Can peripheral venous pressure be interchangeable with central venous pressure in patients undergoing cardiac surgery?
R. E. DesjardinsAndré DenaultSylvain BélisleMichel CarrierDenis BabinSylvie LévesqueRaymond Martineau
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Pulmonary artery catheter
Central venous catheter
In the present study, cardiac output in mechanically ventilated patients were determined using three methods including modified CO2-Fick (mCO2F), pulmonary artery catheter (PAC), and pulse induced contour cardiac output (PiCCO) methods and the results were compared to assess the effectiveness of mCO2F method in measuring the cardiac output.Mechanically ventilated and hemodynamically unstable patients (n=39) were sedated and intubated with Swan-Ganz or PiCCO arterial catheters. At the beginning of the experiment and at 4 h after the experiment, the CO2 concentration in expiratory air was measured through a CO2 monitor and it was used further in the cardiac output calculation using mCO2F method. The cardiac output was also determined using PAC and PiCCO methods.The cardiac output determined by PAC and mCO2F method was not significantly (P>0.05) different [5.53±2.85 L.min(-1) (PAC) and 5.96±2.92 L.min(-1) (mCO2F)] at the beginning of the experiment and [6.22±2.7 L.min(-1) (PAC) and 6.36±2.35 L.min(-1) (mCO2F)] at 4 h after the experiment; however, they were highly correlated (r=0.939 and 0.908, P<0.001). The cardiac output determined by PiCCO and mCO2F method was also not significantly (P>0.05) different [6.05±2.49 L.min(-1) (PiCCO) and 5.44±1.64 L.min(-1) (mCO2F)] at the beginning of the experiment, and [6.17±2.04 L.min(-1) (PiCCO) and 5.70±1.72 L.min(-1) (mCO2F)] at 4 h after the experiment; however, they were highly correlated (r=0.776 and 0.832, P<0.001).The mCO2F method could accurately measure the cardiac output in mechanically ventilated patients without using any expensive equipment's and invasive procedures.
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Central venous pressure (CVP) is commonly measured, but its clinical use is still not clear. We argue that the interpretation of the CVP needs to be considered in conjunction with an assessment of cardiac output. The objective of this study was to define an elevated CVP as one in which there is a low probability for cardiac output to increase with a volume infusion through a Starling mechanism by relating the initial CVP (measured relative to a reference point 5 cm below the sternal angle) to the response in cardiac output with volume infusion. The authors studied consecutive patients who had pulmonary artery catheters in place and who had a volume challenge as part of routine management as ordered by the treating physician. To ensure an adequate test of the Starling mechanism, data were included only if the volume infusion increased CVP by > or = 2 mm Hg. Responders were defined a priori as those with an increase in cardiac index > or = 300 and nonresponders as < 300 mL/min/m2. Patients failed to respond to volume infusion at all CVP values, and even 25% of those with CVP < 5 mm Hg were nonresponders. However, when CVP was > 10 mm Hg, physicians prescribed less fluid challenges, and when they did, a positive response was much less likely. Change in blood pressure or changes in urine output with volume infusion correlated poorly with change in cardiac index. A CVP of > 10 mm Hg should be considered high, and the probability of an increase in cardiac output with volume infusion is low. This value is a reasonable upper limit for algorithms for empiric fluid challenges.
Cardiac index
Intravascular volume status
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The Mostcare monitor is a non-invasive cardiac output monitor. It has been well validated in cardiac surgical patients but there is limited evidence on its use in patients with severe sepsis and septic shock.The study included the first 22 consecutive patients with severe sepsis and septic shock in whom the floatation of a pulmonary artery catheter was deemed necessary to guide clinical management. Cardiac output measurements including cardiac output, cardiac index and stroke volume were simultaneously calculated and recorded from a thermodilution pulmonary artery catheter and from the Mostcare monitor respectively. The two methods of measuring cardiac output were compared by Bland-Altman statistics and linear regression analysis. A percentage error of less than 30% was defined as acceptable for this study.Bland-Altman analysis for cardiac output showed a Bias of 0.31 L.min-1, precision (=SD) of 1.97 L.min-1 and a percentage error of 62.54%. For Cardiac Index the bias was 0.21 L.min-1.m-2, precision of 1.10 L.min-1.m-2 and a percentage error of 64%. For stroke volume the bias was 5 mL, precision of 24.46 mL and percentage error of 70.21%. Linear regression produced a correlation coefficient r2 for cardiac output, cardiac index, and stroke volume, of 0.403, 0.306, and 0.3 respectively.Compared to thermodilution cardiac output, cardiac output studies obtained from the Mostcare monitor have an unacceptably high error rate. The Mostcare monitor demonstrated to be an unreliable monitoring device to measure cardiac output in patients with severe sepsis and septic shock on an intensive care unit.
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Objective To evaluate the accuracy and precision of FloTrac/Vigileo device,the hemodynamic parameters were compared between FloTrac/Vigileo monitor and pulmonary artery catheter in patients with cardiac dysfunction.Methods 32 patients with cardiac dysfunction(NYHA class Ⅳ) were studied from October 2008 to August 2011,all patients were examined by FloTrac/Vigileo monitor and pulmonary artery catheter.The hemodynamic parameters were obtained by FloTrac/Vigileo monitor and pulmonary artery catheter,pearson's relevance analysis was used to investigate the relationship of parameters between FloTrac/Vigileo monitor and pulmonary artery catheter.Results A significant high correlation between FloTrac/Vigileo monitor and pulmonary artery catheter was found in CO,CI,the correlation coefficients were 0.74 and 0.69 respctively(P 0.01).Conclusion The FloTrac/Vigileo cardiac output monitor has the advantages of simple,minimally invasive,There was a good correlation between FloTrac/Vigileo monitor and pulmonary artery catheter.The FloTrac/Vigileo monitor can evaluate the changes of of hemodynamics in patients with cardiac dysfunction.
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Objective To assess the accuracy of pulse-indicator continuous cardiac output (PiCCO) for the hemodynamics monitoring. Methods 30 critically ill patients with different etiological factors were admitted into intensive care unit. Hemodynamics of each patient was monitored by pulse-indicator continuous cardiac output and pulmonary artery catheter simultaneously. Correlation between the two methods was compared. Results Linear regression analysis revealed the two methods had good correlation [r=0.865 for cardiac output, r=0.879 for cardiac index, r=0.824 for stroke volume, r=0.833 for systemic vascular resistance]. Conclusion PiCCO can provide effectively hemodynamics monitoring for the management of the critical illness.
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Pulmonary artery catheter
Fick principle
Cardiac catheterization
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For many years, the pulmonary artery catheter has been used to monitor cardiac filling pressures and to determine cardiac output in hemodynamically unstable patients. Recently, a new pulmonary artery catheter with fiberoptic capabilities, which provides continuous mixed venous O2 saturation (SvO2) measurements, has become available and has been found to be helpful in managing unstable patients. To determine the efficacy of this device in predicting early changes in cardiac output, we studied 46 patients catheterized with the opticath and 25 with the standard pulmonary artery catheter; we compared changes in the SvO2 with associated cardiac index changes. We found that small changes (5%) in SvO2 did not correlate well with changes in cardiac output, yet larger changes (10%) in SvO2 seemed to correlate better. More importantly, we found that only 50% of the SvO2 changes predicted anticipated changes in cardiac output. As can best be determined from the limitations of a nonrandomized study, the value of continuous SvO2 monitoring as an early predictor of cardiac output change remains questionable.
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Pulmonary artery catheter
Fick principle
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Calibration turns pulse contour methods of cardiac output measurement from continuous to intermittent. We evaluated the necessity to recalibrate pulse contour cardiac output methods; LiDCO™plus (LCO), FloTrac/Vigileo (FCO), PiCCO (PCO) and continuous CO measurement with pulmonary artery catheter (Vigilance) (CCO).
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Objective The aim of this study was to assess and compare the agreement of cardiac output(CO)obtained by FloTrac/VigileoV3.0and by continuous cardiac output monitoring using pulmonary artery catheter(PAC),to evaluate the feasibility of FloTrac/VigileoV3.0using in liver transplantation(LT),and to approach the clinical usage of FloTrac/Vigileo for volume treatment.Methods Thirty patients undergoing LT were selected randomly.All patients accepted cardiac output monitoring by arterial pressure waveform cardiac output(APCO)and PAC at the same time.The following data,including cardiac output,stroke volume variation and other hemodynamic parameters,were recorded at eight time points:2hafter anaesthesia induction(T1),before unhepatic stage(T2),2min after unhepatic stage(T3),35 min after unhepatic stage(T4),2 min after neohepatic stage(T5),30 min after neohepatic stage(T6),2hafter neohepatic stage(T7)and end of operation(T8).Statistical analysis was performed among the related parameters.Results Compared with T1,SVV at T2-T5 were significantly increased and decreased at T6;PCCO at T2,T3、T6-T8 were significantly increased and decreased at T4,T5;APCO at T2,T5-T8 were significantly increased and decreased at T3,T4(P0.05 or P0.01).PCCO were higher than APCO at T1-T4,T6-T8 and lower at T5(P0.05 or P0.01).Except for the time points of T3 and T5,the variation of hemodynamic parameters derived from the two methods showed a similar tendency and a well agreement.Conclusion The monitoring results derived from FloTrac/VigileoV3.0system are in accordance with PAC in patients undergoing liver transplantation.It is feasible to reflect CO changes monitored by FloTrac/VigileoV3.0system and to guide volume treatment.
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