Search Results (9)

Advanced hemodynamic monitoring is fundamental in the management of the critically ill. Blood pressure and cardiac function are key markers of cardiovascular system function;, thus, having accurate measurements of these parameters in critically ill patients is essential. Currently, there are various methods available to choose from, as well as a greater understanding of the methods and criteria to be able to compare devices and select the best option for our patients’ needs. Cardiac ultrasound and transpulmonary thermodilution help tailor the therapy for a patient’s individual needs by putting the results of a thorough hemodynamic assessment into context. Both these hemodynamic monitoring techniques have their advantages, drawbacks and limitations. Cardiac ultrasound is a safe, non-invasive, less expensive, efficient bedside tool for diagnosing, monitoring and guiding critically ill patients’ therapy management. It is recommended in the consensus guidelines as the first-choice method, especially when it comes to identifying different types of shock or the various factors involved. Pulse index contour continuous cardiac output (PiCCO) is a minimally invasive hemodynamic monitoring technique, integrating various static and hemodynamic parameters through a combination of trans-cardiopulmonary thermodilution and pulse contour analysis. The PiCCO method provides guidance to fluid and vasoactive therapy in critically ill patients and is also used for intraoperative and postoperative fluid management and monitoring in cardiac surgery. While invasive methods such as PiCCO are recommended for hemodynamic monitoring and can provide accurate information, they are not always necessary and are contraindicated in some cases. Full article

Background: The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) in acute lung failure has witnessed a notable increase. The PiCCO system is frequently used for advanced hemodynamic monitoring in this cohort. Our study aimed to investigate whether the choice of indicator injection site (jugular vs. femoral) in patients undergoing vv-ECMO therapy affects transpulmonary thermodilution (TPTD) measurements using the PiCCO^® device (Pulsion Medical Systems SE, Munich, Germany). Methods: In a retrospective single-center analysis, we compared thermodilution-derived hemodynamic parameters after simultaneous jugular and femoral injections in 28 measurements obtained in two patients with respiratory failure who were undergoing vv-ECMO therapy. Results: Elevated values of the extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end-diastolic volume index (GEDVI) were observed following femoral indicator injection compared to jugular indicator injection (EVLWI: 29.3 ± 10.9 mL/kg vs. 18.3 ± 6.71 mL/kg, p = 0.0003; ITBVI: 2163 ± 631 mL/m² vs. 806 ± 125 mL/m², p < 0.0001; GEDVI: 1731 ± 505 mL/m² vs. 687 ± 141 mL/m², p < 0.0001). The discrepancy between femoral and jugular measurements exhibited a linear correlation with extracorporeal blood flow (ECBF). Conclusions: In a PiCCO®-derived hemodynamic assessment of patients on vv-ECMO, the femoral indicator injection, as opposed to the jugular injection, resulted in an overestimation of all index parameters. This discrepancy can be attributed to mean transit time (MTt) and downslope time-dependent (DSt) variations in GEDVI and cardiac function index and is correlated with ECBF. Full article

Background: Prevention and treatment of haemodynamic instability and increased intracranial pressure (ICP) in patients with subarachnoid haemorrhage (SAH) is vital. This study aimed to evaluate the effects of protocolised cerebral perfusion pressure (CPP)-guided treatment on morbidity and functional outcome in patients admitted to the intensive care unit (ICU) with SAH. Methods: We performed a retrospective study comparing 37 patients who received standard haemodynamic treatment (control group) with 17 individuals (CPP-guided group) who were on the CPP-guided treatment aimed at maintaining CPP > 70 mmHg using both optimisations of ICP and mean arterial pressure (MAP). Results: MAP, cumulative crystalloid doses and fluid balance were similar in both groups. However, the incidence of delayed cerebral ischaemia was significantly lower in the CPP-guided group (14% vs. 64%, p < 0.01), and functional outcome as assessed by the Glasgow Outcome Scale at 30 days after SAH was improved (29.0% vs. 5.5%, p = 0.03). Conclusions: This preliminary analysis showed that implementing a CPP-guided treatment approach aimed at maintaining a CPP > 70 mmHg may reduce the occurrence of delayed cerebral ischaemia and improve functional outcomes in patients with SAH. This observation merits further prospective investigation of the use of CPP-guided treatment in patients with SAH. Full article

During acute respiratory distress syndrome (ARDS), the increase in pulmonary vascular permeability and lung water induced by pulmonary inflammation may be related to altered lung compliance. A better understanding of the interactions between respiratory mechanics variables and lung water or capillary permeability would allow a more personalized monitoring and adaptation of therapies for patients with ARDS. Therefore, our main objective was to investigate the relationship between extravascular lung water (EVLW) and/or pulmonary vascular permeability index (PVPI) and respiratory mechanic variables in patients with COVID-19-induced ARDS. This is a retrospective observational study from prospectively collected data in a cohort of 107 critically ill patients with COVID-19-induced ARDS from March 2020 to May 2021. We analyzed relationships between variables using repeated measurements correlations. We found no clinically relevant correlations between EVLW and the respiratory mechanics variables (driving pressure (correlation coefficient [CI 95%]: 0.017 [−0.064; 0.098]), plateau pressure (0.123 [0.043; 0.202]), respiratory system compliance (−0.003 [−0.084; 0.079]) or positive end-expiratory pressure (0.203 [0.126; 0.278])). Similarly, there were no relevant correlations between PVPI and these same respiratory mechanics variables (0.051 [−0.131; 0.035], 0.059 [−0.022; 0.140], 0.072 [−0.090; 0.153] and 0.22 [0.141; 0.293], respectively). In a cohort of patients with COVID-19-induced ARDS, EVLW and PVPI values are independent from respiratory system compliance and driving pressure. Optimal monitoring of these patients should combine both respiratory and TPTD variables. Full article

Fluid management is a cornerstone in the treatment of burns and, thus, many different formulas were tested for their ability to match the fluid requirements for an adequate resuscitation. Thereof, the Parkland-Baxter formula, first introduced in 1968, is still widely used since then. Though using nearly the same formula to start off, the definition of normovolemia and how to determine the volume status of burn patients has changed dramatically over years. In first instance, the invention of the transpulmonary thermodilution (TTD) enabled an early goal directed fluid therapy with acceptable invasiveness. Furthermore, the introduction of point of care ultrasound (POCUS) has triggered more individualized schemes of fluid therapy. This article explores the historical developments in the field of burn resuscitation, presenting different options to determine the fluid requirements without missing the red flags for hyper- or hypovolemia. Furthermore, the increasing rate of co-morbidities in burn patients calls for a more sophisticated fluid management adjusting the fluid therapy to the actual necessities very closely. Therefore, formulas might be used as a starting point, but further fluid therapy should be adjusted to the actual need of every single patient. Taking the developments in the field of individualized therapies in intensive care in general into account, fluid management in burn resuscitation will also be individualized in the near future. Full article

There are no reliable, non-invasive methods to accurately measure cardiac output (CO) in septic patients. MostCare (Vytech Health™, Vygon, Padova, Italy), is a beat-to-beat, self calibrated method for CO measurement based on continuous analysis of reflected arterial pressure waveforms. We enrolled 40 patients that were suffering from septic shock and requiring norepinephrine infusion to target blood pressure in order to to evaluate the level of agreement between a calibrated transpulmonary thermodilution device (PiCCO System, Pulsion Medical Systems, Feldkirchen, Germany) and the MostCare system in detecting and tracking changes in CO measurements related to norepinephrine reduction in septic shock patients,. PiCCO was connected to a 5 Fr femoral artery catheter and to a central venous catheter. System calibration was performed with 15 mL of cold saline injection over about 3 s. The MostCare device was connected to the artery catheter to analyze the arterial waveform. Before reducing norepinephrine infusion, the PiCCO system was calibrated, the MostCare waveform was optimized, and the values of the complete hemodynamic profile were recorded (T1). Norepinephrine infusion was then reduced by 0.03 mcg/Kg/min. After 30 min, a new calibration of PiCCO system and a new record on both monitors were performed (T2). Static measurements agreements were assessed using the Bland-Altman test, while trending ability was investigated using polar plot analysis. If volume expansion occurred, then related data were separately analyzed. At T1 mean the CO was 5.38 (SD 0.60) L/min, the mean difference was 0.176 L/min, the limits of agreement (LoA) was +1.39 and −1.04 L/min, and the percentage error (PE) was 22.6%; at T2 the mean CO was 5.44 (SD 0.73) L/min, the mean difference was 0.053 L/min, the LoA was +1.51 and −1.40, and the PE was 27%. After considering the volume expansion between T1 and T2, the mean CO at T1 was 5.39 L/min (SD 0.47), the LoA was +1.09 and −0.78 L/min, and the percentage error (PE) was 17%; at T2 the mean CO was 5.35 L/min (SD 0.81), the LoA was +1.73 and −1.52 L/min, and the PE was 30%. The polar plot diagram seems to confirm the trending ability of MostCare system versus the reference method. In septic patients, when the arterial waveform is accurate, MostCare and PiCCO transpulmonary thermodilution exhibit good agreement even after the reduction of norepinephrine and changes in vascular tone or volume expansion. MostCare could be a rapid to set, reliable, and useful tool to monitor hemodynamic variations in septic patients in emergency contexts where thermodilution methods or other advanced systems are not easily available. Full article

The aim of our study was to assess the association between the macrohemodynamic profile and sepsis induced acute kidney injury (AKI). We also investigated which minimally invasive hemodynamic parameters may help identify patients at risk for sepsis-AKI. We included 71 patients with sepsis and septic shock. We performed the initial fluid resuscitation using local protocols and continued to give fluids guided by the minimally invasive hemodynamic parameters. We assessed the hemodynamic status by transpulmonary thermodilution technique. Sequential organ failure assessment (SOFA score) (AUC 0.74, 95% CI 0.61–0.83, p < 0.01) and cardiovascular SOFA (AUC 0.73, 95% CI 0.61–0.83, p < 0.01) were found to be predictors for sepsis-induced AKI, with cut-off values of 9 and 3 points respectively. Persistent low stroke volume index (SVI) ≤ 32 mL/m²/beat (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) and global end-diastolic index (GEDI) < 583 mL/m² (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) after the initial fluid resuscitation are predictive for oliguria/anuria at 24 h after study inclusion. The combination of higher vasopressor dependency index (VDI, calculated as the (dobutamine dose × 1 + dopamine dose × 1 + norepinephrine dose × 100 + vasopressin × 100 + epinephrine × 100)/MAP) and norepinephrine, lower systemic vascular resistance index (SVRI), and mean arterial blood pressure (MAP) levels, in the setting of normal preload parameters, showed a more severe vasoplegia. Severe vasoplegia in the first 24 h of sepsis is associated with a higher risk of sepsis induced AKI. The SOFA and cardiovascular SOFA scores may identify patients at risk for sepsis AKI. Persistent low SVI and GEDI values after the initial fluid resuscitation may predict renal outcome. Full article

Hantavirus cardiopulmonary syndrome (HCPS) is characterized by capillary leak, pulmonary edema (PE), and shock, which leads to death in up to 40% of patients. Treatment is supportive, including mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO). Hemodynamic monitoring is critical to titrate therapy and to decide ECMO support. Transpulmonary thermodilution (TPTD) provides hemodynamic and PE data that have not been systematically used to understand HCPS pathophysiology. We identified 11 HCPS patients monitored with TPTD: eight on MV, three required ECMO. We analyzed 133 measurements to describe the hemodynamic pattern and its association with PE. The main findings were reduced stroke volume, global ejection fraction (GEF), and preload parameters associated with increased extravascular lung water and pulmonary vascular permeability compatible with hypovolemia, myocardial dysfunction, and increased permeability PE. Lung water correlated positively with heart rate (HR, r = 0.20) and negatively with mean arterial pressure (r = −0.27) and GEF (r = −0.36), suggesting that PE is linked to hemodynamic impairment. Pulmonary vascular permeability correlated positively with HR (r = 0.31) and negatively with cardiac index (r = −0.49), end-diastolic volume (r = −0.48), and GEF (r = −0.40), suggesting that capillary leak contributes to hypovolemia and systolic dysfunction. In conclusion, TPTD data suggest that in HCPS patients, increased permeability leads to PE, hypovolemia, and circulatory impairment. Full article

Introduction: Monitoring of lung function during pneumonia is essential for the evaluation of the effectiveness of therapy in ICU patients. Among various bedside techniques, two particularly interesting are the lung ultrasound and the transpulmonary thermodilution technique. In this observational single center study we wanted to assess the correlation between the lung ultrasound examination (LUS) and transpulmonary thermodilution volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Material and methods: We analyzed data obtained from medical history of twelve patients requiring mechanical ventilation and hemodynamics monitoring with PICCO catheter due to newly diagnosed pneumonia. We compared lung ultrasound examination performed on the first and third day of new antimicrobial therapy with results of transpulmonary thermodilution examination made on the same day. We also calculated the difference between values obtained on first and third day to compare the trends. Results: We did not find any association between tested variables, except a correlation between PVPI and EVLWI, both measured at the same day (Rho = 0.3; 95%CI –0.02–0.59; p = 0.03), and trends in the period of 3 days (Rho = 0.6; 95%CI 0.2–0.8; p = 0.005). Conclusions: The results of the study indicate that volumetric values achieved using the PiCCO method as well as lung ultrasound should be interpreted with care and related to the clinical state of a patient, keeping in mind that no correlation between the result achieved and the actual state of inflammatory changes in the lungs may be possible. Full article