Measuring Cardiac Output in the Critically Ill

__Abstract__ Haemodynamic monitoring plays an essential part on the care of the critically ill patient. Monitoring has two goals; the first goal is a signalling function if the patients clinical condition improves or deteriorates adequate measures can be taken. Maintaining the adequacy of the circulation reduces the chance of inadequate oxygen transport to the tissues preventing organ ischemia. The second goal is using the monitoring as a decision making tool. Historically, arterial pressures were measured because they were easier to measure than bloodflow. But the introduction of the pulmonary artery catheter (PAC) in 1970 allowed the regular measurement of cardiac output (CO) at the beside. Beside CO a new array of variables could be monitored. Measuring more variables did not automatically relate to better outcomes

The impact of open versus closed format ICU admission practices on the outcome of high risk surgical patients: a cohort analysis

<p>Abstract</p> <p>Background</p> <p>In the year 2000, the organizational structure of the ICU in the Zaandam Medical Centre (ZMC) changed from an open to a closed format ICU. The objective of this study was to evaluate the effect of this organizational change on outcome in high risk surgical patients.</p> <p>Methods</p> <p>The medical records of all consecutive high risk surgical patients admitted to the ICU from 1996 to 1998 (open format) and from 2003 to 2005 (closed format), were reviewed. High-risk patients were defined according to the Identification of Risk in Surgical patients (IRIS) score. Parameters studied were: mortality, morbidity, ICU length of stay (LOS) and hospital LOS.</p> <p>Results</p> <p>Mortality of ICU patients was 25.7% in the open format group and 15.8% in the closed format group (p = 0.01). Morbidity decreased from 48.6% to 46.1% (p = 0.6). The average length of hospital stay was 17 days in the open format group, and 21 days in the closed format group (p = 0.03).</p> <p>Conclusions</p> <p>High risk surgical patients in the ICU are patients that have undergone complex and often extensive surgery. These patients are in need of specialized treatment and careful monitoring for maximum safety and optimal care. Our results suggest that closed format is a more favourable setting than open format to minimize the effects of high risk surgery, and to warrant safe outcome in this patient group.</p

Respiratoire insufficiëntie na aspiratie van een medicatieblister

Respiratory failure after aspiration of a medication blister package INTRODUCTION To promote coaching of elderly patients in correct use of medication, we present the case of an old man who choked on a medication blister package. In Dutch nursing homes some of the elderly are responsible themselves for the management of their medication. The elderly often suffer from decreased cognition and handicaps which may complicate the correct use of medication. DESCRIPTION A 84-year-old man with a cardiac history and COPD was admitted with chief complaints of dyspnoea and cough productive of white sputum. After 5 days he developed respiratory failure with haemoptysis. Bronchoscopic examination revealed a foreign body in the right main bronchus which was successfully removed. It turned out to be a medication blister package. Two months earlier, the standard packaging of his medication (daily-dose packaging filled with loose tablets] by his pharmacy had been temporarily interrupted during admission to another hospital. After discharge, he choked on a blister package awaiting delivery of the next daily-dose packaging. DISCUSSION At discharge, patients are informed about changes in their medication regimen. Verification of correct medication use in the home setting after discharge is not standard yet in the Netherlands. Problems with handling of packaging can only become manifest once the patient is at home. CONCLUSION Hospital discharge is a critical moment; the ability to adequately deal with medication packaging can be (temporarily) reduced. Coaching chronically ill older patients after discharge, to ensure correct medication use, may reduce the rates of subsequent rehospitalisation

Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports

Abstract Introduction A broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS). Case presentations The first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved. Intervention After consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport. Conclusion This case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest

Cardiac output measured by uncalibrated arterial pressure waveform analysis by recently released software version 3.02 versus thermodilution in septic shock

To evaluate the 3.02 software version of the FloTrac/Vigileo™ system for estimation of cardiac output by uncalibrated arterial pressure waveform analysis, in septic shock. Nineteen consecutive patients in septic shock were studied. FloTrac/Vigileo™ measurements (COfv) were compared with pulmonary artery catheter thermodilution-derived cardiac output (COtd). The mean cardiac output was 7.7 L min-1 and measurements correlated at r = 0.53 (P 10 % in both COtd and COfv (n = 46) were in the same direction. Eighty-five percent of the measurements were within the 30 -330 of the polar axis. COfv with the latest software still underestimates COtd at low SVR in septic shock. The tracking capacities of the 3.02 software are moderate-good when clinically relevant changes are considered

Chloroprocaine versus prilocaine for spinal anesthesia in ambulatory knee arthroscopy: a double-blind randomized trial

Background In ambulatory lower limb surgery, spinal anesthesia with rapid onset and a short duration of block is preferable. We hypothesized that the use of 2-chloroprocaine would be associated with a faster motor block recovery compared with prilocaine in knee arthroscopy. A difference of 15 min was considered clinically relevant. Methods 150 patients were randomly allocated to receive intrathecally either 40 mg of 2-chloroprocaine or 40 mg of prilocaine. The primary outcome was the time to complete recovery from motor blockade. Secondary outcomes included time to full regression of sensory block, peak sensory block level, urine retention needing catheterization, time until hospital discharge, incidence of transient neurologic symptoms and patient satisfaction. Results Time to complete recovery from motor blockade was 15 min shorter for 2-chloroprocaine (median: 60 min; IQR: 60-82.5) than for prilocaine (median: 75 min; IQR: 60-90; p=0.004). 2-Chloroprocaine also resulted in faster full regression of sensory block (median: 120 min; IQR: 90-135 compared with median: 165 min; IQR: 135-190, p<0.001) and faster time to hospital discharge (mean difference: 57 min; 95% CI 38 to 77, p<0.001). Peak sensory block was higher in the 2-chloroprocaine group (median: T9; IQR: T6-T12 compared with median: T10; IQR: T8-T12, p<0.008). Patient satisfaction and urine retention needing catheterization were equal in both groups. Conclusions In knee arthroscopy, spinal anesthesia with 2-chloroprocaine results in a faster recovery of motor and sensory block, leading to quicker hospital discharge compared with prilocaine. Trial registration number NTR6796