Acute kidney injury after liver transplantation, perioperative risk factors, and outcome: prospective observational study of 1681 patients (OLTx Study).

BACKGROUND: Acute kidney injury (AKI) represents a frequent complication after orthotopic liver transplantation (OLT). This study aimed to evaluate early postoperative AKI incidence during the first 72 h after OLT, perioperative risk factors, and AKI impact on survival. METHODS: From January 2011 to December 2013, 1681 patients underwent OLT in 19 centers and were enrolled in this prospective cohort study. RESULTS: According to RIFLE criteria, AKI occurred in 367 patients, 21.8% (R: 5.8%, I: 6.4%, F: 4.8%, L: 4.8%). Based on multivariate analysis, intraoperative risk factors for AKI were: administration of 5-10 RBCs (OR 1.8, 95% CI 1.3-2.7), dopamine use (OR 1.6, 95% CI 1.2-2.3), post-reperfusion syndrome (OR 1.5, 95% CI 1.0-2.3), surgical complications (OR 2.0, 95% CI 1.3-3.0), and cardiological complications (OR 2.2, 95% CI 1.2-4.0). Postoperative risk factors were: norepinephrine (OR 1.4, 95% CI 1.0-2.0), furosemide (OR 4.2, 95% CI 3.0-5.9), more than 10 RBCs transfusion, (OR 3.7, 95% CI 1.4-10.5), platelets administration (OR 1.6, 95% CI 1.1-2.4), fibrinogen administration (OR 3.0, 95% CI, 1.5-6.2), hepatic complications (OR 4.6, 95% CI 2.9-7.5), neurological complications (OR 2.4, 95% CI 1.5-3.7), and infectious complications (OR 2.7, 95% CI 1.8-4.3). NO-AKI patients' 5-year survival rate was higher than AKI patients (68.06, 95% CI 62.7-72.7 and 81.2, 95% CI 78.9-83.3, P<0.001). CONCLUSIONS: AKI still remains an important risk factor for morbidity and mortality after OLT. Further research to develop new strategies aimed at preventing or minimizing post-OLT AKI is needed.

SUGAMMADEX versus neostigmine after ROCURONIUM continuous infusion in patients undergoing liver transplantation.

BACKGROUND: Rapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation. This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation. METHODS: The TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution's internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine). RESULTS: Data from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001). CONCLUSION: Sugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice. TRIAL REGISTRATION: ClinicalTrials.govNCT02697929 (registered 3rd March 2016).

Airway management in anesthesia for thoracic surgery: a "real life" observational study.

BACKGROUND: One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs. METHODS: A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway. RESULTS: Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted. CONCLUSIONS: DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.

Could transesophageal echocardiography be useful in selected cases during liver surgery resection?

PURPOSE: Although only limited scientific evidence exists promoting the use of transesophageal echocardiography (TEE) in non cardiac surgery, several recent studies have documented its usefulness during liver surgery. METHODS AND RESULTS: In the present case study, through the use of color Doppler TEE, compression of the inferior vena cava and the right hepatic vein was clearly evident, as was their restoration after surgery. CONCLUSION: TEE should be encouraged in patients undergoing liver resection, not only for hemodynamic monitoring, but also for its ability to provide information about the anatomy of the liver, its vessels, and inferior vena cava patency.

Phantom model and scoring system to assess ability in ultrasound-guided chest drain positioning.

BACKGROUND: Chest tube positioning is an invasive procedure associated with potentially serious injuries. In the last few years, we have been running a project directed at developing a practical simulator of a surgical procedure taught on our medical training program. The phantom model reconstructs the pleural anatomy, visible by lung ultrasound, used for the assessed performance of the Seldinger technique. The aim of the present study was to investigate the validity of this simulation technology for assessing residents in anesthesia and intensive care medicine; specifically, their skill in positioning a US-guided chest tube drain was tested using the simulator device. The second aim of the paper was to evaluate the learning curve of our residents over their 5-year study course and validate the phantom scoring system. METHODS: This was a prospective, single-blinded observational study. Participants were recruited from residents in anesthesia and intensive care medicine and divided into two groups: 'Novice' and 'Expert,' based on the course year attended (years 1, 2, and 3 vs. years 4 and 5, respectively). We asked them to position a chest tube drain in a phantom model, guided by ultrasound, to drain a simulated pleural effusion. Each subject performed two tests that simulated pleural effusions of 4 and 2 cm, respectively. Every step of the maneuver was constantly monitored and the performance scored by the investigators. We then performed a Spearman correlation analysis to evaluate the effect of experience level on the performance of the two groups of residents. RESULTS: Thirty-one residents were included in this study: 20 in the Novice group and 11 in the Expert group. The mean performance rating score was 0.75 ± 4.38 for the Novice Group and 5.91 ± 3.75 for the Expert group (p = 0.0026). The Spearman correlation analysis examining the relationship between year of residency and performance rating score confirmed a positive correlation (r = 0.58, p = 0.0006). Post-test trend analysis revealed a statistically significant linear trend for skill growth across time, i.e., course year (p = 0.0022). CONCLUSIONS: Our simulated procedure using a phantom model of lung anatomy can accurately and reliably be used to assess the skill levels of operators in their ability to drain pleural effusion.

Point-of-care ultrasound of the diaphragm in a liver transplant patient with acute respiratory failure.

In some intensive care, nowadays, ultrasound diagnostics have become an extension of the physical examination (like a stethoscope). In this report, we discuss the case of an acute respiratory failure which arose immediately after the end of general anesthesia. An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound. We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only. To our knowledge, this is the first case report that has shown the usefulness of ultrasonography in detecting diaphragmatic dysfunction as a cause of acute respiratory failure with a subsequent change in patient management. The use of bedside ultrasonography provides practical functional information on the diaphragmatic function in patients with acute respiratory failure and can also be easily repeated if follow-up is required. This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.

Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach?

BACKGROUND: Fluid management in the perioperative period has been extensively studied but, despite that, "the right amount" still remains uncertain. The purpose of this paper is to summarize the state of the art of intraoperative fluid approach today. DISCUSSION: In the current medical literature there are only heterogeneous viewpoints that gives the idea of how confusing the situation is. The approach to the intraoperative fluid management is complex and it should be based on human physiology and the current evidence. SUMMARY: An intraoperative restrictive fluid approach in major surgery may be beneficial while Goal-directed Therapy should be superior to the liberal fluid strategy. Finally, we propose a rational approach currently used at our institution.

Uncalibrated continuous cardiac output measurement in liver transplant patients: LiDCOrapid™ system versus pulmonary artery catheter.

OBJECTIVE: The aim of the study was to assess the level of agreement between continuous cardiac output estimated by uncalibrated pulse-power analysis (PulseCOLiR) and intermittent (ICO) and continuous cardiac output (CCO) obtained using a pulmonary artery catheter (PAC). DESIGN: Prospective cohort study. SETTING: University hospital intensive care unit. PARTICIPANTS: Twenty patients after liver transplantation. INTERVENTION: Pulmonary artery catheters were placed in all patients, and ICO and CCO were determined using thermodilution. PulseCOLiR measurements were made using a LiDCOrapid(TM) (LiDCO Ltd, Cambridge, UK). MEASUREMENTS AND MAIN RESULTS: ICO data were determined after intensive care unit admission and every 8 hours until the 48th postoperative hour. CCO and PulseCOLiR measurements were recorded simultaneously at these same time intervals as well as hourly. For the 8-hour data set (140 data pairs), the mean bias and percentage errors (PE) were, respectively,-0.10 L/min and 39.2% for ICO versus PulseCOLiR and 0.79 L/min and 34.6% for CCO versus PulseCOLiR. For the hourly comparison of CCO versus PulseCOLiR (980 data pairs), the bias was 0.75 L/min and the PE 37%. To assess the ability to measure change, a 4-quadrant plot was produced for each pair of methods. The performance of PulseCOLiR was moderate in detecting changes in ICO. CONCLUSIONS: In conclusion, the uncalibrated PulseCOLir method should not be used as a substitute for the thermodilution technique for the monitoring of cardiac output in liver transplant patients.

Prediction of early postoperative major cardiac events after elective orthopedic surgery: the role of B-type natriuretic peptide, the revised cardiac risk index, and ASA class.

BACKGROUND: The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date. METHODS: The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge. RESULTS: MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82. CONCLUSIONS: Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.

Effects of catecholamines on microcirculation during general inhalation anesthesia.

OBJECTIVE: The aim of this study was to investigate the effects of clinical dosages of norepinephrine and dobutamine on sublingual microcirculation during general anesthesia with sevoflurane in minor surgical procedures. DESIGN: This prospective study was performed on patients scheduled for breast cancer surgery. SETTING: Tertiary care university hospital. PARTICIPANTS: Twenty patients undergoing elective surgery. INTERVENTIONS: Patients received a continuous infusion of norepinephrine (0.1 µg/kg/min) and afterwards, following a 15-minute interval, a continuous infusion of dobutamine (5 µg/kg/min). Prior to and at the end of each drug infusion period, hemodynamic parameters were measured using an esophageal Doppler probe (ED), and 5 sidestream darkfield (SDF) sublingual microcirculation video recordings were taken. MEASUREMENTS AND MAIN RESULTS: No significant changes to total vessel density (TVD)(mm/mm(2)), perfused vessel density (PVD) (mm/mm(2)), proportion of perfused vessels (PPV) (percentage), or microvascular flow index (MFI) (arbitrary units) were measured at the end of each drug infusion period versus pre-infusion data and no differences were observed between the effects of norepinephrine versus dobutamine. Mean arterial pressure (APm) (mmHg) was significantly greater following both norepinephrine and dobutamine infusions compared to pre-infusion values, while peak velocity (PV) (cm/sec) and the stroke volume index (SVI) (mL/m(2)) only showed a significant increase following the dobutamine infusion. No change in corrected flow time (FTc) (msec) was observed. CONCLUSIONS: During general anesthesia with sevoflurane, the infusion of clinical dosages of norepinephrine and dobutamine did not alter sublingual perfusion, although the expected systemic hemodynamic alterations were induced.

The postoperative airway: unique challenges?

PURPOSE OF REVIEW: The review is focused on the challenge of managing airway and ventilation in the intraoperative and postoperative period. RECENT FINDINGS: In past years, a lot of attention was focused on tracheal intubation in difficult airway, whereas only in recent years extubation time of difficult airway is also covering an important role. Protective ventilation strategies have been studied in acute respiratory distress syndrome and then in general anesthesia, either for thoracic or bariatric surgery, whereas in general abdominal surgery, in healthy lung, few studies are present demonstrating the effective protective role of low tidal volume, lung recruitment maneuvers (LRM) and positive end-expiratory pressure (PEEP). In the early postoperative period, the role of noninvasive ventilation is growing as it reduces postoperative pulmonary complications, postoperative length of stay and costs. SUMMARY: The combination of planning extubation of predicted and unpredicted difficult airway, both intraoperative low tidal volume and low FiO2 with LRM and PEEP at different points of surgery and postoperative noninvasive ventilation should be considered in patients undergoing surgery to decrease the rate of postoperative pulmonary complications and major fatal complications such as brain damage and death.

Prognostic power of pre- and postoperative B-type natriuretic peptide levels in patients undergoing abdominal aortic surgery.

OBJECTIVES: The first aim of the present study was to evaluate the pre- and postoperative B-type natriuretic peptide (BNP) levels in patients undergoing surgery for repair of an infrarenal abdominal aortic aneurysm (AAA) and analyze their power as a predictor of in-hospital cardiac events. The second aim was to evaluate the association among pre- and postoperative BNP levels, postoperative patient complications, and length of hospital stay. DESIGN: Prospective observational study. SETTING: A university hospital. PARTICIPANTS: Forty-five patients undergoing elective surgery for an abdominal aortic aneurysm. INTERVENTIONS: The plasma BNP level was assessed just before surgery and then on postoperative day 1. Cardiac troponin I levels were measured postoperatively on arrival to the intensive care unit (time 0) and then 12, 48, and 72 hours later. MEASUREMENTS AND MAIN RESULTS: The preoperative BNP concentration in patients who developed an acute myocardial infarction was 209 (IQR 84-346) pg/mL compared with 74 (IQR 28-142) pg/mL in those who did not. The difference between groups was statistically significant (p = 0.04). The Spearman correlation showed that postoperative BNP levels correlated significantly with preoperative BNP levels (r = 0.73, p = 0.0001), length of hospital stay (r = 0.35, p = 0.04), and troponin I concentration at 0 hour (r = 0.42, p = 0.02), 12 hours (r = 0.51, p = 0.0052), and 48 hours (r = 0.40, p = 0.033). In contrast, preoperative BNP levels correlated with troponin I at only 12 hours (r = 0.34, p = 0.02). Postoperative BNP levels were influenced significantly by transfusions (p = 0.035) and cross-clamping times (p = 0.038). CONCLUSIONS: The present results confirm the high negative predictive value of preoperative BNP levels; and postoperative BNP levels showed a better correlation with postoperative troponin levels, blood transfusion, and postoperative cardiac events.

The dos and do knots of central venous catheterization.

Central venous catheterization plays an important role in patients with end-stage renal disease undergoing hemodialysis. Placement of a right subclavian hemodialysis catheter was complicated by looping and entrapment of the guidewire. Computed tomographic and three-dimensional scans were essential in locating and determining that the guidewire was outside the vessel.

Uncalibrated arterial pulse cardiac output measurements in patients with moderately abnormal left ventricular function.

OBJECTIVE: The aim of the study was to evaluate the accuracy and precision of the Vigileo/FloTrac system (Edwards Lifesciences, Irvine, CA) when compared with the intermittent cardiac output and continuous cardiac output measurements obtained from pulmonary arterial catheters in patients with moderately abnormal left ventricular function undergoing elective coronary artery bypass graft surgery. DESIGN: A prospective, observational study. SETTING: Tertiary university hospital. PARTICIPANTS: Twenty patients with moderately abnormal left ventricular function undergoing coronary artery bypass graft surgery were enrolled. MEASUREMENTS AND RESULTS: Data were collected before the induction of anesthesia (T1), after the induction of anesthesia (T2), before cardiopulmonary bypass with an open chest (T3), after cardiopulmonary bypass (T4), after sternal closure (T5), on intensive care unit admission (T6), and at 6 hours (T7) and 12 hours after surgery (T8). A total of 360 data measurements were collected; the mean bias between intermittent cardiac output (ICO) and arterial pressure cardiac output (APCO) was -0.50 ± 1.72 L/min, and the percentage error (PE) was 37.00%. The mean difference between CCO and APCO was -0.06 ± 1.84 L/min, and the PE was 37.80%. The correlation between ΔICO and ΔAPCO was r = 0.7; the correlation between ΔCCO and ΔAPCO was r = 0.73. In the intraoperative period, the mean bias between ICO and APCO was -0.41 ± 1.75 L/min, and the PE was 40.87%. The mean difference between CCO and APCO was -0.18 ± 1.90 L/min, and the PE was 41.48%. In the postoperative period, the mean bias between ICO and APCO was -0.56 ± 1.70 L/min, and the PE was 34.43%. The mean difference between CCO and APCO was -0.36 ± 1.76 L/min, and the PE was 34.87%. CONCLUSIONS: In cardiac surgical patients with moderately abnormal left ventricular function, the Vigileo/FloTrac 2nd generation software sensor device showed mild intraoperative and postoperative agreement when compared with a pulmonary arterial catheter.

Continuous right ventricular end-diastolic volume in comparison with left ventricular end-diastolic area.

BACKGROUND AND OBJECTIVE: Intraoperative management of patients with end-stage liver disease undergoing liver transplantation requires fluid administration to increase cardiac output and oxygen delivery to the tissues. Filling pressures have been widely shown to correlate poorly with changes in cardiac output in the critically ill patient. Continuous right ventricular end-diastolic volume index (cRVEDVI) and left ventricular end-diastolic area index (LVEDAI) monitoring have been increasingly used for preload assessment. The aim of this study was to compare cRVEDVI, LVEDAI, central venous pressure and pulmonary artery occlusion pressure with respect to stroke volume index (SVI) during liver transplantation. METHODS: Measurements were made in 20 patients at four predefined steps during liver transplantation. Univariate and multivariate panel-data fixed effect regression models (across phases of the surgical procedure) were fitted to assess associations between SVI and cRVEDVI, pulmonary artery occlusion pressure, central venous pressure and LVEDAI after adjusting for ejection fraction (categorized as 40). RESULTS: SVI was associated with continuous right ventricular ejection fraction. The model showing the best fit to the data was that including cRVEDVI: even after adjusting for continuous right ventricular ejection fraction and phase, the regression coefficient of cRVEDVI in predicting SVI was statistically significant and indicated an increase in SVI of 0.21 ml m(-2) for each increase of 1 ml m(-2). At the multivariate analysis, an increase in LVEDAI of 1 cm m(-2) led to an increase in SVI of 1.47 ml m(-2) (P = 0.054). CONCLUSION: cRVEDVI and LVEDAI gave a better reflection of preload than filling pressure, even if only cRVEDVI reached statistical significance.

Arterial pulse cardiac output agreement with thermodilution in patients in hyperdynamic conditions.

OBJECTIVE: This study aimed to compare continuous cardiac output (CCO) obtained using the arterial pulse wave (APCO) measurement with a simultaneous measurement of the intermittent cardiac output (ICO) and CCO obtained with a pulmonary artery catheter (PAC) in liver transplant patients. DESIGN: A prospective, single-center evaluation. SETTING: A university hospital intensive care unit. PATIENTS: Eighteen patients after liver transplantation. INTERVENTIONS: Pulmonary artery catheters were placed in all patients, and ICO and CCO were determined using thermodilution. APCO measurements were made with the Vigileo System (Edwards Lifesciences, Irvine, CA). MEASUREMENTS AND MAIN RESULTS: The authors obtained 126 data pairs of ICO and APCO and 864 pairs of CCO and APCO. ICO data were collected after intensive care unit admission and every 8 hours until the 48th postoperative hour. CCO and APCO data were collected every hour from admission until the 48th postoperative hour. Bias and precision were 0.95 +/- 1.41 L/min for ICO versus APCO and 1.29 +/- 1.28 L/min for CCO and APCO. Bias and precision for cardiac output (CO) data pairs less than 8 L/min were 0.32 +/- 1.14 L/min between ICO and APCO and 0.71 +/- 0.98 L/min between CCO and APCO. For CO data pairs higher than 8 L/min, bias and precision were 1.79 +/- 1.54 L/min between ICO and APCO and 2.25 +/- 1.14 L/min between CCO and APCO. CONCLUSIONS: APCO enables the assessment of CO with clinically acceptable bias and precision. At higher CO levels, APCO underestimates PAC measurements and it is not as reliable as thermodilution in hyperdynamic liver transplant patients.

Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study.

Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as < or =30, 31-40, and >40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.

Continuous and intermittent cardiac output measurement in hyperdynamic conditions: pulmonary artery catheter vs. lithium dilution technique.

OBJECTIVE: This study aimed to assess the level of agreement of both intermittent cardiac output monitoring by the lithium dilution technique (CO(Li)) and continuous cardiac output monitoring (PulseCO(Li)) using the arterial pressure waveform with intermittent thermodilution using a pulmonary artery catheter (CO(PAC)). DESIGN: Prospective, single-center evaluation. SETTING: University Hospital Intensive Care Unit. PATIENTS: Patients (n=23) receiving liver transplantation. INTERVENTION: Pulmonary artery catheters were placed in all patients and CO(PAC) was determined using thermodilution. CO(Li) and PulseCO(Li) measurements were made using the LiDCO system. MEASUREMENTS AND MAIN RESULTS: Data were collected after intensive care unit admission and every 8h until the 48th hour. A total of 151 CO(PAC), CO(Li) and PulseCO(Li) measurements were analysed. Bias and 95% limit of agreement were 0.11lmin(-1) and -1.84 to + 2.05 lmin(-1) for CO(PAC) vs. CO(Li) (r=0.88) resulting in an overall percentage error of 15.6%. Bias and 95% limit of agreement for CO(PAC) vs. PulseCO(Li) were 0.29 lmin(-1) and -1.87 to + 2.46 lmin(-1) (r=0.85) with a percentage error of 16.8%. Subgroup analysis revealed a percentage error of 15.7% for CO(PAC) vs. CO(Li) and 15.1% for CO(PAC) vs. PulseCO(Li) for data pairs less than 8 lmin(-1), and percentage errors of 15.5% and 18.5% respectively for data pairs higher than 8 lmin(-1). CONCLUSION: In patients with hyperdynamic circulation, intermittent and continuous CO values determined using the LiDCO system showed good agreement with those obtained by intermittent pulmonary artery thermodilution.

Cardiac output monitoring: aortic transpulmonary thermodilution and pulse contour analysis agree with standard thermodilution methods in patients undergoing lung transplantation.

PURPOSE: The PiCCO System is a relatively new device allowing intermittent cardiac output monitoring by aortic transpulmonary thermodilution technique (Aorta intermittent) and continuous cardiac output monitoring by pulse contour analysis (Aorta continuous). The objective of this study was to assess the level of agreement of Aorta intermittent and Aorta continuous with intermittent (PA intermittent) and continuous cardiac output (PA continuous) measured through a special pulmonary artery catheter (Vigilance System SvO(2)/CCO Monitor) in patients undergoing single- or double-lung transplantation. METHODS: Measurements were obtained in 58 patients: at four time points in patients undergoing single-lung transplantation and at six time points in those undergoing double-lung transplantation. Bland and Altman and correlation analyses were used for statistical evaluation. RESULTS: We found close agreement between the techniques. Mean bias between Aorta intermittent and PA intermittent and between Aorta continuous and PA continuous was 0.18 L x min(-1) (2SD of differences between methods = 1.59 L x min(-1)) and -0.07 L x min(-1) (2SD of differences between methods = 1.46 L x min(-1)) respectively. Mean bias between PA continuous and PA intermittent and Aorta continuous and PA intermittent was 0.15 L x min(-1) (2SD of differences between methods = 1.39 L x min(-1)) and 0.08 L x min(-1) (2SD of differences between methods = 1.43 L x min(-1)). CONCLUSION: Measurements with the aortic transpulmonary thermodilution technique give continuous and intermittent values that agree with the pulmonary thermodilution method which is still the current clinical standard.

Propofol or sevoflurane anesthesia without muscle relaxants allow the early extubation of myasthenic patients.

PURPOSE: To compare two non-muscle relaxant anesthetic techniques in myasthenic patients undergoing trans-sternal thymectomy, evaluating the intra- and postoperative conditions including the early extubation in the operating room. METHODS: Sixty-eight consecutive myasthenic patients undergoing trans-sternal thymectomy were prospectively randomized in two groups: propofol and sevoflurane. In both groups anesthesia was induced with propofol (1-2 mg x kg(-1)) and intubation performed after topical anesthesia of the airway with lidocaine. Anesthesia was maintained in the propofol group (36 patients) with a continuous propofol infusion (3-6 mg x kg(-1) x hr(-1)) and nitrous oxide and, in the sevoflurane group (32 patients), with sevoflurane (end-tidal 1-1.5%) in O2:N2O. Intubating conditions, hemodynamic changes, neuromuscular transmission, postoperative intensive care unit and hospital length of stay and complications were evaluated. Data were analyzed with repeated measure two-way analysis of variance (ANOVA), Chi square test and Student's t test. RESULTS: Intubating conditions were good in all patients. There were no hemodynamic changes. All patients were extubated in the operating room and none had to be re-intubated for postoperative respiratory depression. Neuromuscular transmission showed minimal changes, more important in the sevoflurane group, and at the end of the procedure the recovery was complete in all patients. We did not observe any other significant differences between the two groups studied. CONCLUSION: Our data show that these two anesthetic techniques allow the early extubation of myasthenic patients in the operating room.