Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive?

INTRODUCTION: Blood pressure measurements frequently guide management in critical care. Direct readings, commonly from a major artery, are considered to be the gold standard. Because arterial cannulation is associated with risks, alternative noninvasive blood pressure (NIBP) measurements are routinely used. However, the accuracy of NIBP determinations in overweight patients in the outpatient setting is variable, and little is known about critically ill patients. This prospective, observational study was performed to compare direct intra-arterial blood pressure (IABP) with NIBP measurements obtained using auscultatory and oscillometric methods in overweight patients admitted to our medical intensive care unit. METHOD: Adult critically ill patients with a body mass index (BMI) of 25 kg/m2 or greater and a functional arterial line (assessed using the rapid flush test) were enrolled in the study. IABP measurements were compared with those obtained noninvasively. A calibrated aneroid manometer (auscultatory technique) with arm cuffs compatible with arm sizes and a NIBP monitor (oscillometric technique) were used for NIBP measurements. Agreement between methods was assessed using Bland-Altman analysis. RESULTS: Fifty-four patients (23 males) with a mean (+/- standard error) age of 57 +/- 3 years were studied. The mean BMI was 34.0 +/- 1.4 kg/m2. Mean arm circumference was 32 +/- 0.6 cm. IABP readings were obtained from the radial artery in all patients. Only eight patients were receiving vasoactive medications. Mean overall biases for the auscultatory and oscillometric techniques were 4.1 +/- 1.9 and -8.0 +/- 1.7 mmHg, respectively (P < 0.0001), with wide limits of agreement. The overestimation of blood pressure using the auscultatory technique was more important in patients with a BMI of 30 kg/m2 or greater. In hypertensive patients both NIBP methods underestimated blood pressure as determined using direct IABP measurement. CONCLUSION: Oscillometric blood pressure measurements underestimated IABP readings regardless of patient BMI. Auscultatory measurements were also inaccurate, tending to underestimate systolic blood pressure and overestimate mean arterial and diastolic blood pressure. NIBP can be inaccurate among overweight critically ill patients and lead to erroneous interpretations of blood pressure.

Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a "another black sedan".

This article seeks assist physicians or administrators considering establishing a Tele-ICU. Owing to an apparent domination of the Tele-ICU field by a single vendor, some may believe that there is only one design option. In fact, there are many alternative design formats that do not require the consumer to possess high-level technical expertise. As when purchasing any major item, if the consumer can formulate basic concepts of design and research the various vendors, then the consumer can develop the Tele-ICU system best for their facility, finances, availability of staff, coverage model, and quality metric goals.

Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU.

OBJECTIVE: To assess the outcome of adult hematopoietic stem cell transplantation (HSCT) recipients who were admitted to a medical ICU (MICU), and to identify the measurable predictors of their MICU outcome. DESIGN: Retrospective chart review study. SETTING: MICU in a tertiary care, university-affiliated medical center with a comprehensive cancer program. PATIENTS: Consecutive adult HSCT recipients admitted to the MICU between January 1998 and June 2001. MEASUREMENTS AND MAIN RESULTS: Eighty-five patients were admitted to the MICU, representing 11.4% of patients who had undergone HSCT during the study period. The mean (+/- SD) age at MICU admission was 46.6 +/- 11.4 years (women, 67%; men, 33%). Forty-five patients (53%) underwent allogeneic HSCT, and 40 patients (47%) underwent autologous HSCT. Fifty-one patients (60%) required mechanical ventilation (MV). Fifty-two patients (61%) survived their MICU stay, and 35 patients (41%) were discharged alive from the hospital. The long-term survival rate (ie, > 6 months) in this cohort was 28%. Nineteen mechanically ventilated patients (37%) survived their MICU stay, and 33 patients (97%) survived who did not require MV (p < 0.01). The independent predictors of poor outcome during the MICU stay were elevated serum lactate level on admission to the MICU, the need for MV, and the presence of more than two organ systems that failed. CONCLUSIONS: The study showed short-term and long-term survival rates among adult HSCT recipients who had been admitted to MICU that were higher than those previously reported. While there were no absolute predictors of mortality, patients with higher MICU admission serum lactate levels, those requiring MV, or those developing more than two organ system failures had poor MICU outcomes.

An isolated fistula between the right pulmonary artery and the right pulmonary vein: an unusual cause of stroke in a young female.

We describe the case of a 29 year-old female who presented with right sided hemiparesis with global aphasia. She had a history of transient ischemic attack with migraine headaches. Diagnostic workup revealed a right to left cardiac shunt. An isolated right pulmonary artery to left pulmonary vein fistula was diagnosed on pulmonary angiogram. The fistula was occluded successfully by cardiac catheterization. Early recognition and intervention is indicated to prevent further complications.