Pulmonary CT perfusion robustly measures cardiac output in the context of multilevel pulmonary occlusion: a porcine study.

BACKGROUND: To validate pulmonary computed tomography (CT) perfusion in a porcine model by invasive monitoring of cardiac output (CO) using thermodilution method. METHODS: Animals were studied at a single center, using a Swan-Ganz catheter for invasive CO monitoring as a reference. Fifteen pigs were included. Contrast-enhanced CT perfusion of the descending aorta and right and left pulmonary artery was performed. For variation purposes, a balloon catheter was inserted to block the contralateral pulmonary vascular bed; additionally, two increased CO settings were created by intravenous administration of catecholamines. Finally, stepwise capillary occlusion was performed by intrapulmonary arterial injection of 75-µm microspheres in four stages. A semiautomatic selection of AFs and a recirculation-aware tracer-kinetics model to extract the first-pass of AFs, estimating blood flow with the Stewart-Hamilton method, was implemented. Linear mixed models (LMM) were developed to calibrate blood flow calculations accounting with individual- and cohort-level effects. RESULTS: Nine of 15 pigs had complete datasets. Strong correlations were observed between calibrated pulmonary (0.73, 95% confidence interval [CI] 0.6-0.82) and aortic blood flow measurements (0.82, 95% CI, 0.73-0.88) and the reference as well as agreements (± 2.24 L/min and ± 1.86 L/min, respectively) comparable to the state of the art, on a relatively wide range of right ventricle-CO measurements. CONCLUSIONS: CT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by referencing the invasive CO. RELEVANCE STATEMENT: Possible clinical applications of CT perfusion for measuring CO could be in acute pulmonary thromboembolism or to assess right ventricular function to show impairment or mismatch to the left ventricle. KEY POINTS: • CT perfusion measures flow in vessels. • CT perfusion measures cumulative cardiac output in the aorta and pulmonary vessels. • CT perfusion validly measures CO using LMMs at both individual and cohort levels, as demonstrated by using the invasive CO as a reference standard.

Continuous cardiac output measured with a Swan-Ganz catheter reacts too slowly in animal experiments with sudden circulatory failure.

BACKGROUND: In many animal experiments, it is vital to detect sudden changes in cardiac output (CO). This porcine study compared CO that was measured with a Swan-Ganz pulmonary catheter with the gold standard (which was a transit-time flow probe around the pulmonary artery) during interventions that caused hemodynamic instability. METHODS: In one series, 7 pigs were exposed to sudden changes in CO. In another series, 9 pigs experienced more prolonged changes in CO. All the pigs had a Swan-Ganz catheter placed into the pulmonary artery and a flow probe around the pulmonary artery. Adrenaline infusion and controlled hemorrhage were used to increase and decrease CO, respectively. The measurements of CO before and after each intervention were compared for correlation, agreement, and the time delay that it took each method to detect at least a 30% change in CO. A Bland-Altman test was used to identify correlations and agreements between the methods. RESULTS: In the first series, there was a delay of 5-7 min for the Swan Ganz catheter to register a 30% change in cardiac output, compared with the flow probe. However, during prolonged changes in CO in the second series, there was a good correlation between the 2 methods. Mixed venous oxygen saturation reacted faster to changes than did CO; both were measured via the Swan-Ganz catheter. CONCLUSIONS: In many animal studies, the use of Swan-Ganz catheters is suitable; however, in experiments with sudden hemodynamic instability, the flow probe is the most advantageous method for measuring CO.

Cardiac output monitoring - invasive and noninvasive.

PURPOSE OF REVIEW: The purpose of this article is to review various contemporary cardiac output (CO) measurement technologies available and their utility in critically ill patients. RECENT FINDINGS: CO measurement devices can be invasive, minimally invasive, or noninvasive depending upon their method of CO measurement. All devices have pros and cons, with pulmonary artery catheter (PAC) being the gold standard. The invasive techniques are more accurate; however, their invasiveness can cause more complications. The noninvasive devices predict CO via mathematical modeling with several assumptions and are thus prone to errors in clinical situations. Recently, PAC has made a comeback into clinical practice especially in cardiac intensive care units (ICUs). Critical care echocardiography (CCE) is an upcoming tool that not only provides CO but also helps in differential diagnosis. Lack of proper training and nonavailability of equipment are the main hindrances to the wide adoption of CCE. SUMMARY: PAC thermodilution for CO measurement is still gold standard and most suitable in patients with cardiac pathology and with experienced user. CCE offers an alternative to thermodilution and is suitable for all ICUs; however, structural training is required.

Comparison of accuracy of two uncalibrated pulse contour cardiac output monitors in off-pump coronary artery bypass surgery patients using pulmonary artery catheter-thermodilution as a reference.

BACKGROUND: Cardiac output (CO) is a key measure of adequacy of organ and tissue perfusion, especially in critically ill or complex surgical patients. CO monitoring technology continues to evolve. Recently developed CO monitors rely on unique algorithms based on pulse contour analysis of an arterial blood pressure (ABP) waveform. The objective of this investigation was to compare the accuracy of two monitors using different methods of pulse contour analysis - the Retia Argos device and the Edwards Vigileo-FloTrac device - with pulmonary artery catheter (PAC)-thermodilution as a reference. METHODS: Fifty-eight patients undergoing off-pump coronary artery bypass surgery formed the study cohort. A total of 572 triplets of CO measurements from each device - Argos, Vigileo-FloTrac (third generation), and thermodilution - were available before and after interventions (e.g., vasopressors, fluids, and inotropes). Bland-Altman analysis accounting for repeated measurements per subject and concordance analysis were applied to assess the accuracy of the CO values and intervention-induced CO changes of each pulse contour device against thermodilution. Cluster bootstrapping was employed to statistically compare the root-mean-squared-errors (RMSE = √(µ2 + σ2), where µ and σ are the Bland-Altman bias and precision errors) and concordance rates of the two devices. RESULTS: The RMSE (mean (95% confidence intervals)) for CO values was 1.16 (1.00-1.32) L/min for the Argos device and 1.54 (1.33-1.77) L/min for the Vigileo-FloTrac device; the concordance rate for intervention-induced CO changes was 87 (82-92)% for the Argos device and 72 (65-78)% for the Vigileo-FloTrac device; and the RMSE for the CO changes was 17 (15-19)% for the Argos device and 21 (19-23)% for the Vigileo-FloTrac device (p < 0.0167 for all comparisons). CONCLUSIONS: In comparison with CO measured by the PAC, the Argos device proved to be more accurate than the Vigileo-FloTrac device in CO trending and absolute CO measurement in patients undergoing off-pump coronary artery bypass surgery.

Cephalad misplacement of a pulmonary artery catheter in a patient with a preexisting Hickman catheter.

BACKGROUND: Pulmonary artery catheter insertion is a routine practice in high-risk patients undergoing cardiac surgery. However, pulmonary artery catheter insertion is associated with numerous complications that can be devastating to the patient. Incorrect placement is an overlooked complication with few case reports to date. CASE PRESENTATION: An 18-year-old male patient underwent elective mitral valve replacement due to severe mitral valve regurgitation. The patient had a history of synovial sarcoma, and Hickman catheter had been inserted in the right internal jugular vein for systemic chemotherapy. We made multiple attempts to position the pulmonary artery catheter in the correct position but failed. A chest radiography revealed that the pulmonary artery catheter was bent and pointed in the cephalad direction. Removal of the pulmonary artery catheter was successful, and the patient was discharged 10 days after the surgery without complications. CONCLUSIONS: To prevent misplacement of the PAC, clinicians should be aware of multiple risk factors in difficult PAC placement, and be prepared to utilize adjunctive methods, such as TEE and fluoroscopy.

Lack of correlation between the left ventricular outflow tract velocity-time integral and the stroke volume index: Should we be worried about that? / Ausencia de correlación entre la integral velocidad-tiempo en el tracto de salida del ventrículo izquierdo y el índice de volumen sistólico: ¿deberíamos preocuparnos?

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Is There a Need for a Pulmonary Artery Catheter in Cardiac Surgery Today?

Pulmonary artery catheters are a useful tool for hemodynamic monitoring in high-risk patients during surgery and while in intensive care. However, there are major risks inherent to the device, and with modern day technology, their routine use has decreased. We discuss the need for routine insertion of pulmonary artery catheters in cardiac surgery. We also present a case of a left ventricular assist device implantation complicated by serious pulmonary hemorrhage due to pulmonary artery catheter insertion, highlighting the potentially life-threatening risks involved.

Hemodynamic Effects of Ultrasound-Assisted, Catheter-Directed, Very Low-Dose, Short-Time Duration Thrombolysis in Acute Intermediate-High Risk Pulmonary Embolism (from the EKOS-PL Study).

Ultrasound-assisted, catheter-directed, low-dose thrombolysis (USAT) at an average alteplase dose of 20 mg infused over 12 to 24 hours reversed right ventricular disfunction and improved pulmonary hemodynamics in intermediate-high-risk pulmonary embolism patients. As bleeding risk increases with the thrombolytic dose, establishing a minimal effective USAT dosing regimen is of clinical importance. We aimed to investigate hemodynamic effects and safety of a very low-alteplase-dose USAT of 10 mg administered within 5 hours. We included 12 consecutive intermediate-high-risk pulmonary embolism patients with symptoms duration of <14 days and proximal thrombi location in pulmonary arteries. Pulmonary Embolism Response Team decision-based fixed, bilateral ultrasound-assisted alteplase infusions at the rate of 1mg/hour/catheter for 5 hours through EKOS system catheters were made. The primary efficacy measure was the change in invasive systolic and mean pulmonary arteries pressure, and in cardiac index from USAT start to termination. Safety measures were 180-day all-cause death or cardiopulmonary decompensation and bleeding complications. The systolic pulmonary arteries pressure and mean pulmonary arteries pressure decreased from 53 (45.5 to 59) to 37.5 (27.5 to 40.5) mm Hg (p = 0.02) and from 29.5 (27.5 to 32) to 21.5 (15.5 to 25) mm Hg (p = 0.02), respectively. The cardiac index increased from 1.6 (1.5 to 1.8) to 2.2 (1.9 to 2.4) l/min/m2, (p = 0.02). No deaths, decompensations, or need for therapy intensification occurred. There was 1 episode of access-site bleeding, which subsided after conservative management. No intracranial hemorrhages appeared. In conclusion, reduced dose and duration USAT improved pulmonary hemodynamics and cardiac function leading to cardiopulmonary stabilization in intermediate-high risk pulmonary embolism patients at a low periprocedural risk.

Fragmentación mecánica y trombólisis guiada por catéter en la embolia pulmonar de riesgo intermedio / Mechanical fragmentation and catheter-guided thrombolysis in intermediate risk pulmonary embolism

La tromboembolia pulmonar aguda (TEPA) sigue siendo una importante causa de morbilidad y mortalidad a nivel mundial. Su diagnóstico, estratificación de riesgo y tratamiento precoz son fundamentales, siendo su pilar la anticoagulación. En pacientes de bajo riesgo cardiovascular, el pronóstico es excelente y solo basta con la administración de anticoagulantes. No obstante, debido al pobre pronóstico de los pacientes con riesgo elevado (descompensación hemodinámica), el enfoque terapéutico es más agresivo, utilizándose trombolíticos sistémicos que disminuyen la mortalidad pero incrementan el riesgo de complicaciones hemorrágicas mayores. En el TEPA de riesgo intermedio (evidencia de falla de ventrículo derecho, sin descompensación hemodinámica), la relación riesgo-beneficio del tratamiento con trombolíticos es más equilibrada por lo que la decisión es controvertida. La fragmentación mecánica con trombólisis dirigida por catéter es una alternativa con potenciales beneficios. Presentamos dos casos de TEPA de riesgo intermedio, en los que se realizó fragmentación mecánica y trombólisis dirigida por catéter.

Acute pulmonary thromboembolism remains a significant cause of morbidity and mortality worldwide. Its diagnosis, risk stratification and early treatment are essential. The mainstay of treatment is anticoagulation. In patients with low cardiovascular risk, the prognosis is excellent and the treatment consists only of the administration of anticoagulants. Due to the poor prognosis of patients with high risk (hemodynamic decompensation), the approach is more aggressive using systemic thrombolytics, which reduce mortality but increase the risk of major hemorrhagic complications. In the intermediate-risk patients (evidence of right ventricular failure, without hemodynamic decompensation), the risk-benefit relationship of thrombolytic treatment is more balanced, so the choice is controversial. Mechanical fragmentation with catheter-directed thrombolysis is an alternative with potential benefits. We present two cases of intermediate-risk acute pulmonary thromboembolism to whom mechanical fragmentation and catheter-directed thrombolysis was applied.

[Mechanical fragmentation and catheter-guided thrombolysis in intermediate risk pulmonary embolism]. / Fragmentación mecánica y trombólisis guiada por catéter en la embolia pulmonar de riesgo intermedio.

Acute pulmonary thromboembolism remains a significant cause of morbidity and mortality worldwide. Its diagnosis, risk stratification and early treatment are essential. The mainstay of treatment is anticoagulation. In patients with low cardiovascular risk, the prognosis is excellent and the treatment consists only of the administration of anticoagulants. Due to the poor prognosis of patients with high risk (hemodynamic decompensation), the approach is more aggressive using systemic thrombolytics, which reduce mortality but increase the risk of major hemorrhagic complications. In the intermediate-risk patients (evidence of right ventricular failure, without hemodynamic decompensation), the risk-benefit relationship of thrombolytic treatment is more balanced, so the choice is controversial. Mechanical fragmentation with catheter-directed thrombolysis is an alternative with potential benefits. We present two cases of intermediate-risk acute pulmonary thromboembolism to whom mechanical fragmentation and catheter-directed thrombolysis was applied.

La tromboembolia pulmonar aguda (TEPA) sigue siendo una importante causa de morbilidad y mortalidad a nivel mundial. Su diagnóstico, estratificación de riesgo y tratamiento precoz son fundamentales, siendo su pilar la anticoagulación. En pacientes de bajo riesgo cardiovascular, el pronóstico es excelente y solo basta con la administración de anticoagulantes. No obstante, debido al pobre pronóstico de los pacientes con riesgo elevado (descompensación hemodinámica), el enfoque terapéutico es más agresivo, utilizándose trombolíticos sistémicos que disminuyen la mortalidad pero incrementan el riesgo de complicaciones hemorrágicas mayores. En el TEPA de riesgo intermedio (evidencia de falla de ventrículo derecho, sin descompensación hemodinámica), la relación riesgo-beneficio del tratamiento con trombolíticos es más equilibrada por lo que la decisión es controvertida. La fragmentación mecánica con trombólisis dirigida por catéter es una alternativa con potenciales beneficios. Presentamos dos casos de TEPA de riesgo intermedio, en los que se realizó fragmentación mecánica y trombólisis dirigida por catéter.

Mixed Shock States: A Case for the Pulmonary Artery Catheter.

The pulmonary artery catheter is a valuable tool available to the clinician for use in deciphering complex hemodynamic scenarios. Patients in shock, particularly those who are elderly or have premorbid conditions such as heart failure, may have atypical presentations. Additional hemodynamic data may help identify interventions that might seem counterintuitive, such as the use of vasoconstrictors in patients with low cardiac output. Interpretation of pulmonary artery hemodynamic data is a skill that should not be relegated to the past. This article reviews the use of a pulmonary artery catheter in mixed shock states. A case study is used to demonstrate how pulmonary artery catheter hemodynamic values can guide the care of these patients.

Catheter-Directed Pharmacologic Thrombolysis for Acute Submassive and Massive Pulmonary Emboli in Children and Adolescents-An Exploratory Report.

OBJECTIVES: The objective of this study is to report a single-center experience of the safety and efficacy of pulmonary artery catheter-directed thrombolysis for both massive and submassive pulmonary emboli in the pediatric and adolescent population. DESIGN: A 22-month retrospective review of the electronic medical record and picture archiving and communication system was performed of patients less than 21 years old, presenting with massive or submassive pulmonary emboli treated with pulmonary artery catheter-directed thrombolysis at a single, tertiary care pediatric hospital. Multiple variables were analyzed including indications, technical success, clinical efficacy, and complications. SETTING: A single, tertiary care pediatric hospital. PATIENTS: Nine patients (mean 13.9 yr; range 6-19 yr) with massive and/or submassive pulmonary emboli who underwent pulmonary artery catheter-directed thrombolysis met inclusion criteria. INTERVENTIONS: Catheter-directed thrombolysis. MEASUREMENTS AND MAIN RESULTS: Pulmonary emboli was diagnosed by CT angiography in all cases. Catheter-directed thrombolysis alone was clinically successful (defined as improved cardiopulmonary function following catheter-directed thrombolysis) in seven patients (78%) with two patients not improving following catheter-directed thrombolysis. There were no immediate bleeding complications from catheter-directed thrombolysis therapy. All patients were maintained on anticoagulation treatment following catheter-directed thrombolysis. Catheter-directed thrombolysis was technically successful (defined as successful placement of pulmonary artery infusion catheters with full or partial resolution of thrombus) in all cases. Follow-up pulmonary angiography at the cessation of catheter-directed thrombolysis revealed complete thrombus resolution in four patients (44%) and partial resolution in five patients (55%). Mean pulmonary artery pressures decreased in all patients (mean precatheter-directed thrombolysis pulmonary artery pressure = 37 ± 11 mm Hg; mean postcatheter-directed thrombolysis pulmonary artery pressure = 28 ± 10 mm Hg; p = 0.0164). CONCLUSIONS: Pulmonary artery catheter-directed thrombolysis is a technically feasible therapeutic option for children and adolescents with submassive and massive pulmonary emboli.

Utilization and Outcomes of Thrombolytic Therapy for Acute Pulmonary Embolism: A Nationwide Cohort Study.

BACKGROUND: There are increased options to deliver thrombolytic treatment for acute, high-risk pulmonary embolism (PE). The goals of this study were to examine practice patterns of systemic thrombolysis and catheter-directed thrombolysis (CDT) and to compare outcomes following CDT with ultrasound facilitation (CDT-ultrasound) and CDT alone. METHODS: The study analyzed adults aged > 18 years with hospitalizations associated with acute PE and thrombolysis in the 2016 Nationwide Readmissions Database. The study identified characteristics associated with the use of systemic thrombolysis and CDT. Comparisons of CDT-ultrasound vs CDT alone were then made by evaluating in-hospital events and readmissions. The primary outcomes were in-hospital mortality and 30-day readmission rates. RESULTS: Among 5,436 hospitalizations, systemic thrombolysis was used more often (n = 3,376; 62.1%) than CDT (n = 2,060; 37.9%). Compared with CDT, systemic thrombolysis was used more frequently in patients with higher rates of vasopressor use (4.3% vs 1.0%), shock (15.8% vs. 6.9%), cardiac arrest (12.7% vs 3.4%), and mechanical ventilation (19.0% vs 5.9%). Among patients who underwent CDT, 417 (20.2%) received CDT-ultrasound, and 1,643 (79.8%) received CDT alone. Rates of bleeding events, vasopressor use, and mechanical ventilation were similar between therapeutic strategies. Following adjustment, in-hospital mortality (OR, 1.19; 95% CI, 0.63-2.26; P = .59) and 30-day readmission rates (OR, 0.75; 95% CI, 0.47-1.22; P = .25) were not significantly different between CDT-ultrasound and CDT alone. CONCLUSIONS: Systemic thrombolysis is used more often than CDT in patients with acute PE, in particular among those with a greater prevalence of high-risk features. Among patients treated with CDT, there were no differences in events between CDT-ultrasound and CDT alone.

Catheter-directed thrombolysis for submassive pulmonary embolism in children: A case series.

Incidence of venous thromboembolism, including pulmonary embolism (PE), continues to rise in children. Optimum management of submassive PE is unclear. The principal objective of this retrospective study was to investigate the radiological and clinical outcomes in children with submassive PE treated with catheter-directed thrombolysis (CDT). Five patients underwent six episodes of CDT. No patient developed major/clinically relevant non-major bleeding. Most patients had complete radiological thrombus resolution and no patient had evidence of chronic thromboembolic pulmonary hypertension. There is an urgent need for larger prospective cohort studies/randomized controlled trials to investigate the role of CDT in pediatric PE.

Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock: The NICOM Study.

BACKGROUND: The bioreactance technique is a relatively new, totally noninvasive technique that is used to measure cardiac output (CO) and is easy to use. The Non-Invasive Cardiac Output Monitor (NICOM) is 1 such system. Although approved by the Food and Drug Administration for measurement of stroke volume, there is a paucity of literature validating this technology in decompensated heart failure and cardiogenic shock. METHODS AND RESULTS: Fifty patients admitted to our cardiac intensive care unit for cardiogenic shock and Swan-Ganz catheter-guided therapy were prospectively enrolled in the study after informed consent. Simultaneous measurements of CO were obtained using NICOM, indirect Fick and bolus thermodilution. The intraclass correlation coefficient (ICC) was used to assess the precision of NICOM for CO using the 3 repeated measurements of CO over the pooled data. The agreement of the NICOM device in the defined clinical population, compared to indirect Fick and thermodilution, was evaluated by comparing the Pearson correlation coefficient, the Bland-Altman plot and the Lin concordance correlation coefficient. The ICC for cardiac output measured by NICOM showed excellent repeatability (ICC = 0.93, 95% CI = 0.92-0.94, n = 262) in the pooled data. The Pearson correlation coefficient for cardiac output measured by NICOM was poor when compared to indirect Fick (n = 263, r = 0.132, P = 0.033) and TD (n = 258, r = 0.275, P < 0.001). CONCLUSIONS: NICOM technology is not a reliable method of measuring CO in patients with decompensated heart failure and cardiogenic shock.

Monitorizacion del gasto cardiaco con ecocardiografia transtoracica y cateter de Swan Ganz. Estudio comparativo en pacientes en ventilacion mecanica con presión positiva espiratoria final elevada / Cardiac output measured by transthoracic echocardiography and Swan-Ganz catheter. A comparative study in mechanically ventilated patients with high positive end-expiratory pressure

RESUMEN Objetivo: Comparar las medidas de gasto cardiaco por ecocardiografía transtorácica y por catéter arterial pulmonar en pacientes en ventilación mecánica con presión positiva al final de la espiración elevada. Evaluar el efecto de la insuficiencia tricúspide. Métodos: Se estudiaron 16 pacientes en ventilación mecánica. El gasto cardiaco se midió con el catéter arterial pulmonar y por ecocardiografía transtorácica. Las medidas se realizaron en diferentes niveles de presión positiva al final de la espiración (10cmH2O, 15cmH2O, y 20cmH2O). Se evalúo el efecto de la insuficiencia tricúspide sobre la medida de gasto cardiaco. Se estudió el coeficiente de correlación intraclase; el error medio y los límites de concordancia se estudiaron con el diagrama de Bland-Altman. Se calculó el porcentaje de error. Resultados: Se obtuvieron 44 pares de medidas de gasto cardiaco. Se obtuvo un coeficiente de correlación intraclase de 0,908, p < 0,001; el error medio fue 0,44L/min para valores de gasto cardíaco entre 5 a 13L/min. Los límites de concordancia se encontraron entre 3,25L/min y -2,37L/min. Con insuficiencia tricúspide el coeficiente de correlación intraclase fue 0,791, sin insuficiencia tricúspide el coeficiente de correlación intraclase fue 0,935. La presencia de insuficiencia tricúspide aumentó el porcentaje de error de 32 % a 52%. Conclusiones: En pacientes con presión positiva al final de la espiración elevada la medida de gasto cardiaco por ecocardiografía transtorácica es comparable con catéter arterial pulmonar. La presencia de insuficiencia tricúspide influye en el coeficiente de correlación intraclase. En pacientes con presión positiva al final de la espiración elevada, el uso de ecocardiografía transtorácica para medir gasto cardiaco es comparable con las medidas invasivas.

ABSTRACT Objective: To compare cardiac output measurements by transthoracic echocardiography and a pulmonary artery catheter in mechanically ventilated patients with high positive end-expiratory pressure. To evaluate the effect of tricuspid regurgitation. Methods: Sixteen mechanically ventilated patients were studied. Cardiac output was measured by pulmonary artery catheterization and transthoracic echocardiography. Measurements were performed at different levels of positive end-expiratory pressure (10cmH2O, 15cmH2O, and 20cmH2O). The effect of tricuspid regurgitation on cardiac output measurement was evaluated. The intraclass correlation coefficient was studied; the mean error and limits of agreement were studied with the Bland-Altman plot. The error rate was calculated. Results: Forty-four pairs of cardiac output measurements were obtained. An intraclass correlation coefficient of 0.908 was found (p < 0.001). The mean error was 0.44L/min for cardiac output values between 5 and 13L/min. The limits of agreement were 3.25L/min and -2.37L/min. With tricuspid insufficiency, the intraclass correlation coefficient was 0.791, and without tricuspid insufficiency, 0.935. Tricuspid insufficiency increased the error rate from 32% to 52%. Conclusions: In patients with high positive end-expiratory pressure, cardiac output measurement by transthoracic echocardiography is comparable to that with a pulmonary artery catheter. Tricuspid regurgitation influences the intraclass correlation coefficient. In patients with high positive end-expiratory pressure, the use of transthoracic echocardiography to measure cardiac output is comparable to invasive measures.

Pulmonary Artery Catheters: Impact of e-Learning on Hemodynamic Assessments.

Pulmonary artery catheters (PACs) are invasive devices placed in critically ill patients to monitor hemodynamic data. They are a high-risk, and in some settings a low-volume, medical device due to the complex insertion procedure and potentially lethal complications. Smaller intensive care units (ICUs) have large variances in exposure to PACs, therefore strengthening ICU nurses' belief in their ability to manage these hemodynamic monitoring devices is of utmost importance. The design is a single-group, pre/posttest study conducted on a 15-bed ICU to survey nurses' self-efficacy, knowledge, and satisfaction of an e-learning educational module. Both PAC and noninvasive cardiac output monitor patient application data were collected prior to and following the intervention. Fifteen ICU nurses completed all components of the module. Confidence in ability to accurately interpret hemodynamic data increased from pre- to postintervention (P < .001), and knowledge also increased from pre- to postintervention, albeit not statistically significantly (P = .088). Overall, nurses reported satisfaction with the educational module. With increased self-efficacy, nurses can feel empowered and motivated to further improve patient care management. Thus, workplaces should continue to advocate for additional educational tools for high-risk, low-volume devices.

Right Atrial, Right Ventricular, Superior Vena Cava Dissection Caused by Swan-Ganz Catheter Placement.

This case involves Swan-Ganz catheter placement in a patient who developed cardiogenic shock, possibly due to the catheter dissecting the intimal lining of the superior vena cava and endocardium.