Critical Care Literature Review

Continuous Cardiac Output Monitoring


15: Pediatr Crit Care Med. 2008 Mar;9(2):e13-6.
Continuous central venous saturation monitoring in pediatrics: a case report.
Spenceley N, Skippen P, Krahn G, Kissoon N. Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.

OBJECTIVE: To report the use of a new pediatric central venous catheter that offers continuous central venous saturation (ScVO2) monitoring in the critically ill child. DESIGN: Case report. SETTING: Pediatric intensive care unit in a tertiary care children's hospital. PATIENT: A 3-month-old child, following cardiac surgery, with an isolated decrease in central venous saturations. INTERVENTIONS: Diagnosis of pericardial effusion by echocardiography followed by surgical drainage. MEASUREMENTS AND MAIN RESULTS: ScVO2 readings quickly returned to normal, and the remaining patient course was uneventful. CONCLUSIONS: We report the first case of a newly modified central venous catheter (PediaSat Oximetry Catheter, Edwards Lifesciences LLC, Irvine, CA) for children and demonstrate its utility in a patient with impaired oxygen delivery when traditional markers remain stable. This catheter enabled the rapid diagnosis of cardiac compromise due to pericardial effusion, leading to early treatment. Traditional central catheter functions and insertion technique are maintained, making the catheter potentially useful in any critically ill child.

16: Curr Opin Crit Care. 2008 Jun;14(3):322-6.
Minimally invasive cardiac output monitoring.
Morgan P, Al-Subaie N, Rhodes A. Department of Intensive Care Medicine, St George's Hospital, London, UK.

PURPOSE OF REVIEW: The measurement of cardiac output in the critically ill constitutes a vital part in the management of these patients. Minimally invasive techniques are gaining popularity as they allow continuous cardiac output monitoring while avoiding the risks associated with pulmonary artery catheterization. This article focuses on some of the commonly used minimally invasive devices that rely on pulse contour waveform analysis. RECENT FINDINGS: The current studies in the literature that assess the validity and the clinical applications of calibrated and noncalibrated arterial waveform derived cardiac output devices are discussed. SUMMARY: The minimally invasive cardiac output monitoring devices available differ in their methodology and application. Currently there is conflicting evidence as to the accuracy of some of these systems and further investigation into their clinical application is required.

17: Anesth Analg. 2008 Apr;106(4):1195-200, table of contents.
Comment in: Anesth Analg. 2008 Apr;106(4):1031-3.
The ability of a novel algorithm for automatic estimation of the respiratory variations in arterial pulse pressure to monitor fluid responsiveness in the operating room.
Cannesson M, Slieker J, Desebbe O, Bauer C, Chiari P, HÚnaine R, Lehot JJ. Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care, Louis Pradel Hospital, Claude Bernard Lyon 1 university, Lyon, France.

BACKGROUND: Respiratory variations in arterial pulse pressure (deltaPP(man)) are accurate predictors of fluid responsiveness in mechanically ventilated patients. However, they cannot be continuously monitored. In our study, we assessed the clinical utility of a novel algorithm for automatic estimation of deltaPP (deltaPP(auto)). METHODS: We studied 25 patients referred for coronary artery bypass grafting. DeltaPP(auto) was continuously displayed using a method based on automatic detection algorithms, kernel smoothing, and rank-order filters. All patients were under general anesthesia, mechanical ventilation, and were also monitored with a pulmonary artery catheter. DeltaPP(man) and deltaPP(auto) were recorded simultaneously at eight steps during surgery including before and after intravascular volume expansion (500 mL hetastarch). Responders to volume expansion were defined as patients whose cardiac index increased by more than 15% after volume expansion. RESULTS: Agreement between deltaPP(man) and deltaPP(auto) over the 200 pairs of collected data was 0.7% +/- 3.4% (mean bias +/- SD). Seventeen patients were responders to volume expansion. A threshold deltaPP(man) value of 12% allowed discrimination of responders to volume expansion with a sensitivity of 88% and a specificity of 100%. A threshold deltaPP(auto) value of 10% allowed discrimination of responders to volume expansion with a sensitivity of 82% and a specificity of 88%. CONCLUSION: DeltaPP(auto) is strongly correlated to deltaPP(man) is an accurate predictor of fluid responsiveness, and allows continuous monitoring of deltaPP. This novel algorithm has potential clinical applications.

18: Int J Artif Organs. 2008 Feb;31(2):111-26.
Fluid and volume monitoring.
Pinsky MR, Brophy P, Padilla J, Paganini E, Pannu N. Critical Care Medicine, Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA.

BACKGROUND: Fluid resuscitation is not only used to prevent acute kidney injury (AKI) but fluid management is also a cornerstone of treatment for patients with established AKI and renal failure. Ultrafiltration removes volume initially from the intravascular compartment inducing a relative degree of hypovolemia. Normal reflex mechanisms attempt to sustain blood pressure constant despite marked changes in blood volume and cardiac output. Thus, compensated shock with a normal blood pressure is a major cause of AKI or exacerbations of AKI during ultrafiltration. METHODS: We undertook a systematic review of the literature using MEDLINE, Google Scholar and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated clinical practice recommendations and/or directions for future research. RESULTS: We defined three aspects of fluid monitoring: i) normal and pathophysiological cardiovascular mechanisms; ii) measures of volume responsiveness and impending cardiovascular collapse during volume removal, and; iii) measured indices of each using non-invasive and minimally invasive continuous and intermittent monitoring techniques. The evidence documents that AKI can occur in the setting of normotensive hypovolemia and that under-resuscitation represents a major cause of both AKI and mortality ion critically ill patients. Traditional measures of intravascular volume and ventricular filling do not predict volume responsiveness whereas dynamic functional hemodynamic markers, such as pulse pressure or stroke volume variation during positive pressure breathing or mean flow changes with passive leg raising are highly predictive of volume responsiveness. Numerous commercially-available devices exist that can acquire these signals. CONCLUSIONS: Prospective clinical trials using functional hemodynamic markers in the diagnosis and management of AKI and volume status during ultrafiltration need to be performed. More traditional measure of preload be abandoned as marked of volume responsiveness though still useful to assess overall volume status.

19: Liver Transpl. 2008 Mar;14(3):327-32.
Comment in: Liver Transpl. 2008 Mar;14(3):268-9.
Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study.
Rocca GD, Costa MG, Feltracco P, Biancofiore G, Begliomini B, Taddei S, Coccia C,
Pompei L, Di Marco P, Pietropaoli P. Department of Anesthesia and Intensive Care Medicine, University of Udine, Azienda Ospedaliera Universitaria, Udine, Italy.

Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as < or =30, 31-40, and >40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.

20: Ann Card Anaesth. 2008 Jan-Jun;11(1):27-34.
Comment in: Ann Card Anaesth. 2008 Jan-Jun;11(1):1-2.
Early goal-directed therapy in moderate to high-risk cardiac surgery patients.
Kapoor PM, Kakani M, Chowdhury U, Choudhury M, Lakshmy , Kiran U. Department of Cardiac Anaesthesia, Cardiothoracic and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Early goal-directed therapy is a term used to describe the guidance of intravenous fluid and vasopressor/inotropic therapy by using cardiac output or similar parameters in the immediate post-cardiopulmonary bypass in cardiac surgery patients. Early recognition and therapy during this period may result in better outcome. In keeping with this aim in the cardiac surgery patients, we conducted the present study. The study included 30 patients of both sexes, with EuroSCORE >or=3 undergoing coronary artery bypass surgery under cardiopulmonary bypass. The patients were randomly divided into two groups, namely, control and early goal-directed therapy (EGDT) groups. All the subjects received standardized care; arterial pressure was monitored through radial artery, central venous pressure through a triple lumen in the right internal jugular vein, electrocardiogram, oxygen saturation, temperature, urine output per hour and frequent arterial blood gas analysis. In addition, cardiac index monitoring using FloTrac and continuous central venous oxygen saturation using PreSep was used in patients in the EGTD group. Our aim was to maintain the cardiac index at 2.5-4.2 l/min/m2 , stroke volume index 30-65 ml/beat/m2 , systemic vascular resistance index 1500-2500 dynes/s/cm5/m2 , oxygen delivery index 450-600 ml/min/m2 , continuous central venous oximetry more than 70%, stroke volume variation less than 10%; in addition to the control group parameters such as central venous pressure 6-8 mmHg, mean arterial pressure 90-105 mmHg, normal arterial blood gas analysis values, pulse oximetry, hematocrit value above 30% and urine output more than 1 ml/kg/h. The aims were achieved by altering the administration of intravenous fluids and doses of inotropic or vasodilator agents. Three patients were excluded from the study and the data of 27 patients analyzed. The extra volume used (330+/-160 v/s 80+/-80 ml, P=0.043) number of adjustments of inotropic agents (3.4+/-1.5 v/s 0.4+/-0.7, P=0.026) in the EGDT group were significant. The average duration of ventilation (13.8+/-3.2 v/s 20.7+/-7.1 h), days of use of inotropic agents (1.6+/-0.9 v/s 3.8+/-1.6 d), ICU stay (2.6+/-0.9 v/s 4.9+/-1.8 d) and hospital stay (5.6+/-1.2 v/s 8.9+/-2.1 d) were less in the EGDT group, compared to those in the control group. This study is inconclusive with regard to the beneficial aspects of the early goal-directed therapy in cardiac surgery patients, although a few benefits were observed.

21: Crit Care Med. 2008 Jan;36(1):296-327.
Erratum in: Crit Care Med. 2008 Apr;36(4):1394-6.
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL; International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine; Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine.
Cooper University Hospital, Camden, NJ, USA.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

22: Intensive Care Med. 2008 Feb;34(2):257-63. Epub 2007 Oct 6.
Continuous and intermittent cardiac output measurement in hyperdynamic conditions: pulmonary artery catheter vs. lithium dilution technique.
Costa MG, Della Rocca G, Chiarandini P, Mattelig S, Pompei L, Barriga MS, Reynolds T, Cecconi M, Pietropaoli P. Azienda Ospedaliero Universitaria di Udine, Clinica di Anestesia e Rianimazione, P.le S.M. della Misericordia 15, 33100 Udine, Italy.

OBJECTIVE: This study aimed to assess the level of agreement of both intermittent cardiac output monitoring by the lithium dilution technique (CO(Li)) and continuous cardiac output monitoring (PulseCO(Li)) using the arterial pressure waveform with intermittent thermodilution using a pulmonary artery catheter (CO(PAC)). DESIGN: Prospective, single-center evaluation. SETTING: University Hospital Intensive Care Unit. PATIENTS: Patients (n=23) receiving liver transplantation. INTERVENTION: Pulmonary artery catheters were placed in all patients and CO(PAC) was determined using thermodilution. CO(Li) and PulseCO(Li) measurements were made using the LiDCO system. MEASUREMENTS AND MAIN RESULTS: Data were collected after intensive care unit admission and every 8h until the 48th hour. A total of 151 CO(PAC), CO(Li) and PulseCO(Li) measurements were analysed. Bias and 95% limit of agreement were 0.11lmin(-1) and -1.84 to + 2.05 lmin(-1) for CO(PAC) vs. CO(Li) (r=0.88) resulting in an overall percentage error of 15.6%. Bias and 95% limit of agreement for CO(PAC) vs. PulseCO(Li) were 0.29 lmin(-1) and -1.87 to + 2.46 lmin(-1) (r=0.85) with a percentage error of 16.8%. Subgroup analysis revealed a percentage error of 15.7% for CO(PAC) vs. CO(Li) and 15.1% for CO(PAC) vs. PulseCO(Li) for data pairs less than 8 lmin(-1), and percentage errors of 15.5% and 18.5% respectively for data pairs higher than 8 lmin(-1). CONCLUSION: In patients with hyperdynamic circulation, intermittent and continuous CO values determined using the LiDCO system showed good agreement with those obtained by intermittent pulmonary artery thermodilution.

23: Anaesthesia. 2007 Oct;62(10):979-83.
Continuous cardiac output measurement: arterial pressure analysis versus thermodilution technique during cardiac surgery with cardiopulmonary bypass.
Lorsomradee S, Lorsomradee SR, Cromheecke S, De Hert SG. Department of Anaesthesia, Chiangmai University Hospital, Thailand.

This study compared cardiac output measured with an arterial pressure-based cardiac output measurement system and a thermodilution cardiac output measurement system. We studied 36 patients undergoing cardiac surgery with cardiopulmonary bypass. Simultaneous arterial pressure-based and thermodilution cardiac output measurements were compared before and after cardiopulmonary bypass, and after phenylephrine administration. Bland-Altman analysis showed good overall agreement between the two methods. Bias (limits of agreement) before and after cardiopulmonary bypass were - 0.21 (- 2.97-2.55) lxmin(-1) and 0.01 (- 3.79-3.81) lxmin(-1), respectively. Phenylephrine administration decreased thermodilution cardiac output by a mean (SD) of 11 (16)% and increased arterial pressure-based cardiac output by 55 (34)%. We conclude that arterial pressure-based cardiac output and thermodilution cardiac output measurement systems yield comparable results during cardiac surgery with cardiopulmonary bypass. However, after phenylephrine administration, the two measurement systems provided opposing results.

24: Br J Anaesth. 2007 Oct;99(4):484-92. Epub 2007 Jul 24.
Continuous cardiac output during off-pump coronary artery bypass surgery: pulse-contour analyses vs pulmonary artery thermodilution.
Halvorsen PS, Sokolov A, Cvancarova M, Hol PK, Lundblad R, T°nnessen TI. The Interventional Centre, Rikshospitalet-Radiumhospitalet Medical Centre, Oslo, Norway.

BACKGROUND: No gold standard method exists for monitoring continuous cardiac output (CO). In this study, the agreement between the two most frequently used methods, PiCCO pulse-contour analysis (PCCO) and STAT pulmonary artery thermodilution (STAT-CO), was assessed during multiple-vessel off-pump coronary artery bypass (OPCAB) surgery. METHODS: Thirty patients were enrolled in the study. Two time periods were defined during surgery; Period 1 included positioning of the heart and stabilizer device and Period 2 included the coronary occlusion. Measurements were obtained every minute during both periods. The agreement for the continuous CO and the change in CO (DeltaCO) was estimated using the Bland-Altman method. RESULTS: Significant changes in mean arterial pressure (DeltaMAP), central venous saturation, PCCO and STAT-CO were seen only during Period 1. DeltaMAP correlated only with changes in PCCO, (P < 0.001, r = 0.60). The mean difference (2sd) between PCCO and STAT-CO ranged from - 0.29 (1.82) to - 0.71 (2.57) litre min(-1), and the percentage error varied from 32 to 50%. For the CO measurements, the limits of agreements did not differ between Period 1 and Period 2. In contrast, for the DeltaCO measurements, the limits of agreements were wider in Period 1 than in the more haemodynamically stable Period 2. CONCLUSIONS: CCO and STAT-CO show large discrepancies in CO during OPCAB surgery. Clinically acceptable agreement was seen only for trends in CO during haemodynamically stable periods.

25: Br J Anaesth. 2007 Sep;99(3):337-42. Epub 2007 Jul 4.
Measurement of cardiac output: a comparison between transpulmonary thermodilution and uncalibrated pulse contour analysis.
Sakka SG, Kozieras J, Thuemer O, van Hout N. Department of Anaesthesiology and Operative Intensive Care Medicine, Medical Center Cologne-Merheim, Cologne, Germany.

BACKGROUND: Recently, continuous monitoring of cardiac output (CO) based on pulse contour analysis (Vigileo) has been introduced into practice. In this clinical study, we evaluated the accuracy of this system by comparing it with the transpulmonary thermodilution technique (TPID) in septic patients. METHODS: We studied 24 mechanically ventilated patients with septic shock (16 male, 8 female, age 26-77 yr) receiving treatment with norepinephrine who for clinical indication underwent haemodynamic monitoring by the transpulmonary thermodilution technique using a PiCCO plus system (Pulsion Medical Systems, Munich, Germany). In parallel, arterial pulse contour was applied using the femoral arterial pressure curve (FloTrac pressure sensor, Vigileo monitor, Edwards Lifesciences, Irvine, USA). After baseline measurement, mean arterial pressure was elevated by increasing norepinephrine dosage, and CO was measured again before mean arterial pressure was reduced back to baseline levels. Fluid status and ventilator settings remained unchanged throughout. At each time point, CO by transpulmonary thermodilution was calculated from three central venous bolus injections of 15 ml of saline (<8 degrees C). Linear regression and the Bland-Altman method were used for statistical analysis. RESULTS: Overall, CO was 6.7 (sd 1.8) (3.2-10.1) litre min(-1) for CO(TPID) and 6.2 (2.4) (3.0-17.6) litre min(-1) for CO(Vigileo((R))). Linear regression revealed: CO(Vigileo) = 1.54 + 0.72 x CO(TPID) litre min(-1), r(2) = 0.26 (P < 0.0001). Mean bias between techniques [CO(TPID)-CO(Vigileo)] was 0.5 litre min(-1) (SD 2.3 litre min(-1)). Correlation coefficients at the three time points were not significantly different from each other. CONCLUSIONS: Pulse contour analysis-derived CO (Vigileo system) underestimates CO(TPID) and is not as reliable as transpulmonary thermodilution in septic patients.

26: Crit Care Med. 2007 Aug;35(8):1904-9.
Validation of a new arterial pulse contour-based cardiac output device.
de Waal EE, Kalkman CJ, Rex S, Buhre WF. Division of Perioperative and Emergency Care, University Medical Center, Utrecht, The Netherlands.

OBJECTIVE: To evaluate the accuracy and precision of an arterial pulse contour-based continuous cardiac output device (Vigileo). Vigileo cardiac output (VigileoCO) was compared with intermittent transpulmonary thermodilution cardiac output (TPCO) and an established arterial pulse contour-based cardiac output (PCCO). DESIGN: Prospective clinical study. SETTING: University hospital. PATIENTS: Twenty-two patients undergoing coronary artery bypass graft surgery. INTERVENTIONS: Defined volume load during surgery and in the postoperative period. MEASUREMENTS AND MAIN RESULTS: We obtained 184 pairs of VigileoCO and TPCO, 140 pairs of VigileoCO and PCCO, and 140 pairs of PCCO and TPCO. Measurements were performed after induction of anesthesia (T1), after sternotomy (T2), immediately after (T3) and 20 mins after volume challenge with 10 hydroxyethyl starch 6% (T4), 15 mins after coronary pulmonary bypass (T5), after retransfusion of autologous blood (T6), after arrival at the intensive care unit (T7), and immediately after (T8) and 20 mins after (T9) a second volume load with 10 hydroxyethyl starch 6%. TPCO was used to calibrate PCCO. For pooled data, including uncalibrated PCCO data immediately after weaning from coronary pulmonary bypass (T5), the correlation coefficient of TPCO vs. VigileoCO, PCCO vs. VigileoCO, and TPCO vs. PCCO was 0.75, 0.60, and 0.75 respectively. Bland-Altman analysis showed a bias of 0.00, -0.01, and 0.02 L.min, the precision (=sd) was 0.87, 1.08, and 0.93 L.min, and the mean error was 33%, 40%, and 35%. When we compared calibrated PCCO values (T2-T4, T6, T7-9), the correlation coefficients of PCCO-VigileoCO and TPCO-PCCO were 0.72 and 0.85, bias was -0.16 and 0.19 L.min, and mean error was 33% and 27%, respectively. Best correlations and the least differences between TPCO and VigileoCO were observed in postbypass closed-chest conditions and in the intensive care unit. CONCLUSIONS: Our results showed that VigileoCO enables clinically acceptable assessment of cardiac output in postbypass closed-chest conditions and during stable conditions in the intensive care unit.

27: Intensive Care Med. 2007 Oct;33(10):1805-10. Epub 2007 Jun 5.
Comparison of two methods for enhanced continuous circulatory monitoring in patients with septic shock.
Sp÷hr F, Hettrich P, Bauer H, Haas U, Martin E, B÷ttiger BW. Department of Anaesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.

OBJECTIVE: To compare a modified pulmonary artery catheter (PAC) and pulse-contour analysis by the PiCCO (Pulsion Medical Systems, Munich, Germany) system for continuous assessment of cardiac output in patients with septic shock. In addition, to assess the relationships between an index of global end-diastolic volume (GEDV) derived by the PiCCO system with traditional PAC-derived indicators of filling: central venous pressure; pulmonary artery occlusion pressure; and right ventricular end-diastolic volume (RVEDV). DESIGN: Prospective cohort study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: 14 patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A significant correlation was found between continuous cardiac output by PAC (CCO(PAC)) and by pulse-contour analysis (r (2) = 0.714, p < 0.0001), accompanied by a bias of 0.1 l min(-1) and a precision of 2.7 l min(-1). The correlation between CCO(PAC) and cardiac output measured by transcardiopulmonary thermodilution was also significant (r (2) = 0.781, p < 0.0001). There was a bias for the two methods of 0.2 l min(-1), and a precision of 2.2 lmin(-1). The GEDV showed no correlation with central venous pressure, pulmonary artery occlusion pressure, or RVEDV. CONCLUSION: In patients with septic shock, the averaged bias in continuous measurement of cardiac output by both a modified pulmonary artery catheter and pulse-contour analysis was small, but variability was large. No correlation was found between GEDV and RVEDV. The clinical importance of different cardiac filling parameters needs further investigation.


28. Crit Care. 2005;9(6):R687-93. Epub 2005 Nov 8.

Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445].

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED.



Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery.


This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min(-1) m(-2) or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days.


Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD +/- 878 ml versus 1,204 SD +/- 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD +/- 0.9 per patient versus 1.5 SD +/- 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59).


Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.

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