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1.
J Cardiothorac Vasc Anesth ; 33(5): 1230-1236, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30318421

RESUMO

OBJECTIVE: Evaluate the accuracy and trending ability of the fourth-generation FloTrac/EV1000 (Edwards Lifesciences, Irvine, CA) system in patients with severe aortic valve stenosis by comparing FloTrac/EV1000-derived cardiac output (CCO-FT) with continuous thermodilution pulmonary artery catheter (CCO-PAC) measurements before and after surgical valve replacement. DESIGN: Prospective clinical study. SETTING: Anesthesia for cardiac surgery, operating room, single-center university hospital. PARTICIPANTS: Twenty-five patients were included. After exclusion, 20 patients undergoing elective aortic valve replacement were analyzed. INTERVENTIONS: After induction of general anesthesia, CCO-FT and CCO-PAC values were recorded every 30 seconds before and after aortic valve replacement with a bioprosthesis under cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: Data were analyzed separately from skin incision to last suture and before and after CPB. Regression analyses, Bland-Altman analyses, and trending analyses (4-quadrant plot, polar plot) were performed. The percentage errors of the FloTrac/EV1000 were 69.7% and 59.3% before and after CPB, respectively. The concordance rates (CRs) and angular CRs of the FloTrac/EV1000 were 50.9% and 57.1%, and 48.7% and 61.9% before and after CPB, respectively. CONCLUSION: This study revealed a low level of agreement and poor trending ability of the FloTrac/EV1000 system compared to continuous thermodilution pulmonary artery catheter in patients with severe aortic stenosis. Although there was a slight improvement after surgical valve replacement and CPB, the results were not within acceptable limits to replace CCO-PAC in this patient population.


Assuntos
Estenose da Valva Aórtica/cirurgia , Débito Cardíaco/fisiologia , Cateterismo de Swan-Ganz/tendências , Implante de Prótese de Valva Cardíaca/tendências , Índice de Gravidade de Doença , Termodiluição/tendências , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Cateterismo de Swan-Ganz/normas , Feminino , Implante de Prótese de Valva Cardíaca/normas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Termodiluição/normas
2.
Crit Care ; 21(1): 147, 2017 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-28625165

RESUMO

BACKGROUND: For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. MAIN BODY: Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. CONCLUSIONS: Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of "advanced" devices that are indicated for the most critically ill and/or complex patients.


Assuntos
Estado Terminal/terapia , Monitorização Fisiológica/métodos , Termodiluição/métodos , Termodiluição/normas , Débito Cardíaco/fisiologia , Cateterismo de Swan-Ganz/métodos , Cateterismo de Swan-Ganz/normas , Hemodinâmica/fisiologia , Humanos , Unidades de Terapia Intensiva/organização & administração , Monitorização Fisiológica/normas , Análise de Onda de Pulso/métodos
3.
Anesth Analg ; 122(5): 1480-3, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27101495

RESUMO

BACKGROUND: Pulmonary artery catheters (PACs) are frequently used for monitoring patient temperatures in the intensive care unit. Nevertheless, data regarding the accuracy of these measurements are lacking, and few data testify to the accuracy of temperatures recorded after the PAC has been in place for several days. The absolute values of such measurements are relevant for critical care because patient temperatures are often used as diagnostic criteria for sepsis and antibiotic therapy. We thus hypothesized that the Edwards Lifesciences PAC would accurately measure blood temperature. To test our hypothesis, we compared temperature measurements obtained from PACs inserted in patients for different lengths of time with measurements of a reference platinum resistance thermometer (PRT). METHODS: PACs were removed and analyzed in 39 patients in whom PACs were inserted for 0 to 5 days. The PACs were placed in calibration baths, and 10 consecutive measurements at each of 7 different temperatures were obtained (36°C, 36.5°C, 37°C, 38°C, 38.3°C, 39°C, and 40°C). The temperature measurements obtained using PACs were compared with measurements obtained using a PRT. Bland-Altman statistical analyses were performed. Outliers, defined as PAC temperature measurements that varied more than ±0.3°C from PRT measurements, were identified. We considered a catheter unfit for clinical diagnostic or therapeutic use if ≥15% of data pairs were outliers. RESULTS: A total of 2730 data pairs were analyzed. Overall, the bias was -0.15°C; the precision was +0.13°C; and the limits of agreement were -0.45°C to +0.13°C. The bias and limits of agreement did not differ according to the age of the catheter or the temperature tested. One hundred fourteen data pairs (4.2% [95% confidence interval, 2.0%-6.4%]), involving 13 PACs and mostly from 4 PACs, were outliers. CONCLUSIONS: We conclude that temperature measurements obtained using the Edwards Lifesciences PACs are thus sufficiently accurate to be used for clinical temperature monitoring in critically ill patients.


Assuntos
Regulação da Temperatura Corporal , Cateterismo de Swan-Ganz/instrumentação , Cateteres de Demora , Monitorização Fisiológica/instrumentação , Termodiluição/instrumentação , Termômetros , Dispositivos de Acesso Vascular , Calibragem , Cateterismo de Swan-Ganz/normas , Cateteres de Demora/normas , Estado Terminal , Desenho de Equipamento , Humanos , Unidades de Terapia Intensiva , Teste de Materiais , Monitorização Fisiológica/normas , Valor Preditivo dos Testes , Padrões de Referência , Reprodutibilidade dos Testes , Termodiluição/normas , Termômetros/normas , Fatores de Tempo , Dispositivos de Acesso Vascular/normas
4.
Eur Respir Rev ; 24(138): 642-52, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26621978

RESUMO

Right heart catheterisation (RHC) plays a central role in identifying pulmonary hypertension (PH) disorders, and is required to definitively diagnose pulmonary arterial hypertension (PAH). Despite widespread acceptance, there is a lack of guidance regarding the best practice for performing RHC in clinical practice. In order to ensure the correct evaluation of haemodynamic parameters directly measured or calculated from RHC, attention should be drawn to standardising procedures such as the position of the pressure transducer and catheter balloon inflation volume. Measurement of pulmonary arterial wedge pressure, in particular, is vulnerable to over- or under-wedging, which can give rise to false readings. In turn, errors in RHC measurement and data interpretation can complicate the differentiation of PAH from other PH disorders and lead to misdiagnosis. In addition to diagnosis, the role of RHC in conjunction with noninvasive tests is widening rapidly to encompass monitoring of treatment response and establishing prognosis of patients diagnosed with PAH. However, further standardisation of RHC is warranted to ensure optimal use in routine clinical practice.


Assuntos
Cateterismo de Swan-Ganz/normas , Hipertensão Pulmonar/diagnóstico , Artéria Pulmonar/fisiopatologia , Pressão Arterial , Benchmarking , Cateteres Cardíacos/normas , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/instrumentação , Erros de Diagnóstico/prevenção & controle , Desenho de Equipamento , Humanos , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/terapia , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Prognóstico , Pressão Propulsora Pulmonar , Reprodutibilidade dos Testes , Transdutores de Pressão/normas
5.
J Cardiothorac Vasc Anesth ; 29(4): 881-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25976600

RESUMO

OBJECTIVE: To investigate the effects of ventilatory mode, injectate temperature, and clinical situation on the precision of cardiac output measurements. DESIGN: Randomized, prospective observational study. SETTING: Single university hospital. PARTICIPANTS: Forty patients undergoing planned cardiac surgery, receiving a pulmonary artery catheter according to institutional routine. INTERVENTIONS: Cardiac output was measured at 4 predefined time points during the perioperative patient course, twice during controlled and twice during spontaneous ventilation, using 2 blocks of 8 measurement replications with cold and tepid injectate in random order. MEASUREMENTS AND MAIN RESULTS: The data were analyzed using a hierarchical linear mixed model. Clinical precision was determined as half the width of the 95% confidence interval for the underlying true value. The single-measurement precision measured in 2 different clinical situations for each temperature/ventilation combination was 8% to 10%, 11% to 13%, 13% to 15%, and 23% to 24% in controlled ventilation with cold injectate, controlled ventilation with tepid injectate, spontaneous breathing with cold injectate, and spontaneous breathing with tepid injectate, respectively. Tables are provided for the number of replications needed to achieve a certain precision and for how to identify significant changes in cardiac output. CONCLUSIONS: Clinical precision of cardiac output measurements is reduced significantly during spontaneous relative to controlled ventilation. The differences in precision between repeated measurement series within the temperature/ventilation combinations indicate influence of other situation-specific factors not related to ventilatory mode. Compared with tepid injectate in patients breathing spontaneously, the precision is 3-fold better with cold injectate and controlled ventilation.


Assuntos
Débito Cardíaco/fisiologia , Procedimentos Cirúrgicos Cardíacos/normas , Cateterismo de Swan-Ganz/normas , Injeções Intra-Arteriais/normas , Temperatura , Termodiluição/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Cateterismo de Swan-Ganz/métodos , Estudos Cross-Over , Feminino , Humanos , Injeções Intra-Arteriais/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Termodiluição/métodos
6.
J Cardiothorac Vasc Anesth ; 29(3): 656-62, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25440654

RESUMO

OBJECTIVES: The aims of this study were to compare cardiac output (CO) measured by the new fourth-generation FloTrac™/Vigileo™ system (Version 4.00) (COFVS) with that measured by a pulmonary artery catheter (COREF), and to investigate the ability of COFVS to track CO changes induced by increased peripheral resistance. DESIGN: Prospective study. SETTING: University Hospital. PARTICIPANTS: Twenty-three patients undergoing cardiac surgery. INTERVENTIONS: Phenylephrine (100 µg) was administered. MEASUREMENTS AND MAIN RESULTS: Hemodynamic variables, including CO(REF) and CO(FVS), were measured before and after phenylephrine administration. Bland-Altman analysis was used to assess the discrepancy between CO(REF) and CO(FVS). Four-quadrant plot and polar-plot analyses were utilized to evaluate the trending ability of CO(FVS) against CO(REF) after phenylephrine boluses. One hundred thirty-six hemodynamic interventions were performed. The bias shown by the Bland-Altman analysis was-0.66 L/min, and the percentage error was 55.4%. The bias was significantly correlated with the systemic vascular resistance index (SVRI) before phenylephrine administration (p<0.001, r(2) = 0.420). The concordance rate determined by four-quadrant plot analysis and the angular concordance rate calculated using polar-plot analysis were 87.0% and 83.0%, respectively. Additionally, this trending ability was not affected by SVRI state. CONCLUSIONS: The trending ability of the new fourth-generation FloTrac™/Vigileo™ system after increased vasomotor tone was greatly improved compared with previous versions; however, the discrepancy of the new system in CO measurement was not clinically acceptable, as in previous versions. For clinical application in critically ill patients, this vasomotor tone-dependent disagreement must be decreased.


Assuntos
Débito Cardíaco/fisiologia , Procedimentos Cirúrgicos Cardíacos/normas , Cateterismo de Swan-Ganz/normas , Monitorização Intraoperatória/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Cateterismo de Swan-Ganz/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Estudos Prospectivos , Termodiluição/métodos , Termodiluição/normas
7.
Medicina (B Aires) ; 74(4): 326-32, 2014.
Artigo em Espanhol | MEDLINE | ID: mdl-25188663

RESUMO

Investigators have raised doubts as to the safety of the Swan Ganz catheter (SGC). In order to define the point of view of cardiologists in our country, the Argentine Society of Cardiology's Emergency Council organized a meeting to analyze their views in different settings (non-cardiac surgery, cardiac surgery, acute coronary syndromes and heart failure) using the RAND-UCLA appropriateness method. A detailed review with the scientific evidence was sent to the experts in cardiology prior to the meeting in the SAC auditorium where the panellists selected the clinical variables create the specific situations. These hypothetic situations were resent to the panellists at a second stage for their individual evaluation, rating the benefit-to-harm ratio of the procedure on a scale of 1 to 9 (1 meant that the expected harms greatly outweighed the expected benefits, and 9 that the expected benefits greatly outweighed the expected harms, 5 could mean either that the harms and benefits were roughly equal). Two experts analyzed the results, describing the agreement/disagreement ratio. Finally, each indication was classified as "appropriate" "uncertain" or "inappropriate" ,for the procedure in accordance with the panelists' median score: median scores in the 1-3 range were classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. We observed high disagreement rates in SGC indications between cardiologists. However, the panelists were in favor of SGC use when situations included shock and myocardial dysfunction, especially in the presence of organic dysfunction. There were some situations when panelists considered SGC not useful, in patients without organ failure.


Assuntos
Síndrome Coronariana Aguda/terapia , Cardiologia , Cateterismo de Swan-Ganz , Consenso , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/normas , Medicina Baseada em Evidências , Insuficiência Cardíaca/terapia , Humanos , Medição de Risco
8.
Medicina (B.Aires) ; 74(4): 326-332, ago. 2014. ilus, tab
Artigo em Espanhol | LILACS | ID: lil-734394

RESUMO

Actualmente existen dudas sobre la seguridad del uso del catéter de Swan Ganz (CSG). Para definir la opinión de los cardiólogos de nuestro país, el Consejo de Emergencias Cardiovasculares de la Sociedad Argentina de Cardiología (SAC) realizó una reunión para evaluar la opinión de expertos en diferentes escenarios (cirugía no cardíaca, cardíaca, síndromes coronarios e insuficiencia cardíaca), usando el método RAND-UCLA appropiateness. Se envió la evidencia bibliográfica previa a la reunión en la SAC y en la misma los panelistas seleccionaron las variables para conformar las situaciones clínicas que luego fueron enviadas para que individualmente, en una segunda etapa, determinaran si consideraban beneficioso o perjudicial la utilización del catéter con una escala de 1 a 9 (1 significaba que los potenciales perjuicios superaban a los beneficios, 9 que los beneficios eran mayores y 5 que podía considerarse indistintamente beneficioso o perjudicial). Dos expertos analizaron los resultados, describiendo la tasa de acuerdo/desacuerdo. Finalmente, cada indicación se clasificó como “apropiada”, “dudosa” o inapropiada de acuerdo a la mediana definida por los panelistas: 1-3 se clasificó como inapropiado, 4-6 dudoso y 7-9 como indicación apropiada. Observamos gran discrepancia en la opinión sobre la indicación de CSG entre los expertos. Sin embargo, los panelistas estuvieron a favor de su utilización en situaciones que incluían shock y disfunción miocárdica, especialmente cuando se asoció disfunción orgánica. Hubo situaciones en las que los panelistas consideraron inapropiada la indicación del CSG, en pacientes sin disfunción orgánica.


Investigators have raised doubts as to the safety of the Swan Ganz catheter (SGC). In order to define the point of view of cardiologists in our country, the Argentine Society of Cardiology’s Emergency Council organized a meeting to analyze their views in different settings (non-cardiac surgery, cardiac surgery, acute coronary syndromes and heart failure) using the RAND-UCLA appropriateness method. A detailed review with the scientific evidence was sent to the experts in cardiology prior to the meeting in the SAC auditorium where the panellists selected the clinical variables create the specific situations. These hypothetic situations were resent to the panellists at a second stage for their individual evaluation, rating the benefit-to-harm ratio of the procedure on a scale of 1 to 9 (1 meant that the expected harms greatly outweighed the expected benefits, and 9 that the expected benefits greatly outweighed the expected harms, 5 could mean either that the harms and benefits were roughly equal). Two experts analyzed the results, describing the agreement/disagreement ratio. Finally, each indication was classified as “appropriate,” “uncertain” or “inappropriate” for the procedure in accordance with the panelists’ median score: median scores in the 1-3 range were classified as inappropriate, those in the 4-6 range as uncertain, and those in the 7-9 range as appropriate. We observed high disagreement rates in SGC indications between cardiologists. However, the panelists were in favor of SGC use when situations included shock and myocardial dysfunction, especially in the presence of organic dysfunction. There were some situations when panelists considered SGC not useful, in patients without organ failure.


Assuntos
Humanos , Síndrome Coronariana Aguda/terapia , Cardiologia , Cateterismo de Swan-Ganz , Consenso , Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/normas , Medicina Baseada em Evidências , Insuficiência Cardíaca/terapia , Medição de Risco
9.
J Crit Care ; 29(5): 828-34, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24857639

RESUMO

PURPOSE: Advanced hemodynamic monitoring in cardiac surgery translates into improvement in outcomes. We evaluated the relationship between central venous (ScvO2) and mixed venous (SvO2) saturations over the early postoperative period. The adequacy of their interchangeability was tested in patients with varying degrees of cardiac performance. METHODS: In this prospective observational study, we evaluated 156 consecutive cardiac surgical patients in an academic center. The ScvO2 and SvO2 data were harvested from 468 paired samples taken preoperatively (T0), after weaning from cardiopulmonary bypass (T1) and on postoperative day 1 (T2). RESULTS: The relationship between ScvO2 and SvO2 was inconsistent, with inferior correlations in patients with lower cardiac indices (CI) (Pearson r(2) = 0.37 if CI ≤2.0 L/min per square meter vs r(2) = 0.73 if CI >2.0 L/min per square meter, both P < .01). Patients with lower CI also had wider 95% limits of agreement between SvO2 and ScvO2. The proportion of patients with a negative SvO2-ScvO2 gradient increased over time (48/156 [31%] at T0 to 73/156 [47%] at T2; P < .01). This subgroup more frequently required inotropes at T2 than patients with a positive SvO2-ScvO2 gradient (odds ratio, 6.46 [95% confidence interval, 0.81-51.87], P = .06) and also had higher serum lactate levels (1.5 ± 0.8 vs 1.0 ± 0.4; P < .01). CONCLUSIONS: The diagnostic accuracy of ScvO2 for estimating SvO2 is proportional to cardiac performance. A negative SvO2-ScvO2 gradient at T2 correlated with inotropic support requirement, higher operative risk score, age, lactate level, and duration of cardiopulmonary bypass.


Assuntos
Baixo Débito Cardíaco/sangue , Procedimentos Cirúrgicos Cardíacos , Cateterismo de Swan-Ganz/métodos , Oxigênio/sangue , Adulto , Idoso , Baixo Débito Cardíaco/fisiopatologia , Ponte Cardiopulmonar , Cateterismo de Swan-Ganz/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Período Pós-Operatório , Estudos Prospectivos , Reprodutibilidade dos Testes , Termodiluição/métodos
10.
J Crit Care ; 28(5): 857-61, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23876703

RESUMO

PURPOSE: Given decreasing use of pulmonary artery (PA) catheterization, we sought to evaluate whether current pulmonary and critical care fellows have adequate opportunity to obtain proficiency in PA catheter placement and data interpretation. METHODS: All US pulmonary and critical care program directors were invited to participate in an anonymous online survey regarding current training opportunities in PA catheterization. RESULTS: The response rate was 51% (69/136). Eighty-three percent reported that the number of PA catheterizations performed by fellows within their program has decreased in the past decade. Fifty-four percent estimated that their fellows currently participate in less than 10 supervised procedures during fellowship. The most frequently identified barriers to training were procedure volume and reluctance to place PA catheters in the medical intensive care unit. Forty-three percent of respondents agreed that training in PA catheter placement is currently adequate within their program, and 55% agreed that training in data interpretation is adequate. Only 39% of respondents believe that PA catheter placement should continue to be an Accreditation Council for Graduate Medical Education training requirement. CONCLUSIONS: Many current pulmonary and critical care fellows do not have the opportunity to gain proficiency in PA catheterization. Fellowship training programs should consider alternate means of training fellows in PA catheter data interpretation, such as simulation.


Assuntos
Cateterismo de Swan-Ganz/normas , Cuidados Críticos/normas , Educação de Pós-Graduação em Medicina/normas , Bolsas de Estudo , Pneumologia/educação , Acreditação , Competência Clínica , Currículo , Humanos , Inquéritos e Questionários , Estados Unidos
13.
Curr Opin Crit Care ; 17(3): 296-302, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21499096

RESUMO

PURPOSE OF REVIEW: Hemodynamic monitoring has gained widespread acceptance in intensive care units. Despite ongoing debate regarding its safety and efficacy, monitoring with the pulmonary artery catheter (PAC) remains used for the management of severe heart failure and shock. RECENT FINDINGS: To reanalyze using the most recently published literature in the field, the role of the PAC to manage critically ill patients with right ventricular failure, pulmonary hypertension and weaning failure from cardiac origin. The role of PAC as a gold standard to validate new cardiac output monitoring devices was also reported. SUMMARY: Despite competition with less invasive hemodynamic monitoring devices or ultrasonic methods, the PAC remains a useful monitoring device in situations in which the knowledge of pulmonary artery pressure, pulmonary artery occlusion pressure and oxygenation parameters are needed. The proper use of PAC requires, however, a perfect knowledge of the numerous pitfalls and difficulties in interpretation of its measurements.


Assuntos
Cateterismo de Swan-Ganz/normas , Monitorização Fisiológica/métodos , Hemodinâmica/fisiologia , Humanos , Unidades de Terapia Intensiva , Artéria Pulmonar
15.
Crit Care ; 15(1): 106, 2011 Jan 19.
Artigo em Inglês | MEDLINE | ID: mdl-21349140

RESUMO

Three pulse contour systems for monitoring cardiac output - LiDCO Plus™, PiCCO Plus™ and FloTrac™ - were compared in postcardiac surgery patients. None of the three methods demonstrated good trending ability according to concordance analysis. Pulse contour systems remain unreliable in the haemodynamically unstable patient.


Assuntos
Cateterismo Cardíaco/normas , Débito Cardíaco/fisiologia , Cateterismo de Swan-Ganz/normas , Artéria Pulmonar/fisiologia , Feminino , Humanos , Masculino
17.
Crit Care ; 14(6): R212, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-21092290

RESUMO

INTRODUCTION: Although less invasive than pulmonary artery catheters (PACs), arterial pulse pressure analysis techniques for estimating cardiac output (CO) have not been simultaneously compared to PAC bolus thermodilution CO (COtd) or continuous CO (CCO) devices. METHODS: We compared the accuracy, bias and trending ability of LiDCO™, PiCCO™ and FloTrac™ with PACs (COtd, CCO) to simultaneously track CO in a prospective observational study in 17 postoperative cardiac surgery patients for the first 4 hours following intensive care unit admission. Fifty-five paired simultaneous quadruple CO measurements were made before and after therapeutic interventions (volume, vasopressor/dilator, and inotrope). RESULTS: Mean CO values for PAC, LiDCO, PiCCO and FloTrac were similar (5.6 ± 1.5, 5.4 ± 1.6, 5.4 ± 1.5 and 6.1 ± 1.9 L/min, respectively). The mean CO bias by each paired method was -0.18 (PAC-LiDCO), 0.24 (PAC-PiCCO), -0.43 (PAC-FloTrac), 0.06 (LiDCO-PiCCO), -0.63 (LiDCO-FloTrac) and -0.67 L/min (PiCCO-FloTrac), with limits of agreement (1.96 standard deviation, 95% confidence interval) of ± 1.56, ± 2.22, ± 3.37, ± 2.03, ± 2.97 and ± 3.44 L/min, respectively. The instantaneous directional changes between any paired CO measurements displayed 74% (PAC-LiDCO), 72% (PAC-PiCCO), 59% (PAC-FloTrac), 70% (LiDCO-PiCCO), 71% (LiDCO-FloTrac) and 63% (PiCCO-FloTrac) concordance, but poor correlation (r(2) = 0.36, 0.11, 0.08, 0.20, 0.23 and 0.11, respectively). For mean CO < 5 L/min measured by each paired devices, the bias decreased slightly. CONCLUSIONS: Although PAC (COTD/CCO), FloTrac, LiDCO and PiCCO display similar mean CO values, they often trend differently in response to therapy and show different interdevice agreement. In the clinically relevant low CO range (< 5 L/min), agreement improved slightly. Thus, utility and validation studies using only one CO device may potentially not be extrapolated to equivalency of using another similar device.


Assuntos
Cateterismo Cardíaco/normas , Débito Cardíaco/fisiologia , Cateterismo de Swan-Ganz/normas , Artéria Pulmonar/fisiologia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/métodos , Cateterismo de Swan-Ganz/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Termodiluição/métodos , Termodiluição/normas
18.
Liver Transpl ; 16(6): 773-82, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20517912

RESUMO

Arterial pressure-based cardiac output monitors (APCOs) are increasingly used as alternatives to thermodilution. Validation of these evolving technologies in high-risk surgery is still ongoing. In liver transplantation, FloTrac-Vigileo (Edwards Lifesciences) has limited correlation with thermodilution, whereas LiDCO Plus (LiDCO Ltd.) has not been tested intraoperatively. Our goal was to directly compare the 2 proprietary APCO algorithms as alternatives to pulmonary artery catheter thermodilution in orthotopic liver transplantation (OLT). The cardiac index (CI) was measured simultaneously in 20 OLT patients at prospectively defined surgical landmarks with the LiDCO Plus monitor (CI(L)) and the FloTrac-Vigileo monitor (CI(V)). LiDCO Plus was calibrated according to the manufacturer's instructions. FloTrac-Vigileo did not require calibration. The reference CI was derived from pulmonary artery catheter intermittent thermodilution (CI(TD)). CI(V)-CI(TD) bias ranged from -1.38 (95% confidence interval = -2.02 to -0.75 L/minute/m(2), P = 0.02) to -2.51 L/minute/m(2) (95% confidence interval = -3.36 to -1.65 L/minute/m(2), P < 0.001), and CI(L)-CI(TD) bias ranged from -0.65 (95% confidence interval = -1.29 to -0.01 L/minute/m(2), P = 0.047) to -1.48 L/minute/m(2) (95% confidence interval = -2.37 to -0.60 L/minute/m(2), P < 0.01). For both APCOs, bias to CI(TD) was correlated with the systemic vascular resistance index, with a stronger dependence for FloTrac-Vigileo. The capability of the APCOs for tracking changes in CI(TD) was assessed with a 4-quadrant plot for directional changes and with receiver operating characteristic curves for specificity and sensitivity. The performance of both APCOs was poor in detecting increases and fair in detecting decreases in CI(TD). In conclusion, the calibrated and uncalibrated APCOs perform differently during OLT. Although the calibrated APCO is less influenced by changes in the systemic vascular resistance, neither device can be used interchangeably with thermodilution to monitor cardiac output during liver transplantation.


Assuntos
Pressão Sanguínea , Débito Cardíaco , Cateterismo de Swan-Ganz , Transplante de Fígado , Monitorização Intraoperatória/instrumentação , Termodiluição , Idoso , Algoritmos , Calibragem , Cateterismo de Swan-Ganz/normas , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Missouri , Monitorização Intraoperatória/normas , Valor Preditivo dos Testes , Curva ROC , Sensibilidade e Especificidade , Processamento de Sinais Assistido por Computador , Termodiluição/normas , Fatores de Tempo , Resistência Vascular
20.
Anesth Analg ; 106(5): 1480-6, table of contents, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18420863

RESUMO

BACKGROUND: Cardiac output (CO) and invasive hemodynamic measurements are useful during liver transplantation. The pulmonary artery catheter (PAC) is commonly used for these patients, despite the potential complications. Recently, a less invasive device (Vigileo/FloTrac) became available, which estimates CO using arterial pressure waveform analysis without external calibration. In this study, we compared CO obtained with a PAC using automatic thermodilution, instantaneous CO stat-mode (ICO(SM)), and CO obtained with the new device, arterial pressure waveform analysis (APCO) in patients undergoing liver transplantation. METHODS: Twenty sets of simultaneous measurements of APCO and ICO(SM) were determined in sedated and mechanically ventilated patients undergoing liver transplantation. Time points were as follows: after PAC insertion (T1-3), after portal clamping (T4-6), during anhepathy (T7-9), after graft reperfusion (T10-15), and in the postoperative period in the intensive care unit (T15-20). RESULTS: We enrolled 20 patients and 400 measurements were obtained. No data were rejected. Bias between ICO(SM) and APCO was 0.8 L/min, 95% limits of agreement were -1.8 to 3.5 L/min. The percentage error was 43%. Bias between ICO(SM) and APCO was correlated with systemic vascular resistance [r(2) = 0.55, P < 0.0001, y = 15.8-2.2 ln(x)] and subgroup analysis revealed an increase in the bias and in the percentage error in patients with low systemic vascular resistance (Child-Pugh grade B and C patients). There was no difference between the different surgical periods. CONCLUSIONS: Our results suggest that Vigileo/FloTrac CO monitoring data do not agree well with those of automatic thermodilution in patients undergoing liver transplantation, especially in Child-Pugh grade B and C patients with low systemic vascular resistance.


Assuntos
Monitores de Pressão Arterial , Pressão Sanguínea , Débito Cardíaco , Cateterismo de Swan-Ganz , Falência Hepática/cirurgia , Transplante de Fígado , Monitorização Intraoperatória/métodos , Artéria Radial/fisiopatologia , Viés , Calibragem , Cateterismo de Swan-Ganz/instrumentação , Cateterismo de Swan-Ganz/normas , Complacência (Medida de Distensibilidade) , Desenho de Equipamento , Feminino , Humanos , Falência Hepática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Monitorização Intraoperatória/normas , Fluxo Pulsátil , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Termodiluição , Fatores de Tempo , Transdutores , Resistência Vascular
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