensión/prevención & control , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/estadística & datos numéricosRESUMEN
Induction of general anesthesia frequently induces arterial hypotension, which is often treated with a vasopressor, such as phenylephrine. As a pure α-agonist, phenylephrine is conventionally considered to solely induce arterial vasoconstriction and thus increase cardiac afterload but not cardiac preload. In specific circumstances, however, phenylephrine may also contribute to an increase in venous return and thus cardiac output (CO). The aim of this study is to describe the initial time course of the effects of phenylephrine on various hemodynamic variables and to evaluate the ability of advanced hemodynamic monitoring to quantify these changes through different hemodynamic variables. In 24 patients, after induction of anesthesia, during the period before surgical stimulus, phenylephrine 2 µg kg-1 was administered when the MAP dropped below 80% of the awake state baseline value for > 3 min. The mean arterial blood pressure (MAP), heart rate (HR), end-tidal CO2 (EtCO2), central venous pressure (CVP), stroke volume (SV), CO, pulse pressure variation (PPV), stroke volume variation (SVV) and systemic vascular resistance (SVR) were recorded continuously. The values at the moment before administration of phenylephrine and 5(T5) and 10(T10) min thereafter were compared. After phenylephrine, the mean(SD) MAP, SV, CO, CVP and EtCO2 increased by 34(13) mmHg, 11(9) mL, 1.02(0.74) L min-1, 3(2.6) mmHg and 4.0(1.6) mmHg at T5 respectively, while both dynamic preload variables decreased: PPV dropped from 20% at baseline to 9% at T5 and to 13% at T10 and SVV from 19 to 11 and 14%, respectively. Initially, the increase in MAP was perfectly aligned with the increase in SVR, until 150 s after the initial increase in MAP, when both curves started to dissociate. The dissociation of the evolution of MAP and SVR, together with the changes in PPV, CVP, EtCO2 and CO indicate that in patients with anesthesia-induced hypotension, phenylephrine increases the CO by virtue of an increase in cardiac preload.
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Anestesia General/efectos adversos , Gasto Cardíaco/efectos de los fármacos , Monitorización Hemodinámica/métodos , Hipotensión/tratamiento farmacológico , Hipotensión/etiología , Fenilefrina/uso terapéutico , Anciano , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Fenilefrina/administración & dosificación , Estudios Prospectivos , Factores de Tiempo , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéuticoRESUMEN
Technologies for minimally-invasive cardiac output measurement in patients during surgery remain little used in routine practice. We tested a redeveloped system based on CO2 elimination (VCO2) by the lungs for use in ventilated patients, which can be seamlessly integrated into a modern anesthesia/monitoring platform, and provides automated, continuous breath-by-breath cardiac output monitoring. A prototype measurement system was constructed to measure VCO2 and end-tidal CO2 concentration with each breath. A baseline measurement of non-shunt cardiac output was made during a brief oscillating change in ventilator rate, according to the differential CO2 Fick approach and repeated at 5-10 min intervals. Continuous breath-by-breath monitoring of cardiac output was performed between these intervals from measurement of VCO2, using a derivation of the Fick equation applied to pulmonary CO2 elimination and cardiac output displayed in real time. Measurements were compared with simultaneous measurements by thermodilution in 50 patients undergoing cardiac surgery or liver transplantation. Overall mean bias [sd] for agreement in cardiac output measurement was - 0.3 [1.1] L/min, percentage error ± 38.7%, intraclass correlation coefficient = 0.91. Concordance in measurement of changes of at least 15% in cardiac output was 81.4%, with a mean angular bias of - 1.7°, and radial limits of agreement of ± 76.2° on polar plot analysis. The accuracy and precision compared favourably to other clinical techniques. The method is relatively seamless and automated and has potential for continuous, cardiac output monitoring in ventilated patients during anesthesia and critical care.
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Capnografía/instrumentación , Dióxido de Carbono/metabolismo , Gasto Cardíaco , Monitorización Hemodinámica/instrumentación , Pulmón/metabolismo , Monitoreo Fisiológico/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Capnografía/estadística & datos numéricos , Dióxido de Carbono/sangre , Diseño de Equipo , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/estadística & datos numéricos , Respiración Artificial , Termodilución/estadística & datos numéricosRESUMEN
Central venous-to-arterial carbon dioxide difference (PcvaCO2), and its correction by the arterial-to-venous oxygen content difference (PcvaCO2/CavO2) have been proposed as additional tools to evaluate tissue hypoxia. Since the relationship between pressure and content of CO2 (CCO2) might be affected by several factors, some authors advocate for the use of CcvaCO2/CavO2. The aim of the present study was to explore the factors that might intervene in the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2, and to analyze their association with mortality. Observational study in a 30-bed mixed ICU. Fifty-two septic shock patients within the first 24 h of ICU admission were studied. After restoration of mean arterial pressure, hemodynamic and metabolic parameters were evaluated. A total of 110 sets of measurements were performed. Simultaneous PcvaCO2/CavO2 and CcvaCO2/CavO2 values were correlated, but agreement analysis showed a significant proportional bias. The difference between PcvaCO2/CavO2 and CcvaCO2/CavO2 was independently associated with pH, ScvO2, baseline CcvaCO2/CavO2 and hemoglobin. A stepwise regression analysis showed that pH was the single best predictor for the magnitude of such difference, with very limited effect of other variables. At inclusion, variables associated with ICU-mortality were lactate, pH, PcvaCO2/CavO2, and the difference between PcvaCO2/CavO2 and CcvaCO2/CavO2. Initial ScvO2, PcvaCO2, CcvaCO2/CavO2, and cardiac index were not different in survivors and non-survivors. In a population of early septic shock patients, simultaneous values of PcvaCO2/CavO2 and CcvaCO2/CavO2 were not equivalent, and the main determinant of the magnitude of the difference between these two parameters was pH. The PcvaCO2/CavO2 ratio was associated with ICU mortality, whereas CcvaCO2/CavO2 was not.
Asunto(s)
Dióxido de Carbono/sangre , Choque Séptico/sangre , Choque Séptico/fisiopatología , Anciano , Análisis de los Gases de la Sangre/estadística & datos numéricos , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Pronóstico , Estudios Prospectivos , Choque Séptico/mortalidadRESUMEN
The present pilot study investigated whether respiratory variation in subclavian vein (SCV) diameters correlates with fluid responsiveness in mechanically ventilated patients. Monocentric, prospective clinical study on fluid responsiveness in adult sedated, mechanically ventilated ICU patient, monitored with the PiCCO™ system (Pulsion Medical System, Germany), and requiring a fluid challenge (FC). A 10-min fluid bolus of 500 mL of 0.9% saline was administered. Cardiac output (CO) and dynamic parameters [stroke volume variation (SVV) and pulse pressure variation (PPV)] measured by transpulmonary thermodilution and pulse contour analysis (PiCCO™) as well as classical hemodynamic parameters were recorded at baseline and after FC. Fluid responsiveness was described as an increase in CO of ≥ 15%. Ultrasound measurements obtained in the subclavian long-axis view were used to calculate the SCVvariability index. A cut-off value for SCV variation for the prediction of fluid responsiveness was determined using receiver operating curve (ROC) analysis. Nine of 20 FCs (45%) induced an increase in CO of ≥ 15%. At baseline, the SCVvariability index was greater in responders than in non-responders (34.0 ± 21.4 vs. 9.0 ± 5.5; p = 0.0005). Diagnostic performance for the SCVvariability index revealed a cut-off value of 14 with a sensitivity of 100% [Confidence interval (CI) 95% (90; 100)] and a specificity of 82% [CI 95% (48; 98)] for the prediction of fluid responsiveness. Other parameters, such as SVV and PPV, could not predict fluid responsiveness. The correlation coefficient between CO variation and the SCVvariability index was 0.73 (p < 0.001). The SCVvariability index was a reliable, non-invasive parameter for the prediction of fluid responsiveness at the bedside of mechanically ventilated, critically ill patients in this pilot study.
Asunto(s)
Fluidoterapia , Monitorización Hemodinámica , Respiración Artificial , Vena Subclavia/diagnóstico por imagen , Anciano , Análisis de Varianza , Presión Sanguínea , Gasto Cardíaco , Cuidados Críticos , Femenino , Monitorización Hemodinámica/métodos , Monitorización Hemodinámica/estadística & datos numéricos , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Volumen Sistólico , Vena Subclavia/fisiopatología , UltrasonografíaRESUMEN
An intraoperative automated closed-loop system for goal-directed fluid therapy has been successfully tested in silico, in vivo and in a clinical case-control matching. This trial compared intraoperative cardiac output (CO) in patients managed with this closed-loop system versus usual practice in an academic medical center. The closed-loop system was connected to a CO monitoring system and delivered automated colloid fluid boluses. Moderate to high-risk abdominal surgical patients were randomized either to the closed-loop or the manual group. Intraoperative final CO was the primary endpoint. Secondary endpoints were intraoperative overall mean cardiac index (CI), increase from initial to final CI, intraoperative fluid volume and postoperative outcomes. From January 2014 to November 2015, 46 patients were randomized. There was a lower initial CI (2.06 vs. 2.51 l min-1 m-2, p = 0.042) in the closed-loop compared to the control group. No difference in final CO and in overall mean intraoperative CI was observed between groups. A significant relative increase from initial to final CI values was observed in the closed-loop but not the control group (+ 28.6%, p = 0.006 vs. + 1.2%, p = 0.843). No difference was found for intraoperative fluid management and postoperative outcomes between groups. There was no significant impact on the primary study endpoint, but this was found in a context of unexpected lower initial CI in the closed-loop group.Trial registry number ID-RCB/EudraCT: 2013-A00770-45. ClinicalTrials.gov Identifier NCT01950845, date of registration: 17 September 2013.
Asunto(s)
Gasto Cardíaco , Fluidoterapia/métodos , Monitorización Hemodinámica/métodos , Monitoreo Intraoperatorio/métodos , Abdomen/cirugía , Anciano , Algoritmos , Procedimientos Quirúrgicos Electivos , Femenino , Fluidoterapia/instrumentación , Fluidoterapia/estadística & datos numéricos , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/estadística & datos numéricos , Estudios Prospectivos , Diseño de Software , Terapia Asistida por Computador/métodos , Terapia Asistida por Computador/estadística & datos numéricosRESUMEN
The aim of this study was to evaluate the accuracy and precision of non-invasive continuous blood pressure measurement by applanation tonometry (AT) in awake or anaesthetised cardiological intensive care patients. Patients suffering from highly impaired left ventricular function atrial fibrillation or severe aortic valve stenosis were included into the study. Arterial blood pressure was recorded by applanation tonometry (T-Line 400, Tensys Medical®, USA) and an arterial line in awake or anaesthetised patients. Discrepancies in mean (MAP), systolic (SAP), and diastolic (DAP) arterial pressure between the two methods were assessed as bias, limits of agreement and percentage error respectively. In 31 patients a total of 27,900 measurements were analyzed. The concordance correlation coefficient was 0.23, 0.45 and 0.06 for MAP, SAP and DAP, respectively. For all patients bias for MAPAT compared to MAPAL was 14.96 mmHg (SAPAT 4.51 mmHg; DAPAT 19.12 mmHg) with limits of agreement for MAPAT of 46.25 and - 16.33 mm Hg (SAPAT 48.00 and - 38.98 mmHg; DAPAT 50.12 and - 11.89 mmHg). Percentage error for MAPAT was 56.8% (42.7% for SAPAT; 75.2% for DAPAT). We conclude that the AT method is not reliable in ICU patients with severe cardiac comorbidities.
Asunto(s)
Determinación de la Presión Sanguínea/métodos , Monitorización Hemodinámica/métodos , Manometría/métodos , Anciano , Estenosis de la Válvula Aórtica/fisiopatología , Presión Arterial/fisiología , Fibrilación Atrial/fisiopatología , Determinación de la Presión Sanguínea/estadística & datos numéricos , Unidades de Cuidados Coronarios , Cuidados Críticos , Femenino , Monitorización Hemodinámica/estadística & datos numéricos , Humanos , Masculino , Manometría/estadística & datos numéricos , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Disfunción Ventricular Izquierda/fisiopatología , Análisis de OndículasRESUMEN
VPloop, the graphical representation of pressure versus velocity, and its characteristic angles, GALA and ß, can be used to monitor cardiac afterload during anesthesia. Ideally VPloop should be measured from pressure and velocity obtained at the same arterial location but standard of care usually provide either radial or femoral pressure waveforms. The purpose of this study was to look at the influence of arterial sites and the use of a transfer function (TF) on VPloop and its related angles. Invasive pressure signals were recorded in 25 patients undergoing neuroradiology intervention under general anesthesia with transesophageal flow velocity monitoring. Pressures were recorded in the descending thoracic aorta, abdominal aorta, femoral and radial arteries. We compared GALA and ß from VPloops generated from each location and in high and low risk patients. GALA was similar in the central locations (55°[49-63], 52°[47-61] and 54°[45-62] from descending thoracic to femoral artery, median[interquartile], p = 0.10), while there was a difference in ß angle (16°[4-27] to 8°[3-15], p < 0.0001). GALA and ß obtained from radial waveforms were different (39°[31-47] compared to 46°[36-54] and 6°[2-14] compared to 16°[4-27] for GALA and ß angles respectively, p < 0.001) which was corrected by the use of a TF (45°[32-55] and 17°[5-28], p = ns). GALA and ß are underestimated when measured with a radial catheter. Using pressure waveforms from femoral locations alters VPloops, GALA and ß in a smaller extend. The use of a TF on radial pressure allows to correctly plot VPloops and their characteristic angles for routine clinical use.