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

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

Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study.

BACKGROUND: Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time. AIM: To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour. METHODS: A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared "standard practice" and "intervention" periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24th postoperative hour. RESULTS: Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period). CONCLUSION: The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

Cerebral oximetry and return of spontaneous circulation after cardiac arrest: A systematic review and meta-analysis.

AIM: The prediction of return of spontaneous circulation (ROSC) during resuscitation of patients suffering of cardiac arrest (CA) is particularly challenging. Regional cerebral oxygen saturation (rSO2) monitoring through near-infrared spectrometry is feasible during CA and could provide guidance during resuscitation. METHODS: We conducted a systematic review and meta-analysis on the value of rSO2 in predicting ROSC both after in-hospital (IH) or out-of-hospital (OH) CA. Our search included MEDLINE (PubMed) and EMBASE, from inception until April 4th, 2015. We included studies reporting values of rSO2 at the beginning of and/or during resuscitation, according to the achievement of ROSC. RESULTS: A total of nine studies with 315 patients (119 achieving ROSC, 37.7%) were included in the meta-analysis. The majority of those patients had an OHCA (n=225, 71.5%; IHCA: n=90, 28.5%). There was a significant association between higher values of rSO2 and ROSC, both in the overall calculation (standardized mean difference, SMD -1.03; 95%CI -1.39,-0.67; p<0.001), and in the subgroups analyses (rSO2 at the beginning of resuscitation: SMD -0.79; 95%CI -1.29,-0.30; p=0.002; averaged rSO2 value during resuscitation: SMD -1.28; 95%CI -1.74,-0.83; p<0.001). CONCLUSIONS: Higher initial and average regional cerebral oxygen saturation values are both associated with greater chances of achieving ROSC in patients suffering of CA. A note of caution should be made in interpreting these results due to the small number of patients and the heterogeneity in study design: larger studies are needed to clinically validate cut-offs for guiding cardiopulmonary resuscitation.