Transpulmonary thermodilution cardiac output measurement is not affected by severe pulmonary oedema: a newborn animal study

Editor's key points † The effect of pulmonary oedema on reliability of transpulmonary thermodilution cardiac output measurement was investigated. † Cardiac output was measured in newborn lambs in the presence of increased extravascular lung water. † Measurement of cardiac output by transpulmonary thermodilution is not affected by severe pulmonary oedema in a newborn lamb model. Background. The transpulmonary thermodilution (TPTD) technique is widely used in clinical practice for measuring cardiac output (CO). This study was designed to investigate the influence of various levels of pulmonary oedema on the reliability of CO measurements by the TPTD method

Less invasive methods of advanced hemodynamic monitoring: principles, devices, and their role in the perioperative hemodynamic optimization.

The monitoring of the cardiac output (CO) and other hemodynamic parameters, traditionally performed with the thermodilution method via a pulmonary artery catheter (PAC), is now increasingly done with the aid of less invasive and much easier to use devices. When used within the context of a hemodynamic optimization protocol, they can positively influence the outcome in both surgical and non-surgical patient populations. While these monitoring tools have simplified the hemodynamic calculations, they are subject to limitations and can lead to erroneous results if not used properly. In this article we will review the commercially available minimally invasive CO monitoring devices, explore their technical characteristics and describe the limitations that should be taken into consideration when clinical decisions are made

Advanced hemodynamic monitoring in children

Contains fulltext : 117512.pdf (publisher's version ) (Open Access)Radboud Universiteit Nijmegen, 28 november 2013Promotor : Hoeven, J.G. van der Co-promotores : Lemson, J., Boode, W.P. d

Cardiac output-guided hemodynamic therapy for adult living donor kidney transplantation in children under 20 kg: A pilot study

Contains fulltext : 208587.pdf (publisher's version ) (Open Access)BACKGROUND: A living-donor (adult) kidney transplantation in young children requires an increased cardiac output to maintain adequate perfusion of the relatively large kidney. To achieve this, protocols commonly advise liberal fluid administration guided by high target central venous pressure. Such therapy may lead to good renal outcomes, but the risk of tissue edema is substantial. AIMS: We aimed to evaluate the safety and feasibility of the transpulmonary thermodilution technique to measure cardiac output in pediatric recipients. The second aim was to evaluate whether a cardiac output-guided hemodynamic therapy algorithm could induce less liberal fluid administration, while preserving good renal results and achieving increased target cardiac output and blood pressure. METHODS: In twelve consecutive recipients, cardiac output was measured with transpulmonary thermodilution (PiCCO device, Pulsion). The algorithm steered administration of fluids, norepinephrine and dobutamine. Hemodynamic values were obtained before, during and after transplantation. Results are given as mean (SD) [minimum-maximum]. RESULTS: Age and weight of recipients was 3.2 (0.97) [1.6-4.9] yr and 14.1 (2.4) [10.4-18] kg, respectively. No complications related to cardiac output monitoring occurred. After transplantation, cardiac index increased with 31% (95% CI = 15%-48%). Extravascular lung water and central venous pressure did not change. Fluids given decreased from 158 [124-191] mL kg(-1) in the first 2 patients to 80 (18) [44-106] mL kg(-1) in the last 10 patients. The latter amount was 23 mL kg(-1) less (95% CI = 6-40 mL kg(-1) ) than in one recent study, but similar to that in another. After reperfusion, all patients received norepinephrine (maximum dose 0.45 (0.3) [0.1-0.9] mcg kg(-1) min(-1) ). Patient and graft survivals were 100% with excellent kidney function at 6 months post-transplantation. CONCLUSION: Transpulmonary thermodilution-cardiac output monitoring appeared to be safe and feasible. Using the cardiac output-guided algorithm led to excellent renal results with a trend toward less fluids in favor of norepinephrine

Oscillometric and intra-arterial blood pressure in children post-kidney transplantation: Is invasive blood pressure measurement always needed?

Contains fulltext : 202679.pdf (publisher's version ) (Closed access

Development of entrustable professional activities for paediatric intensive care fellows: A national modified Delphi study

Contains fulltext : 232752.pdf (Publisher’s version ) (Open Access)Entrustable professional activities (EPAs), as a focus of learner assessment, are supported by validity evidence. An EPA is a unit of professional practice requiring proficiency in multiple competencies simultaneously, that can be entrusted to a sufficiently competent learner. Taken collectively, a set of EPAs define and inform the curriculum of a specialty training. The goal of this study was to develop a set of EPAs for Dutch PICU fellows. A multistage methodology was employed incorporating sequential input from task force members, a medical education expert, PICU fellowship program directors, and PICU physicians and fellows via a modified three-round Delphi study. In the first modified Delphi round, experts rated indispensability and clarity of preliminary EPAs. In the subsequent rounds, aggregated scores for each EPA and group comments were provided. In round two, respondents rated indispensability and clarity of revised EPAs. Round three was used to gain explicit confirmation of suitability to implement these EPAs. Based on median ratings and content validity index (CVI) analysis for indispensability in the first two rounds, all nine preliminary EPAs covered activities that were deemed essential to the clinical practice of PICU physicians. Based on median ratings and CVI analysis for clarity however, four EPAs needed revision. With an agreement percentage of 93-100% for all individual EPAs as well as the set as a whole, a high degree of consensus among experts was reached in the third round. The resulting nine PICU EPAs provide a succinct overview of the core tasks of Dutch PICU physicians. These EPAs were created as an essential first step towards developing an assessment system for PICU fellows, grounded in core professional activities. The robust methodology used, may have broad applicability for other (sub)specialty training programs aiming to develop specialty specific EPAs

Klinisch denken en beslissen in de praktijk: een pasgeborene met dyspnoe

markdownabstractPatiënt A, een meisje van 2 dagen oud, werd opgenomen op de afdeling Kinderintensivecare wegens dreigende respiratoire insufficiëntie. De zwangerschap en partus waren ongecompliceerd verlopen, het geboortegewicht was 3500 g. De ademhaling was vanaf de geboorte snel en ging gepaard met intrekkingen. Gedurende de eerste 2 dagen werd de borstvoeding met pauzes gedronken, maar goed verdragen. De baby was opvallend snel moe, had moeite met huilen en neigde tot hypothermie. Zij vertoonde geen tekenen van cyanose of transpireren. De familieanamnese leverde geen bijzonderheden op. Wegens progressieve dyspnoe en tachypnoe werd patiëntje verwezen naar een ziekenhuis. Aldaar werd een ernstig dyspnoïsche zuigeling gezien met een versnelde ademhaling en hartslag en een marginale lichaamstemperatuur, bij wie niet-afwijkende harttonen zonder souffles en een symmetrisch ademgeruis werden gehoord. Er was geen stridor aanwezig. Arteriële pulsaties en capillaire vulling waren niet-afwijkend. De saturatie bleek 75% en de bloeddruk was 70/44 mmHg. Bij palpatie van de buik werden geen afwijkingen opgemerkt, met name geen hepatosplenomegalie. Er waren geen dysmorfe kenmerken en ook het neurologisch onderzoek toonde geen afwijkingen