27 Dec 06
Posted in PA catheter at 16:19 by Laci
By E Robin, M Costecalde, G Lebuffe and B Vallet
Critical Care 2006, 10(Suppl 3):S3
The usefulness of parameters measured using the pulmonary artery catheter has been challenged because no benefit in patient outcome has been observed in clinical trials. However, technological advances have been made, including continuous measurement of cardiac output (CO), mixed venous saturation (SvO2), and right ventricle end-diastolic volume (CEDV) have been made. Pulmonary artery occlusion pressure (PAOP), CEDV and right atrial pressure (RAP) are not good predictors of fluid load responsiveness except when very low. Despite this methodological limitation, variation of these parameters during fluid loading remains a good indicator of fluid challenge tolerance. Accuracy of continuous thermodilution and SvO2 measurement has been demonstrated in vitro and at bedside. A decrease in SvO2 is a global index of an inadequate oxygen delivery (DO2)/oxygen requirement relationship. In this setting, a therapeutic decision to improve determinants of SvO2 should be considered with the help of all other PAC parameters. Technological improvement transforms PAC in a real time integrated physiological device and allows one to observe the impact of therapeutic intervention. What we need now is a clinical trial with a PAC-guided treatment algorithm taking into account the above integrated PAC parameters.
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Posted in PA catheter at 16:17 by Laci
By SL Zanotti Cavazzoni and R P Dellinger
Critical Care 2006, 10(Suppl 3):S2
Sepsis is associated with cardiovascular changes that may lead to development of tissue hypoperfusion. Early recognition of sepsis and tissue hypoperfusion is critical to implement appropriate hemodynamic support and prevent irreversible organ damage. End points for resuscitation need to be defined and invasive hemodynamic monitoring is usually required. Targets for hemodynamic optimization should include intravascular volume, blood pressure, and cardiac output. Therapeutic interventions aimed at optimizing hemodynamics in patients with sepsis include aggressive fluid resuscitation, the use of vasopressor agents, inotropic agents and in selected cases transfusions of blood products. This review will cover the most important aspects of hemodynamic optimization for treatment of sepsis induced tissue-hypoperfusion.
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Posted in PA catheter at 16:16 by Laci
By Jean-Louis Vincent
Critical Care 2006, 10(Suppl 3):S1
The history of the pulmonary artery catheter spans almost 90 years from the first reported cardiac catheterization by Werner Forssmann (on himself!) in 1929. Some 25 years later, a balloon-tipped catheter was developed by Lategola and Rahn and used in dogs, but the name of the catheter (and much of the credit for its invention) went to Swan and Ganz, whose now famous paper on the use of a balloon-tipped catheter to catheterize the pulmonary artery was published in 1970. The innovative use of the balloon to guide the catheter made this a huge advance for cardiology and haemodynamic monitoring and management. Since that date, the pulmonary artery (Swan-Ganz) catheter (PAC) has changed little in size or structure, and has become one of the most widely used pieces of equipment in the intensive care unit.
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11 Dec 06
Posted in Critical Care, Glycemic control at 15:29 by Laci
By SB Clayton, JE Mazur, S Condren, KL Hermayer, C Strange
Critical Care Medicine 2006;34:2974-2978
Intensive insulin therapy to normalize blood glucose may improve outcome in intensive care unit patients. We prospectively evaluated the implementation of an intensive insulin protocol in medical intensive care patients to identify and overcome obstacles that this complex therapy creates.
Design
This prospective, quality assessment study was designed to establish a standard protocol for glucose control in critically ill patients.
Setting
The study took place in the medical intensive care unit at the Medical University of South Carolina, a tertiary care center.
Patients
Patients diagnosed with sepsis and two consecutive blood glucose measurements of >120 mg/dL were included in the study.
Interventions
The protocol, targeting blood glucose of 80-120 mg/dL, was a multidisciplinary initiative involving extensive education of house staff before subject enrollment. Based on predefined criteria, patients were monitored daily for glycemic control, inclusion criteria, and protocol adherence. Protocol improvements were assessed at 6 and 12 months via nursing surveys.
Measurements and Main Results
Seventy patients receiving insulin infusion for >8 hrs were included in data analysis, accounting for 4,920 glucose readings. Eighty-six hypoglycemic events were recorded, with the number of events decreasing from 7.6% to 0.3% by the final version of the protocol. Average duration on protocol was 6 days, and average time to target range was 5.4 hrs. Identifiable causes of hypoglycemia and survey results led to four protocol revisions by study completion.
Conclusions
In comparison to studies suggesting that normoglycemia is an easily achievable goal, our protocol often recorded glucose values <80 mg/dL, although values <60 mg/dL were rare and usually due to protocol violations. In the interval before automated glucose-sensing insulin infusion devices become available for the intensive care unit, the current protocol is available to assist others in achieving target glucose levels shown to improve mortality rate in an intensive care unit population.
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