Less invasive hemodynamic monitoring in critically ill patients
TL;DR: The advantages and limits of using continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability are discussed.
Abstract: Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.
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Pontifical Catholic University of Chile1, ICESI University2, University of São Paulo3, National University of La Plata4, University of the Republic5, American Society of Safety Engineers6, Universidade Federal do Rio Grande do Sul7, University of Paris-Sud8, Humanitas University9, Central University of Ecuador10
TL;DR: Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality.
Abstract: Importance Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. Objective To determine if a peripheral perfusion–targeted resuscitation during early septic shock in adults is more effective than a lactate level–targeted resuscitation for reducing mortality. Design, Setting, and Participants Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Interventions Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation–, renal replacement therapy–, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Results Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02];P = .06; risk difference, −8.5% [95% CI, −18.2% to 1.2%]). Peripheral perfusion–targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, −1.00 [95% CI, −1.97 to −0.02];P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Conclusions and Relevance Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier:NCT03078712
432 citations
Cites background from "Less invasive hemodynamic monitorin..."
...Intravenous fluid loading per weight, mL/kgf 25 (16-40) 30 (20-43)...
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Erasmus University Rotterdam1, St George's Hospital2, Université libre de Bruxelles3, Beth Israel Deaconess Medical Center4, University of Paris-Sud5, University of Pittsburgh6, Autonomous University of Barcelona7, King's College8, Marche Polytechnic University9, University of Zurich10, Pontifical Catholic University of Chile11, University of Paris12, Royal Free Hospital13, University College London14, University of Münster15, Columbia University Medical Center16
TL;DR: This consensus aims to provide clinicians with guidelines for practical use and interpretation of the sublingual microcirculation and promote the integration of routine application of HVM microcirculatory monitoring in conventional hemodynamic monitoring of systemic hemodynamic variables.
Abstract: Hand-held vital microscopes (HVMs) were introduced to observe sublingual microcirculatory alterations at the bedside in different shock states in critically ill patients This consensus aims to provide clinicians with guidelines for practical use and interpretation of the sublingual microcirculation Furthermore, it aims to promote the integration of routine application of HVM microcirculatory monitoring in conventional hemodynamic monitoring of systemic hemodynamic variables In accordance with the Delphi method we organized three international expert meetings to discuss the various aspects of the technology, physiology, measurements, and clinical utility of HVM sublingual microcirculatory monitoring to formulate this consensus document A task force from the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine (with endorsement of its Executive Committee) created this consensus as an update of a previous consensus in 2007 We classified consensus statements as definitions, requirements, and/or recommendations, with a minimum requirement of 80% agreement of all participants In this consensus the nature of microcirculatory alterations is described The nature of variables, which can be extracted from analysis of microcirculatory images, is presented and the needed dataset of variables to identify microcirculatory alterations is defined Practical aspects of sublingual HVM measurements and the nature of artifacts are described Eleven statements were formulated that pertained to image acquisitions and quality statements Fourteen statements addressed the analysis of the images, and 13 statements are related to future developments This consensus describes 25 statements regarding the acquisition and interpretation of microcirculatory images needed to guide the assessment of the microcirculation in critically ill patients
280 citations
Cites background from "Less invasive hemodynamic monitorin..."
..., the guideline on circulatory shock and hemodynamic monitoring [54] and the position paper on hemodynamic monitoring [55]....
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TL;DR: Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management and belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
Abstract: For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
166 citations
Cites background from "Less invasive hemodynamic monitorin..."
...It must be performed early in every patient with acute circulatory failure [1, 3] (Fig....
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...It is recommended to average the result of three bolus injections [3]....
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...In this regard, both are suitable for complex and critically ill patients [1, 3, 84, 92]....
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TL;DR: The aim of this work was to systematically review all the previously published studies assessing the accuracy of the diameter of IVC or its respiratory variations measured through US in predicting fluid responsiveness, and found an extreme heterogeneity of included studies.
Abstract: Objective:Fluid responsiveness is the ability to increase the cardiac output in response to a fluid challenge. Only about 50% of patients receiving fluid resuscitation for acute circulatory failure...
97 citations
Cites methods from "Less invasive hemodynamic monitorin..."
...However, these methods are not completely capable to predict fluid responsiveness, especially in certain circumstances, such as arrhythmias or spontaneously breathing patients.(5-9) Transthoracic echocardiography (TTE) currently is probably the most used method to evaluate the fluid responsiveness....
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TL;DR: What is known about the effects of severe acute respiratory syndrome coronavirus-2 infection on different parts of the respiratory system, clues to understanding the underlying biology of respiratory disease, and current and future translation and clinical research questions are reviewed.
Abstract: The severe acute respiratory syndrome coronavirus-2 emerged as a serious human pathogen in late 2019, causing the disease coronavirus disease 2019 (COVID-19). The most common clinical presentation of severe COVID-19 is acute respiratory failure consistent with the acute respiratory distress syndrome. Airway, lung parenchymal, pulmonary vascular, and respiratory neuromuscular disorders all feature in COVID-19. This article reviews what is known about the effects of severe acute respiratory syndrome coronavirus-2 infection on different parts of the respiratory system, clues to understanding the underlying biology of respiratory disease, and highlights current and future translation and clinical research questions.
96 citations
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TL;DR: This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsi and the intensive care unit mortality in the various countries.
Abstract: Objective:To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units.Design:Cohort, multiple-center, observational study.Setting:One hundred and ninety-eight intensive care units in 24 European countries.Patients:All new adult admissi
2,495 citations
TL;DR: Graphically, it was shown that limits of agreement of up to ±30% were acceptable and accepted when using bias and precision statistics, cardiac output, bias, Limits of agreement, and percentage error should be presented.
Abstract: Introduction. Bias and precision statistics have succeeded regression analysis when measurement techniques are compared. However, when applied to cardiac output measurements, inconsistencies occur in reporting the results of this form of analysis. Methods. A MEDLINE search was performed, dating from 1986. Studies comparing techniques of cardiac output measurement using bias and precision statistics were surveyed. An error-gram was constructed from the percentage errors in the test and reference methods and was used to determine acceptable limits of agreement between methods. Results. Twenty-five articles were found. Presentation of statistical data varied greatly. Four different statistical parameters were used to describe the agreement between measurements. The overall limits of agreement in studies evaluating bioimpedance (n = 23) was ±37% (15–82%) and in those evaluating Doppler ultrasound (n = 11) ±65% (25–225%). Objective criteria used to assess outcome were given in only 44% of the articles. These were (i) limits of agreement approaching ±15–20%, (ii) limits of agreement of less than 1 L/min, and (iii) more than 75% of bias measurements within ±20% of the mean. Graphically, we showed that limits of agreement of up to ±30% were acceptable. Conclusions. When using bias and precision statistics, cardiac output, bias, limits of agreement, and percentage error should be presented. Using current reference methods, acceptance of a new technique should rely on limits of agreement of up to ±30%.
1,224 citations
"Less invasive hemodynamic monitorin..." refers background in this paper
...In such situations and provided that CO is normal or low, the most recent versions of uncalibrated CO monitoring devices provide reliable CO measurements [23], as suggested by percentage errors of less than 30 % [24] found in validation studies [23]....
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TL;DR: It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaP p is a more reliable indicator of fluid responsiveness than DeltaPs.
Abstract: In mechanically ventilated patients with acute circulatory failure related to sepsis, we investigated whether the respiratory changes in arterial pressure could be related to the effects of volume expansion (VE) on cardiac index (CI). Forty patients instrumented with indwelling systemic and pulmonary artery catheters were studied before and after VE. Maximal and minimal values of pulse pressure (Pp(max) and Pp(min)) and systolic pressure (Ps(max) and Ps(min)) were determined over one respiratory cycle. The respiratory changes in pulse pressure (DeltaPp) were calculated as the difference between Pp(max) and Pp(min) divided by the mean of the two values and were expressed as a percentage. The respiratory changes in systolic pressure (DeltaPs) were calculated using a similar formula. The VE-induced increase in CI was >/= 15% in 16 patients (responders) and < 15% in 24 patients (nonresponders). Before VE, DeltaPp (24 +/- 9 versus 7 +/- 3%, p < 0.001) and DeltaPs (15 +/- 5 versus 6 +/- 3%, p < 0.001) were higher in responders than in nonresponders. Receiver operating characteristic (ROC) curves analysis showed that DeltaPp was a more accurate indicator of fluid responsiveness than DeltaPs. Before VE, a DeltaPp value of 13% allowed discrimination between responders and nonresponders with a sensitivity of 94% and a specificity of 96%. VE-induced changes in CI closely correlated with DeltaPp before volume expansion (r(2) = 0. 85, p < 0.001). VE decreased DeltaPp from 14 +/- 10 to 7 +/- 5% (p < 0.001) and VE-induced changes in DeltaPp correlated with VE-induced changes in CI (r(2) = 0.72, p < 0.001). It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaPp is a more reliable indicator of fluid responsiveness than DeltaPs.
1,178 citations
"Less invasive hemodynamic monitorin..." refers methods in this paper
...Using PPV and SVV to predict fluid responsiveness is based upon the concept of heart–lung interactions during mechanical ventilation revealing cardiac preload dependence [12]....
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TL;DR: In this article, the authors identified and critically reviewed the published peer-reviewed, English-language studies investigating predictive factors of fluid responsiveness in ICU patients and compared responder and nonresponder patients' characteristics before volume expansion.
1,144 citations
TL;DR: In this article, the authors provide support to the bedside clinician regarding the diagnosis, management and monitoring of circulatory shock, which is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate.
Abstract: Objective
Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.
1,142 citations