Critical care : the official journal of the Critical Care Forum
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Review
Evidence-based review of the use of the pulmonary artery catheter: impact data and complications.
The pulmonary artery catheter (PAC) was introduced in 1971 for the assessment of heart function at the bedside. Since then it has generated much enthusiasm and controversy regarding the benefits and potential harms caused by this invasive form of hemodynamic monitoring. This review discusses all clinical studies conducted during the past 30 years, in intensive care unit settings or post mortem, on the impact of the PAC on outcomes and complications resulting from the procedure. Although most of the historical observational studies and randomized clinical trials also looked at PAC-related complications among their end-points, we opted to review the data under two main topics: the impact of PAC on clinical outcomes and cost-effectiveness, and the major complications related to the use of the PAC.
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For positive end-expiratory pressure (PEEP) to have lung protective efficacy in patients with acute respiratory distress syndrome, it must increase the end-expiratory lung volume through alveolar recruitment while avoiding lung over-inflation. PEEP may increase the end-expiratory lung volume either by increasing the proportion of aerated alveoli at end-expiration or by further inflating already ventilated lung regions. The optimal PEEP regimen is still a matter of debate. ⋯ Interesting work by Lu and coworkers, published in the previous issue of this journal, deals with the problem of measuring PEEP-induced alveolar recruitment. The 'gold standard' technique (i.e. the computed tomography method) is compared with the pressure-volume curve method. Because implementation of the latter method at the bedside would be relatively simple, that report, in addition to its intrinsic scientific value, may have important clinical implications.
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Randomized Controlled Trial
Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients.
Central venous cannulation is crucial in the management of the critical care patient. This study was designed to evaluate whether real-time ultrasound-guided cannulation of the internal jugular vein is superior to the standard landmark method. ⋯ The present data suggest that ultrasound-guided catheterisation of the internal jugular vein in critical care patients is superior to the landmark technique and therefore should be the method of choice in these patients.
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Comparative Study
Antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study.
Acquired antithrombin III (AT) deficiency may induce heparin resistance and premature membrane clotting during continuous renal replacement therapy (CRRT). The purpose of this study was to evaluate the effect of AT supplementation on filter lifespan in critically ill patients with septic shock requiring CRRT. ⋯ In sepsis patients requiring CRRT and with acquired AT deficiency, anticoagulation with unfractionated heparin plus AT supplementation prevent premature filter clotting and may contribute to improving outcome, but the cost-effectiveness of AT remains to be determined.
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Comparative Study Clinical Trial
Comparison of uncalibrated arterial waveform analysis in cardiac surgery patients with thermodilution cardiac output measurements.
Cardiac output (CO) monitoring is indicated only in selected patients. In cardiac surgical patients, perioperative haemodynamic management is often guided by CO measurement by pulmonary artery catheterisation (COPAC). Alternative strategies of CO determination have become increasingly accepted in clinical practice because the benefit of guiding therapy by data derived from the PAC remains to be proven and less invasive alternatives are available. Recently, a device offering uncalibrated CO measurement by arterial waveform analysis (COWave) was introduced. As far as this approach is concerned, however, the validity of the CO measurements obtained is utterly unclear. Therefore, the aim of this study was to compare the bias and the limits of agreement (LOAs) (two standard deviations) of COWave at four specified time points prior, during, and after coronary artery bypass graft (CABG) surgery with a simultaneous measurement of the gold standard COPAC and aortic transpulmonary thermodilution CO (COTranspulm). ⋯ Arterial waveform analysis with an uncalibrated algorithm COWave underestimated COPAC to a clinically relevant extent. The wide range of LOAs requires further evaluation. Better results might be achieved with an improved new algorithm. In contrast to this, we observed a better correlation of thermodilution COTranspulm and thermodilution COPAC measurements prior, during, and after CABG surgery.