Noninvasive cardiac output monitors: a state-of the-art review.
01 Feb 2013-Journal of Cardiothoracic and Vascular Anesthesia (J Cardiothorac Vasc Anesth)-Vol. 27, Iss: 1, pp 121-134
TL;DR: The resuscitation of hemodynamically unstable patients requires an accurate assessment of the patients' intravascular volume status (cardiac preload) and the ability to predict the hemodynamic response after a fluid challenge (volume responsiveness) to minimize the risks of over- or under-resuscitation.
About: This article is published in Journal of Cardiothoracic and Vascular Anesthesia.The article was published on 2013-02-01. It has received 258 citations till now.
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1,835 citations
TL;DR: PLR-induced changes in CO very reliably predict the response of CO to volume expansion in adults with acute circulatory failure and when PLR effects are assessed by changes in PP, the specificity of the PLR test remains acceptable but its sensitivity is poor.
Abstract: We performed a systematic review and meta-analysis of studies investigating the passive leg raising (PLR)-induced changes in cardiac output (CO) and in arterial pulse pressure (PP) as predictors of fluid responsiveness in adults. MEDLINE, EMBASE and Cochrane Database were screened for relevant original and review articles. The meta-analysis determined the pooled area under the ROC curve, the sensitivity, specificity and threshold for the PLR test when assessed with CO and PP. Twenty-one studies (991 adult patients, 995 fluid challenges) were included. CO was measured by echocardiography in six studies, calibrated pulse contour analysis in six studies, bioreactance in four studies, oesophageal Doppler in three studies, transpulmonary thermodilution or pulmonary artery catheter in one study and suprasternal Doppler in one study. The pooled correlation between the PLR-induced and the fluid-induced changes in CO was 0.76 (0.73–0.80). For the PLR-induced changes in CO, the pooled sensitivity was 0.85 (0.81–0.88) and the pooled specificity was 0.91 (0.88–0.93). The area under the ROC curve was 0.95 ± 0.01. The best threshold was a PLR-induced increase in CO ≥10 ± 2 %. For the PLR-induced changes in PP (8 studies, 432 fluid challenges), the pooled sensitivity was 0.56 (0.49–0.53), the pooled specificity was 0.83 (0.77–0.88) and the pooled area under the ROC curve was 0.77 ± 0.05. Sensitivity and subgroup analysis were consistent with the primary analysis. PLR-induced changes in CO very reliably predict the response of CO to volume expansion in adults with acute circulatory failure. When PLR effects are assessed by changes in PP, the specificity of the PLR test remains acceptable but its sensitivity is poor.
282 citations
Additional excerpts
...This must be regarded as a limitation, since the reliability of the PLR test likely depends on the accuracy of the device used to measure CO [49]....
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01 Jan 2012
TL;DR: In a large group of critically ill African children, fluid boluses significantly increased 48-hour mortality and do not support the routine use of bolus resuscitation in severely ill febrile children with impaired perfusion in African hospitals.
Abstract: In a large group of critically ill African children, fluid boluses significantly increased 48-hour mortality. The results were most marked in those with haemoglobin levels less than 5 g/dL. The results do not support the routine use of bolus resuscitation in severely ill febrile children with impaired perfusion in African hospitals. Level of evidence: 1B: individual randomised control trial with narrow confidence intervals.
209 citations
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.
205 citations
Cites background or methods from "Noninvasive cardiac output monitors..."
...The continuous and real-time estimation of CO based on the pulse wave transit time method (esCCO, Nihon Kohden, Japan) requires an electrocardiogram and a pulse oximetry plethysmographical waveform [34, 35]....
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...Bioimpedance [BioZ (Cardiodynamics, USA), Aesculon (Osypka Medical, Germany)] and bioreactance (NICOM, Cheetah Medical, Israel) systems derive CO from changes in thoracic impedance or phase shift in voltage over the cardiac cycle because pulsatile changes in intrathoracic blood volume induce changes in the electrical conductivity of the thorax [34, 35, 47]....
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TL;DR: The underlying principles and validation data of the following technologies are presented: thoracic electrical bioimpedance, thorACic bioreactance, vascular unloading technique, pulse wave transit time, and radial artery applanation tonometry, which are capable of providing cardiac output readings noninvasively and continuously.
Abstract: Summary. The determination of blood flow, i.e. cardiac output, is an integral part of haemodynamic monitoring. This is a review on noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine. We present the underlying principles and validation data of the following technologies: thoracic electrical bioimpedance, thoracic bioreactance, vascular unloading technique, pulse wave transit time, and radial artery applanation tonometry. According to clinical studies, these technologies are capable of providing cardiac output readings noninvasively and continuously. They, therefore, might prove to be innovative tools for the assessment of advanced haemodynamic variables at the bedside. However, for most technologies there are conflicting data regarding the measurement performance in comparison with reference methods for cardiac output assessment. In addition, each of the reviewed technology has its own limitations regarding applicability in the clinical setting. In validation studies comparing cardiac output measurements using these noninvasive technologies in comparison with a criterion standard method, it is crucial to correctly apply statistical methods for the assessment of a technology's accuracy, precision, and trending capability. Uniform definitions for ‘clinically acceptable agreement' between innovative noninvasive cardiac output monitoring systems and criterion standard methods are currently missing. Further research must aim to further develop the different technologies for noninvasive continuous cardiac output determination with regard to signal recording, signal processing, and clinical applicability.
144 citations
References
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TL;DR: An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.
43,884 citations
TL;DR: This study randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit.
Abstract: Background Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit. Methods We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Results Of the 263 enrolled patients, 130 were ...
8,811 citations
TL;DR: Pressures in the right side of the heart and pulmonary capillary wedge can be obtained by cardiac catheterization without the aid of fluoroscopy.
Abstract: Pressures in the right side of the heart and pulmonary capillary wedge can be obtained by cardiac catheterization without the aid of fluoroscopy. A No. 5 Fr double-lumen catheter with a balloon just proximal to the tip is inserted into the right atrium under pressure monitoring. The balloon is then inflated with 0.8 ml of air. The balloon is carried by blood flow through the right side of the heart into the smaller radicles of the pulmonary artery. In this position when the balloon is inflated wedge pressure is obtained. The average time for passage of the catheter from the right atrium to the pulmonary artery was 35 seconds in the first 100 passages. The frequency of premature beats was minimal, and no other arrhythmias occurred.
1,927 citations
1,835 citations
TL;DR: A systematic review of the literature demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge.
1,295 citations