Comparison of pulmonary vascular permeability index PVPI and global ejection fraction GEF derived from jugular and femoral indicator injection using the PiCCO-2 device: A prospective observational study.

BACKGROUND: Transpulmonary thermodilution (TPTD) is used to derive cardiac output CO, global end-diastolic volume GEDV and extravascular lung water EVLW. To facilitate interpretation of these data, several ratios have been developed, including pulmonary vascular permeability index (defined as EVLW/(0.25*GEDV)) and global ejection fraction ((4*stroke volume)/GEDV). PVPI and GEF have been associated to the aetiology of pulmonary oedema and systolic cardiac function, respectively. Several studies demonstrated that the use of femoral venous access results in a marked overestimation of GEDV. This also falsely reduces PVPI and GEF. One of these studies suggested a correction formula for femoral venous access that markedly reduced the bias for GEDV. Consequently, the last PiCCO-algorithm requires information about the CVC, and correction for femoral access has been shown. However, two recent studies demonstrated inconsistencies of the last PiCCO algorithm using incorrected GEDV for PVPI, but corrected GEDV for GEF. Nevertheless, these studies were based on mathematical analyses of data displayed in a total of 15 patients equipped with only a femoral, but not with a jugular CVC. Therefore, this study compared PVPI_fem and GEF_fem derived from femoral TPTD to values derived from jugular indicator injection in 25 patients with both jugular and femoral CVCs. METHODS: 54 datasets in 25 patients were recorded. Each dataset consisted of three triplicate TPTDs using the jugular venous access as the gold standard and the femoral access with (PVPI_fem_cor) and without (PVPI_fem_uncor) information about the femoral indicator injection to evaluate, if correction for femoral GEDV pertains to PVPI_fem and GEF_fem. RESULTS: PVPI_fem_uncor was significantly lower than PVPI_jug (1.48±0.47 vs. 1.84±0.53; p<0.001). Similarly, PVPI_fem_cor was significantly lower than PVPI_jug (1.49±0.46 vs. 1.84±0.53; p<0.001). This is explained by the finding that PVPI_fem_uncor was not different to PVPI_fem_cor (1.48±0.47 vs. 1.49±0.46; n.s.). This clearly suggests that correction for femoral CVC does not pertain to PVPI. GEF_fem_uncor was significantly lower than GEF_jug (20.6±5.1% vs. 25.0±6.1%; p<0.001). By contrast, GEF_fem_cor was not different to GEF_jug (25.6±5.8% vs. 25.0±6.1%; n.s.). Furthermore, GEF_fem_cor was significantly higher than GEF_fem_uncor (25.6±5.8% vs. 20.6±5.1%; p<0.001). This finding emphasizes that an appropriate correction for femoral CVC is applied to GEF_fem_cor. The extent of the correction (25.5/20.6; 124%) for GEF and the relation of PVPI_jug/PVPI_fem_uncor (1.84/1.48; 124%) are in the same range as the ratio of GEDVI_fem_uncor/GEDVI_fem_cor (1056ml/m2/821mL/m2; 129%). This further emphasizes that GEF, but not PVPI is corrected in case of femoral indicator injection. CONCLUSIONS: Femoral indicator injection for TPTD results in significantly lower values for PVPI and GEF. While the last PiCCO algorithm appropriately corrects GEF, the correction is not applied to PVPI. Therefore, GEF-values can be used in case of femoral CVC, but PVPI-values are substantially underestimated.

Impact of Therapeutic Plasma Exchange on Hemodynamic Parameters in Medical Intensive Care Unit Patients: An Observational Study.

Therapeutic plasma exchange (TPE) is an extracorporeal treatment with reported beneficial as well as detrimental effects on circulation. However, there is a lack of data using advanced hemodynamic monitoring during TPE. Therefore, we investigated the effects of TPE on hemodynamic parameters derived from transpulmonary thermodilution (TPTD) as well as the risk for transfusion-related acute lung injury (TRALI). We compared hemodynamic parameters obtained before and after a total of 30 sessions of TPE treatment in 10 intensive care unit patients. Among standard hemodynamic parameters, heart rate (P < 0.012) and systolic blood pressure (P < 0.008) significantly increase, whereas neither mean arterial pressure nor diastolic blood pressure was altered after TPE. The TPTD-derived cardiac function parameters, cardiac index (CI; P = 0.035), cardiac power index (CPI; P = 0.008), global ejection fraction (GEF; P = 0.002), and stroke volume index (SVI; P = 0.014), were significantly higher after TPE. Furthermore, systemic vascular index significantly increased (P < 0.042). Among the cardiac preload parameters, central venous pressure was significantly lower after TPE (P < 0.001), while the global end-diastolic volume index (GEDVI) did not change. Contractility marker dPmax did not change. Finally, TPE application did not significantly alter the pulmonary hydration and permeability parameters, extravascular lung water index (EVLWI) and pulmonary vascular permeability index. Vasopressor dose was not statistically significantly altered. Considering increases in SVI, CI, GEF, and CPI and stable values for GEDVI, EVLWI, and dPmax, our data do not give any hint for hemodynamic impairment or TRALI.

Consistency of cardiac function index and global ejection fraction with global end-diastolic volume in patients with femoral central venous access for transpulmonary thermodilution: a prospective observational study.

Global ejection fraction (GEF) and cardiac function index (CFI) are transpulmonary thermodilution (TPTD)-derived indices of the systolic function. Their validity relies on an accurate determination of the global end-diastolic volume (GEDV). Due to an overestimation of GEDV using a femoral central venous catheter (CVC) a correction formula for indexed GEDV (GEDVI) has been implemented in the latest PiCCO™-algorithm. However, a recent study demonstrated that correction for femoral CVC does not pertain to pulmonary vascular permeability index PVPI, which is calculated of extravascular lung water EVLW and GEDV. Therefore, it was the aim of our study to evaluate, if GEF and CFI are corrected for femoral CVC. In ten adult ICU-patients with PiCCO™-monitoring, ten triplicate TPTDs were performed within 30 h. 95 complete data sets were analyzed, if a GEDV corrected for CVC site was applied to derive CFI and GEF. Therefore, we compared displayed values CFIdisplayed and GEFdisplayed to CFIcalculated and GEFcalculated, which were calculated from displayed GEDV, cardiac output and stroke volume. GEDVcalculated derived from division of GEDVI by predicted body surface area did not substantially differ from GEDVdisplayed (1448 ± 414 ml vs. 1447 ± 416 ml), which suggests a correction of GEDV for CVC site. However, CFIdisplayed was significantly lower than CFIcalculated (3.8 ± 1.6/min vs. 5.1 ± 1. 8/min: p < 0.001), suggesting that CFIdisplayed is based on an uncorrected GEDV. By contrast, GEFcalculated (23.1 ± 8.7 %) was not substantially different from GEFdisplayed (22.4 ± 8.6 %). Although GEDV and GEF are corrected for femoral CVC site, this does not apply to CFI. However, all indices derived from GEDV should be calculated consistently.

Clinical value of the Integrated Pulmonary Index® during sedation for interventional upper GI-endoscopy: A randomized, prospective tri-center study.

BACKGROUND AND STUDY AIMS: The Integrated Pulmonary Index® (IPI) is a mathematically-determined factor based on parameters of capnography and pulse oximetry, which should enable sensitive detection of impaired respiratory function. Aim was to investigate whether an additional measurement of the IPI during sedation for interventional endoscopy, compared to standard monitoring alone, allows a reduction of sedation-related respiratory depression. PATIENTS AND METHODS: 170 patients with standard monitoring randomly underwent either a blinded recording of capnography (control group, n=87) or capnography, including automated IPI calculation (IPI group, n=83), during deep sedation with midazolam and propofol. The primary endpoint was the maximum decrease of oxygen saturation from the baseline level before sedation. Secondary endpoints: incidence of hypoxemia (SaO2<90%), other sedation-related complications (apnea rate, bradycardia, hypotension), patient cooperation and satisfaction (VAS). RESULTS: Mean propofol dose in the IPI group (245±61mg) was comparable to the control group (225±47mg). The average drop of the oxygen saturation in the IPI group (6.5±4.1%) was nearly identical to that of the control group (7.1±4.6%, p=0.44). Apnea episodes >15s was found in 46 patients of the control and 31 of the IPI group (p<0.05). Frequency of occurrence of a drop in pO2-saturation <90%, bradycardia <50/min or a drop of systolic pressure <90mmHg were not significantly different in both groups. Mechanical ventilation was not required in any case. Patient cooperation and satisfaction were assessed similar in both groups. CONCLUSION: A clinically appealing advantage of IPI-assessment during deep sedation with midazolam and propofol for interventional endoscopy could not be documented. However, IPI registration was more effective in reducing the incidence of apnea episodes.

Usage of 1,3-ß-D-Glucan for Early Detection of Invasive Mycoses and Outcome Parameter in Immunocompromised Critically Ill Patients.

INTRODUCTION: Invasive fungal disease (IFD) remains a significant cause of morbidity and mortality in critically ill patients. METHODS: Examination of 1,3-ß-D-glucan (BDG) for IFD and as outcome parameter in immunocompromised critically ill patients with septic shock. RESULTS: Thirty-two (69 %) out of 46 included patients had BDG beyond the cutoff of >80 pg/ml (mean 320 pg/ml). Twelve (37 %) had findings of Aspergillus spp. in BAL (mean BDG 413 pg/ml). EORTC/MSG guidelines classified these as probable invasive aspergillosis (IA)/IFD. Five (16 %) had candidaemia (mean BDG level 361 pg/ml). Sensitivity of 78 % (95 % CI 58-88 %) and specificity of 68 % (95 % CI 52-77 %) for IFD were found on the BDG Fungitell assay. In detail, a sensitivity of 73 % (95 % 58-84 %) and specificity of 83 % (95 % CI 68-93 %) for IA and a sensitivity of 77 % (CI 95 % 62-87 %) and specificity 53 % (95 % CI 37-73 %) for candidaemia were found. APACHE II, SOFA score and mortality rate were in the elevated BDG group significantly altered (26 vs. 21, p < 0.003; 15 vs. 13, p < 0.006; 72 vs. 50 %, p < 0.004). CONCLUSION: 1,3-ß-D-glucan assay is helpful for early detection of IFD; moreover, elevated BDG levels can be used as a predictor for outcome in immunocompromised critically ill patients as presented in our study.

Sodium Bicarbonate Prevents Contrast-Induced Nephropathy in Addition to Theophylline: A Randomized Controlled Trial.

In this study, we investigated whether hydration with sodium bicarbonate is superior to hydration with saline in addition to theophylline (both groups) in the prophylaxis of contrast-induced nephropathy (CIN). It was a prospective, randomized, double-blinded study in a university hospital on 2 general intensive care units (63% of investigations) and normal wards.After approval of the local ethics committee and informed consent 152 patients with screening serum creatinine ≥1.1 mg/dL and/or at least 1 additional risk factor for CIN undergoing intravascular contrast media (CM) exposure were randomized to receive a total of 9 mL/kg bicarbonate 154 mmol/L (group B; n = 74) or saline 0.9% (group S; n = 78) hydration within 7 h in addition to intravenous application of 200 mg theophylline. Serum creatinine was determined immediately before, 24 and 48 h after CM exposure. As primary endpoint we investigated the incidence of CIN (increase of serum creatinine ≥0.5 mg/dL and/or ≥25% within 48 h of CM).Both groups were comparable regarding baseline characteristics. Incidence of CIN was significantly less frequent with bicarbonate compared to sodium hydration (1/74 [1.4%] vs 7/78 [9.0%]; P = 0.035). Time course of serum creatinine was more favorable in group B with decreases in serum creatinine after 24 h (-0.084 mg/dL [95% confidence interval: -0.035 to -0.133 mg/dL]; P = 0.008) and 48 h (-0.093 mg/dL (-0.025 to -0.161 mg/dL); P = 0.007) compared to baseline which were not observed in group S.In patients at increased risk of CIN receiving prophylactic theophylline, hydration with sodium bicarbonate reduces contrast-induced renal impairment compared to hydration with saline.

Comparison of Serum Galactomannan and 1,3-Beta-D-Glucan Determination for Early Detection of Invasive Pulmonary Aspergillosis in Critically Ill Patients with Hematological Malignancies and Septic Shock.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in critically ill patients with hematological malignancies. New diagnosis strategies include the noninvasive biomarkers 1,3-beta-D-glucan (BDG) and serum galactomannan (GM). METHODS: For early detection of IPA, we compared BDG Fungitell assay with GM Platelia assay. RESULTS: Twenty-two out of 30 patients (74 %) had elevated BDG levels (mean 306 pg/ml) beyond the cutoff of 80 pg/ml. GM levels were elevated in only 3 patients (10 %) over the ODI cutoff of >0.5. Following the BDG/GM and microbiological findings, 10 (34 %) cases were classified as probable IPA and 12 (40 %) as possible IPA. Eight (26 %) were classified as no IPA. An overall sensitivity of 90 % (95 % CI 86-96 %) and specificity of 85 % (95 % CI 79-86 %) was found for the BDG Fungitell assay in IPA. In contrast, an overall sensitivity of 30 % (95 % CI 26-38 %) and specificity of 98 % (95 % CI 94-100 %) was found for the GM Platelia assay. A false-negative rate of 70 % for probable IPA and 85 % for probable/possible IPA was detected for GM. The false-negative rate for BDG was 0 % in cases of probable IPA and 45 % in cases of possible cases. CONCLUSION: BDG is a sensitive marker for patients' surveillance at risk of IPA. In patients with hematological malignancies and septic shock, early diagnosis of IPA might be significantly improved by BDG compared to GM, also considering that BDG has the advantage of detecting fungal diseases other than IPA.

Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal.

BACKGROUND: Acute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, "acute" connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals. OBJECTIVES, METHODS: Since data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150 mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of "acute" connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection. RESULTS: Comparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049). CONCLUSIONS: TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a "post-RRT volume change" to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.

Pseudallescheria boydii with Aspergillus fumigatus and Aspergillus terreus in a Critically Ill Hematopoietic Stem Cell Recipient with ARDS.

Pseudallescheria boydii is a fungal organism known to affect immunocompromised patients. This organism is known to cause, in severe cases, invasive infection of various organs such as the central nervous, cardiovascular, and respiratory systems. We report an unusual case of pulmonary P. boydii pneumonia in an immunocompromised critically ill patient with a co-infection of Aspergillus fumigatus and Aspergillus terreus with ARDS. This case highlights the importance of a high index of suspicion for superimposed fungal infections in patients who are critically ill and immunocompromised. Uncommon fungal pathogens should be considered in the differential diagnosis of respiratory failure, especially if diagnostic markers such as galactomannan (from BAL and serum) or 1,3-beta-D-glucan are elevated. Further diagnostic interventions are warranted when insufficient clinical improvement is observed to prevent treatment failure and adverse outcomes.

Sustained low-efficiency dialysis with regional citrate anticoagulation in medical intensive care unit patients with liver failure: A prospective study.

PURPOSE: Patients with liver failure requiring dialysis are at increased risk for citrate accumulation during sustained low-efficiency dialysis (SLED). The aim of this study was to evaluate the feasibilty of citrate SLED in critical ill patients with liver failure and investigate predictive parameters regarding citrate accumulation. MATERIALS AND METHODS: This is a prospective study in 24 medical intensive care unit patients with liver failure and a total of 43 SLED runs (maximum of 3 runs per patient) using citrate anticoagulation. Liver function was characterized before SLED using not only laboratory parameters but also determination of the plasma disappearance rate of indocyanine green. In addition, blood gas parameters as well total calcium and citrate in serum were measured at baseline and defined time points during SLED. RESULTS: Accumulation of citrate could be observed in all SLED runs, which were nearly normalized until the end of SLED and 24 hours after SLED, respectively. However, the critical threshold of total calcium/ionized calcium on ratio of greater than 2.5 was exceeded in only 1 patient. Equalization of initial metabolic acidosis was possible without major disturbances of acid base and electrolyte status. Liver function parameters showed poor predicitve capabilities regarding citrate accumulation. CONCLUSIONS: Despite substantial accumulation of citrate in serum, SLED is save and feasible in patients with liver failure using a citrate anticoagulation. Careful monitoring of electrolytes and acid base status is mandatory to ensure patient safety.

Influence of echinocandin administration on hemodynamic parameters in medical intensive care unit patients: a single center prospective study.

PURPOSE: Fungal infections present a constant risk to critically ill and immunocompromised patients. Therefore, treatment guidelines recommend echinocandins as first-line antifungals in critically ill patients to improve patient outcomes. Echinocandins are usually well tolerated; nevertheless, rare adverse events can occur. There are reports of temporary deterioration of hemodynamic parameters during loading doses, especially in critically ill patients. The objective of this study is to analyze the hemodynamic changes during administration of the echinocandin antifungals, caspofungin and anidulafungin, in medical intensive care unit patients. METHODS: A prospective study in medical ICU patients receiving echinocandins was monitored using single-indicator transpulmonary thermodilution (TPTD). TPTD measurements were performed immediately before, directly after, and 4 h after echinocandins on two following days. RESULTS: Mean arterial pressure and also diastolic blood pressure showed significant changes (p < 0.042 and p < 0.007) after echinocandin application in the measurement immediately after application, but not after 4 h. Basic hemodynamic parameters as well as the TPTD-derived cardiac function parameters did not significantly change after echinocandin application at all. In patients with the need for norepinephrine therapy, the vasopressor dose was not statistically significantly altered. CONCLUSION: To conclude, administration of echinocandins in this observed study population is safe, even in severely critically ill patients if application rules of these agents are followed. However, adverse effects could be observed and practitioners should be cognizant of these effects. These observations can be optimized by high-level assessments, such as the pulse contour cardiac output monitoring, and clinicians should continue to be vigilant with cardiac monitoring of patients receiving echinocandin antifungals.

Patient age and duration of colonoscopy are predictors for adenoma detection in both proximal and distal colon.

AIM: To investigate the relation of patient characteristics and procedural parameters to the endoscopic detection rate of colonic adenomas. Further to study, which factors may be capable to predict the localization of adenomatous lesions. METHODS: We used the data base of a prospective randomized colonoscopy study (The ColoCap trial) to identify patients being diagnosed with colon adenoma. Logistic regression analysis was conducted to reveal predictors for adenoma detection in the entire colon and also with respect to the proximal and distal part. Covariates including age, gender, duration of colonoscopy and comorbidities were defined to determine association between predictors and adenoma detection. RESULTS: Equal numbers of adenomas were detected in the proximal and distal side of the splenic flexure [126 (57%) vs 94 (43%), P = 0.104]. Simultaneous occurrence of adenomas in both sides of the colon was rare. The appearance of both proximal and distal adenoma was associated with increasing age (P = 0.008 and P = 0.024) and increasing duration of colonoscopy (P < 0.001 and P = 0.001). Male gender was a predictor for adenoma detection in the proximal colon (P = 0.008) but statistical significance was slightly missed with respect to the distal colon (P = 0.089). Alcohol abuse was found to be a predictor for the detection of distal adenoma (P = 0.041). CONCLUSION: Increasing age and longer duration of colonoscopy are factors with a strong impact on adenoma detection both in the proximal and distal colon. Since proximal adenomas occurred in absence of distal adenomas, complete colonoscopy should be performed for screening.

Room-temperature vs iced saline indicator injection for transpulmonary thermodilution.

PURPOSE: Ice-cold injectate is assumed to provide best accuracy for transpulmonary thermodilution (TPTD)-derived cardiac index (CI), global end-diastolic volume index (GEDVI), and extravascular lung-water index (EVLWI). Room-temperature injectate might facilitate TPTD. Therefore, this study compares TPTD-results derived from iced injectate with room-temperature injectate TPTDs (TPTDRoom). MATERIALS AND METHODS: Forty-five adult intensive care unit patients with PiCCO monitoring (Pulsion Medical Systems, Munich, Germany) were included in this observational study. Four hundred one sets of TPTDs were recorded. Each set consisted of four 15 mL TPTDs (twice with 21°C and subsequently twice with 4°C saline). Means of 2 TPTDRoom were compared with means of 2 cold TPTDs (primary end point). RESULTS: Mean CI (4.70±1.60 vs 4.54±1.52 L/min per square meter; P<.001), GEDVI (985±294 vs 954±269 mL/m2; P<.001), and EVLWI (14.4±7.8 vs 13.8±7.3 mL/kg; P<.001) were significantly higher for TPTDRoom compared with TPTD-results derived from iced injectate. Mean bias and percentage error were 0.15±0.52 L/min per square meter and 21.9% for CI, 30±145 mL/m2 and 29.3% for GEDVI, and 0.59±2.1 mL/kg and 29.3% for EVLWI. Percentage error values were higher in case of femoral compared with jugular indicator injection for CI (25% vs 20%), GEDVI (35% vs 25%), and EVLWI (41% vs 23%). CONCLUSIONS: Room-temperature injectate TPTDs results in slight but significant overestimation of CI, GEDVI, and EVLWI. Percentage error values for GEDVIRoom and EVLWIRoom are acceptable only in case of "jugular" indicator injection.

Positive predictors for gastroesophageal reflux disease and the therapeutic response to proton-pump inhibitors.

AIM: To identify objective and subjective predictors for the reliable diagnosis of gastroesophageal reflux disease (GERD) and the response to proton pump inhibitor (PPI) therapy. METHODS: Retrospectively, 683 consecutive patients suspected for GERD who underwent pH-metry/impedance measurement (pH/MII) were analyzed. All patients had previously undergone standard PPI treatment (e.g., pantoprazole 40 mg/d or comparable). Four hundred sixty patients were at least 10 d off PPIs (group A), whereas 223 patients were analyzed during their ongoing PPI therapy (group B). In addition, all patients completed a standardized symptom- and lifestyle-based questionnaire, including the therapeutic response to previous PPI trials on a 10-point scale. Uni- and multivariance analyses were performed to identify criteria associated with positive therapeutic response to PPIs. RESULTS: In group A, positive predictors (PPs) for response in empirical PPI trials were typical GERD symptoms (heartburn and regurgitation), a positive symptom index (SI) and pathological results in pH/MII, along with atypical symptoms, including hoarseness and fullness. In group B, regular alcohol consumption was associated with the therapeutic response. The PPs for pathological results in pH/MII in group A included positive SI, male gender, obesity, heartburn and regurgitation. In group B, the PPs were positive SI and vomiting. Analyzing for positive SI, the PPs were pathological pH and/or MII, heartburn regurgitation, fullness, nausea and vomiting in group A and pathological pH and/or MII in group B. CONCLUSION: Anamnestic parameters (gender, obesity, alcohol) can predict PPI responses. In non-obese, female patients with non-typical reflux symptoms, pH/MII should be considered instead of empirical PPIs.

Pulmonary vascular permeability index and global end-diastolic volume: are the data consistent in patients with femoral venous access for transpulmonary thermodilution: a prospective observational study.

BACKGROUND: Transpulmonary thermodilution (TPTD) derived parameters are used to direct fluid management in ICU-patients. Extravascular lung water EVLW and its ratio to pulmonary blood volume (pulmonary vascular permeability index PVPI) have been associated with mortality. In single indicator TPTD pulmonary blood volume (PBV) is estimated to be 25% of global end-diastolic volume (GEDV). A recent study demonstrated marked overestimation of GEDV indexed to body-surface area (BSA; GEDVI) when using a femoral central venous catheter (CVC) for indicator injection due to the additional volume measured in the vena cava inferior. Therefore, a correction formula derived from femoral TPTD and biometric data has been suggested. Consequence, one of the commercially available TPTD-devices (PiCCO; Pulsion Medical Systems, Germany) requires information about CVC site. Correction of GEDVI for femoral CVC can be assumed. However, there is no data if correction also pertains to unindexed GEDV, which is used for calculation of PBV and PVPI. Therefore, we investigated, if also GEDV, PBV and PVPI are corrected by the new PiCCO-algorithm. METHODS: In this prospective study 110 triplicate TPTDs were performed within 30 hours in 11 adult ICU-patients with PiCCO-monitoring and femoral CVC. We analyzed if the femoral TPTD correction formula for GEDVI was also applied to correct GEDV. Furthermore, we compared PVPIdisplayed to PVPIcalculated which was calculated as EVLWdisplayed/(0.25*GEDVdisplayed). RESULTS: Multiplication of GEDVIdisplayed by BSA resulted in GEDVcalculated which was not significantly different to GEDVdisplayed (1459 ± 365 mL vs. 1459 ± 366 mL) suggesting that correction for femoral indicator injection also pertains to GEDVdisplayed. However, PVPIdisplayed was significantly lower than PVPIcalculated (1.64 ± 0.57 vs. 2.27 ± 0.72; p < 0.001). In addition to a bias of -0.64 ± 0.22 there was a percentage error of 22%. Application of the correction formula suggested for GEDVI to PVPIdisplayed reduced the bias of PVPIdisplayed compared to EVLW/PBV from -0.64 ± 0.22 to -0.10 ± 0.05 and the percentage error from 22% to 4%. CONCLUSIONS: Correction for femoral CVC in the PiCCO-device pertains to both GEDVIdisplayed and GEDVdisplayed, but not to PVPIdisplayed. To provide consistent information, PVPI should be calculated based on GEDVcorrected in case of femoral CVC.

Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: a randomized, controlled study (ColoCap Study).

OBJECTIVES: The aim of this randomized study was to determine whether intervention based on additional capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol sedation for colonoscopy. METHODS: Patients (American Society of Anesthesiologists classification (ASA) 1-3) scheduled for colonoscopy under propofol sedation were randomly assigned to either a control arm with standard monitoring (standard arm) or an interventional arm in which additional capnographic monitoring (capnography arm) was available. In both study arms, detection of apnea or altered respiration induced withholding propofol administration, stimulation of the patient, chin lift maneuver, or further measures. The primary study end point was the incidence of arterial oxygen desaturation (defined as a fall in oxygen saturation (SaO(2)) of ≥5% or <90%); secondary end points included the occurrences of hypoxemia (SaO(2) <90%), severe hypoxemia (SaO(2) ≤85%), bradycardia, hypotension, and the quality of sedation (patient cooperation and patient satisfaction). RESULTS: A total of 760 patients were enrolled at three German endoscopy centers. The intention-to-treat analysis revealed a significant reduction of the incidence of oxygen desaturation in the capnography arm in comparison with the standard arm (38.9% vs. 53.2%; P<0.001). The numbers of patients with a fall in SaO(2) <90% and ≤85% were also significantly different (12.5% vs. 19.8%; P=0.008 and 3.7 vs. 7.8%; P=0.018). There were no differences regarding the rates of bradycardia and hypotension. Quality of sedation was similar in both groups. Results of statistical analyses were maintained for the per-protocol population. CONCLUSIONS: Additional capnographic monitoring of ventilatory activity reduces the incidence of oxygen desaturation and hypoxemia during propofol sedation for colonoscopy.