European Resuscitation Council Guidelines for Resuscitation 2015

Note: This article was originally published with an incorrect version of the Acknowledgments, which appeared on p. 218 of the print version. The correct version of the Acknowledgments appeared on pp. 1–2. The corrected article is available below.

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Human Health Risk Assessment for Aluminium, Aluminium Oxide, and Aluminium Hydroxide

Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.

Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society

Numerous cardiac output (CO) monitors have been produced that provide continuous rather than intermittent readings. Bland and Altman has become the standard method for validating their performance against older standards. However, the Bland and Altman method only assesses precision and does not assess how well a device detects serial changes in CO (trending ability). Currently, there is no consensus on how trending ability, or trend analysis, should be performed. Therefore, we performed a literature review to identify articles published between 1997 and 2009 that compared methods of continuous CO measurement. Identified articles were grouped according to measurement technique and statistical methodology. Articles that analyzed trending ability were reviewed with the aim of finding an acceptable statistical method. Two hundred two articles were identified. The most popular methods were pulse contour (69 articles), Doppler (54), bioimpedance (38), and transpulmonary or continuous thermodilution (27). Forty-one articles addressed trending, and of these only 23 provided an in-depth analysis. Several common statistical themes were identified: time plots, regression analysis, Bland and Altman using change in CO (ΔCO), and the 4-quadrant plot, which used direction of change of ΔCO to determine the concordance. This plot was further refined by exclusion of data when values were small. Receiver operating characteristic curves were used to define the exclusion zone. In animal studies, a reliable reference standard such as an aortic flowprobe was frequently used, and regression or time plots could be used to show trending. Clinical studies were more problematic because data collection points were fewer (8-10 per subject). The consensus was to use the 4-quadrant plot with exclusion zones and apply concordance analysis. A concordance rate of >92% when using a 15% zone indicated good trending. A new method of presenting trend data (ΔCO) on a polar plot is proposed. Agreement was shown by the angle with the horizontal axis and ΔCO by the distance from the center. Trending can be assessed by the vertical limits of the data, similar to the Bland and Altman method.

A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output.

Pediatric Pulmonary Hypertension

Background: Previous studies have demonstrated that there is a lack of agreement between intermittent cold bolus thermodilution (ICO) and a semicontinuous method with dilution of heat (CCO) in cardiac surgical patients following hypothermic extracorporeal circulation (HCPB). Therefore, the aim of the present study was to compare both ICO and CCO with continuous pulse contour analysis (PCCO): a method based on a fundamentally different principle of determining cardiac output (CO).



Methods:  A prospective criterion standard study of 25 cardiac surgery patients undergoing HCPB. Cardiac output was determined using the three methods (ICO, CCO, and PCCO) before and after HCPB up to 12 h after arrival on the ICU. Bias and precision were evaluated.



Results:  A total of 380 triple determinations of CO could be analyzed. During the entire study period bias PCCO-ICO was −0.14 l*/min (precision 1.16 l*/min) and bias CCO-ICO was −0.40 l*/min (precision 1.25 l*/min). Up to 45 min after bypass PCCO agreed with ICO (bias −0.21 l*/min, precision 1.37 l*/min), while bias CCO-ICO was −1.30 l*/min (precision 1.45 l*/min).



Conclusion:  The agreement between PCCO and ICO in contrast to CCO in the first 45 min after HCPB indicates that CCO underestimates CO during this period.

Pulse contour analysis versus thermodilution in cardiac surgery patients.

Continuous versus intermittent cardiac output measurement in cardiac surgical patients undergoing hypothermic cardiopulmonary bypass

Objective
Commercially available semi-continuous cardiac output (SCCO) monitoring systems are based on the pulsed warm thermodilution technique. There is evidence that SCCO fails to correlate with standard intermittent bolus cardiac output (ICO) in clinical situations with thermal instability in the pulmonary artery. Furthermore, ventilation may potentially influence thermodilution measurements by enhanced respiratory variations in pulmonary artery blood temperature and by cyclic changes in venous return. Therefore, we evaluated the correlation, accuracy and precision of SCCO versus ICO measurements before and after extubation.

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Semi-continuous versus injectate cardiac output measurement in intensive care patients after cardiac surgery.

Objectives
Pilot study to compare the effect of inhaled nitric oxide (iNO) and aerosolized iloprost in preventing perioperative pulmonary hypertensive crises (PHTCs).

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Comparison of inhaled nitric oxide with aerosolized iloprost for treatment of pulmonary hypertension in children after cardiopulmonary bypass surgery

BACKGROUND Successful surgical repair of a regurgitant mitral valve (MV) is dependent on a comprehensive assessment of its complex anatomy. Although there is limited evidence of the feasibility and accuracy of intraoperative real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in MV surgery, its use is increasing worldwide. We designed this prospective observational study of patients with mitral regurgitation to test initial findings on the accuracy of RT3DTEE images in the diagnosis of MV prolapse and chordal rupture relative to 2D imaging and to assess the potential of RT3DTEE for visualizing leaflet clefts. METHODS TEE-certified anesthesiologists examined 62 consecutive patients undergoing MV surgery by acquiring a full standard set of 2D TEE sections and 3D zoom recordings. Offline, 2D and 3D images were presented independently and in randomized order to 2 expert interpreters. Accuracy was determined using the surgical findings as the "gold standard." RESULTS Surgical inspection identified 52 cases of MV prolapse (MVP). RT3DTEE correlated stronger with the surgical findings than 2D TEE for detection and localization of MVP (difference in proportions=33.9%, P<0.001) and chordal rupture (difference in proportions=25.8%, P<0.001). The superiority of RT3DTEE was significant for scallops A2, P1, P2 in MVP and A2, P2 in chordal rupture (all P<0.05). In 22 patients, leaflet clefts were also surgically repaired, and RT3DTEE was feasible in accessing them (κ=0.65, confidence interval [0.44, 0.81]). CONCLUSION Although 2D TEE is currently the standard tool for intraoperative imaging in MV surgery, RT3DTEE improves the visualization of MV pathology and increases the accuracy of interpretation by facilitating spatial orientation. Further investigations, particularly those aimed at establishing its cost effectiveness, are indicated.

Helmut Rauch

Papers

Pulse contour analysis versus thermodilution in cardiac surgery patients.

Continuous versus intermittent cardiac output measurement in cardiac surgical patients undergoing hypothermic cardiopulmonary bypass

Semi-continuous versus injectate cardiac output measurement in intensive care patients after cardiac surgery.

Comparison of inhaled nitric oxide with aerosolized iloprost for treatment of pulmonary hypertension in children after cardiopulmonary bypass surgery

Real-time three-dimensional transesophageal echocardiography : improvements in intraoperative mitral valve imaging