Monitoraggio emodinamico mini-invasivo in terapia intensiva: approccio metodologico

Minimally invasive hemodynamic monitoring in intensive care: methodological approach The aim of the study was to validate the reliability of some new systems of hemodynamic monitoring: the Nexfin system (BMEYE BV, Amsterdam, Netherlands ) totally non-invasive, and the Pressure-Recording Analytical Method (PRAM/MostCare, Vygon, Italy ), minimally invasive and without the need of calibration, either external or internal. MATERIALS AND METHODS NEXFIN. We enrolled 40 patients admitted to two intensive care units at Padua Hospital. For each patient we collected data about systolic blood pressure (SBP) and diastolic blood pressure (DBP) continuously for 30 minutes, both using standard intra-arterial method (IBP) and Nexfin system (“finger cuff” technology). We compared a total of 79263 pairs of blood pressure values. On 9 patients we compared the value of cardiac output (CO) with the value measured by trans-thoracic echocardiography Doppler (TTE ) . PRAM. We connected the PRAM system to a Siemens sc7000 monitor linked to a sophisticated simulator HPS/METI® HPS/METI® which can produce different CO values according to the clinical conditions set. We simulated 6 different clinical scenarios to obtain a total of 168 measurements of CO . In the second step, we tested the system on 38 hemodynamically stable patients by comparing the values of CO with those measured by TTE with Doppler technique. Finally, we compared the CO data on 21 hemodynamically unstable patients, supported by Norepinephrine in continuous infusion, by comparing the CO values with those measured by transpulmonary thermodilution system: PiCCO2 (Pulse Contour Cardiac Output, Pulsion Medical Systems, Munich, Germany ). We compared the data before (T1) and after (T2) the reduction of 0,05 mcg/kg/min of the drug. The results obtained were analyzed according to the Bland and Altman method. We calculated mean differences, limits of agreement and percentual errors. RESULTS NEXFIN. We collected 158525 pressure points, 79263 for each device: for SBP the mean a difference was -4,89 mmHg, limits of agreement were +18,11mmHg/-27,91 mmHg, %error 18%; for DBP the mean difference was +6.07 mmHg, limits of agreement +23,60/-11,45 mmHg, with %error of 26%. For values of CO we calculated a mean difference of -0,5 L/min, with limits of agreement +2.24/-3.38 L/min. PRAM/MostCare. The comparison of 168 values of CO with those set to HPS/METI® showed a mean difference of -0,32 L/min, limits of agreement respectively +0,88 and -1,53 L/min. The %error calculated was 23%; R2 = 78.1%. The comparison of the values of CO with those measured with TTE on 38 stable patients showed a mean difference of -0,03 L/min (SD 0,66) and the limits of agreement respectively between + 1,28 e -1,35 L/min. The comparison of the values of CO with those measured by transpulmonary thermodilution on 21 hemodynamically unstable patients showed a mean difference of 0,13 L/min at T1 and 0,1 L/min at T2, with limits of agreement = -1,41/1,69 L/min at T1 and -1,67/1,87 L/min at T2. The percentage error at T1 was 28,27%, at T2 was 32%. In the subgroup of patients with atrial fibrillation, the mean difference was 0,28 L/min at T1, with the limits of agreement of -0,79 and +1,37 L/min and with a %error of 22%; at T2 the mean difference was 0,55 L/min, the limits of agreement were between -1,82 and 2,93 L/min and the error rate was 49%. CONCLUSIONS About Nexfin we can conclude that the values of SBP, DBP and CO measured by this device can not be considered reliable in critically ill patients; there might be a more appropriate application in the operating room or in medical departiments. The method remains strongly linked to correctly reading the wave form, which appears to be strongly influenced by several pathophysiological and environmental variables . Regarding PRAM, in relation to the CO measurement compared with both the TTE and the method of the transpulmonary thermodilution, its application seems useful in the context of critically ill patients, providing fundamental information about hemodynamic setting to the intensivist without risk. To confirm our results the study needs to be expand to include more hemodynamically unstable patients as well as patients affected by atrial fibrillation. The PRAM system is operator-dependent: it needs to be used by experienced staff, who are able to asses the correct arterial wave form

Veno-Venous ECMO: An Alternative Strategy for Acute Respiratory Failure After High-Voltage Electrocution. The Utility of Point-of-Care Tests

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Monitoraggio emodinamico mini-invasivo in terapia intensiva: approccio metodologico

Minimally invasive hemodynamic monitoring in intensive care: methodological approach The aim of the study was to validate the reliability of some new systems of hemodynamic monitoring: the Nexfin system (BMEYE BV, Amsterdam, Netherlands ) totally non-invasive, and the Pressure-Recording Analytical Method (PRAM/MostCare, Vygon, Italy ), minimally invasive and without the need of calibration, either external or internal. MATERIALS AND METHODS NEXFIN. We enrolled 40 patients admitted to two intensive care units at Padua Hospital. For each patient we collected data about systolic blood pressure (SBP) and diastolic blood pressure (DBP) continuously for 30 minutes, both using standard intra-arterial method (IBP) and Nexfin system (“finger cuff” technology). We compared a total of 79263 pairs of blood pressure values. On 9 patients we compared the value of cardiac output (CO) with the value measured by trans-thoracic echocardiography Doppler (TTE ) . PRAM. We connected the PRAM system to a Siemens sc7000 monitor linked to a sophisticated simulator HPS/METI® HPS/METI® which can produce different CO values according to the clinical conditions set. We simulated 6 different clinical scenarios to obtain a total of 168 measurements of CO . In the second step, we tested the system on 38 hemodynamically stable patients by comparing the values of CO with those measured by TTE with Doppler technique. Finally, we compared the CO data on 21 hemodynamically unstable patients, supported by Norepinephrine in continuous infusion, by comparing the CO values with those measured by transpulmonary thermodilution system: PiCCO2 (Pulse Contour Cardiac Output, Pulsion Medical Systems, Munich, Germany ). We compared the data before (T1) and after (T2) the reduction of 0,05 mcg/kg/min of the drug. The results obtained were analyzed according to the Bland and Altman method. We calculated mean differences, limits of agreement and percentual errors. RESULTS NEXFIN. We collected 158525 pressure points, 79263 for each device: for SBP the mean a difference was -4,89 mmHg, limits of agreement were +18,11mmHg/-27,91 mmHg, %error 18%; for DBP the mean difference was +6.07 mmHg, limits of agreement +23,60/-11,45 mmHg, with %error of 26%. For values of CO we calculated a mean difference of -0,5 L/min, with limits of agreement +2.24/-3.38 L/min. PRAM/MostCare. The comparison of 168 values of CO with those set to HPS/METI® showed a mean difference of -0,32 L/min, limits of agreement respectively +0,88 and -1,53 L/min. The %error calculated was 23%; R2 = 78.1%. The comparison of the values of CO with those measured with TTE on 38 stable patients showed a mean difference of -0,03 L/min (SD 0,66) and the limits of agreement respectively between + 1,28 e -1,35 L/min. The comparison of the values of CO with those measured by transpulmonary thermodilution on 21 hemodynamically unstable patients showed a mean difference of 0,13 L/min at T1 and 0,1 L/min at T2, with limits of agreement = -1,41/1,69 L/min at T1 and -1,67/1,87 L/min at T2. The percentage error at T1 was 28,27%, at T2 was 32%. In the subgroup of patients with atrial fibrillation, the mean difference was 0,28 L/min at T1, with the limits of agreement of -0,79 and +1,37 L/min and with a %error of 22%; at T2 the mean difference was 0,55 L/min, the limits of agreement were between -1,82 and 2,93 L/min and the error rate was 49%. CONCLUSIONS About Nexfin we can conclude that the values of SBP, DBP and CO measured by this device can not be considered reliable in critically ill patients; there might be a more appropriate application in the operating room or in medical departiments. The method remains strongly linked to correctly reading the wave form, which appears to be strongly influenced by several pathophysiological and environmental variables . Regarding PRAM, in relation to the CO measurement compared with both the TTE and the method of the transpulmonary thermodilution, its application seems useful in the context of critically ill patients, providing fundamental information about hemodynamic setting to the intensivist without risk. To confirm our results the study needs to be expand to include more hemodynamically unstable patients as well as patients affected by atrial fibrillation. The PRAM system is operator-dependent: it needs to be used by experienced staff, who are able to asses the correct arterial wave form.Monitoraggio emodinamico mini-invasivo in terapia intensiva: approccio metodologico Negli ultimi anni sono stati proposti diversi sistemi di monitoraggio emodinamico che promettono una buona affidabilità a fronte di una minima invasività. Scopo dello studio è stato quello di validarne alcuni, in particolare il sistema Nexfin (BMEYE BV, Amsterdam, Paesi Bassi) nuovo e totalmente non invasivo, e il Pressure-Recording Analytical Method (PRAM/Mostcare, Vygon, Italia), mini-invasivo e che non necessita di calibrazione né esterna, né interna. MATERIALI E METODI Abbiamo studiato i due sistemi testandoli su pazienti ricoverati in due terapie intensive polivalenti dell’Azienda Ospedaliera di Padova. Per il sistema Nexfin abbiamo arruolato 40 pazienti, per ognuno abbiamo rilevato per 30 minuti in continuo la pressione arteriosa sistolica (SBP) e diastolica (DBP), sia con il metodo standard della cannulazione intra-arteriosa (IBP) che con il sistema Nexfin (tecnologia finger cuff) e abbiamo confrontato un totale 79263 coppie di valori pressori. Su 9 pazienti abbiamo confrontato anche il valore di cardiac output (CO) con quello misurato mediante ecografia transtoracica con tecnica Doppler (TTE). Per quanto riguarda il sistema PRAM lo abbiamo collegato mediante cavo ad un monitor Siemens sc7000 connesso ad un sofisticatissimo simulatore HPS/METI®, in grado di riprodurre valori di CO diversi in base alle condizioni cliniche impostate. Abbiamo simulato 6 scenari clinici differenti per ottenere un totale di 168 misurazioni di CO che abbiamo confrontato con quelli noti risultanti dalle impostazioni del simulatore. Successivamente abbiamo testato il sistema su 38 pazienti emodinamicamente stabili confrontando i valori di CO con quelli misurati mediante TTE con tecnica Doppler. Infine abbiamo confrontato i dati di CO su 21 pazienti emodinamicamente instabili e sostenuti da Noradrenalina in infusione continua, confrontando i valori di CO con quelli misurati tramite termodiluizione transpolmonare con sistema PiCCO2 (Pulse Contour Cardiac Output, Pulsion Medical System, Munich, Germany). Abbiamo confrontato i dati prima (T1) e dopo (T2) la riduzione di 0,05 mcg/Kg/min del farmaco. I risultati ottenuti sono stati analizzati statisticamente secondo il metodo di Bland e Altman; sono state calcolate le differenze medie, i livelli di concordanza e le percentuali d’errore. RISULTATI NEXFIN. Su un totale 158525 punti pressione, 79263 per dispositivo, abbiamo ottenuto per la SBP una mean difference di -4,89 mmHg, dei limits of agreement di +18,11mmHg e -27,91 mmHg ed un errore percentuale del 18% e per la DBP una mean difference di +6,07 mmHg, dei limits of agreement di +23,60 mmHg e -11,45 mmHg, con una percentuale d’errore del 26%. Per i valori di CO abbiamo calcolato una mean difference -0,5 L/min, con dei limits of agreement rispettivamente di +2,24 e -3,38 L/min. PRAM/Mostcare. Il confronto di 168 valori di CO con quelli impostati su HPS/METI® ha mostrato una mean difference di -0,32 L/min e dei limits of agreement rispettivamente di +0,88 e -1,53 L/min. L’errore percentuale calcolato era del 23%. con un R2 = 78,1%. Il confronto dei valori di CO con quelli misurati con TTE su 38 pazienti stabili ha mostrato una mean difference di -0,03 L/min (SD 0,66) e dei limits of agreement rispettivamente compresi tra + 1,28 e -1,35 L/min. Il confronto dei valori di CO con quelli misurati con termodiluizione transpolmonare su 21 pazienti emodinamicamente instabili ha evidenziato una mean diffenrence di 0,13 L/min al T1 e di 0,1 L/min al T2, con dei limits of agreement rispettivamente compresi tra -1,41 e 1,69 L/min e tra -1,67 e 1,87 L/min. L’errore percentuale al T1 è risultato essere pari al 28,27%, al T2 era pari al 32%. Nel sottogruppo di pazienti affetti da fibrillazione atriale la mean difference era di 0,28 L/min a T1, con dei limits of agreement di -0,79 e +1,37 L/min e con un errore percentuale del 22%; al T2 la mean difference era di 0,55 L/min, i limits of agreement erano compresi tra -1.82 e 2,93 L/min e la percentuale d’errore era del 49%. CONCLUSIONI Per quanto riguarda il sistema Nexfin possiamo concludere che i valori di SBP, DBP e CO misurati da questo device completamente non invasivo non possono essere considerati affidabili nei pazienti critici; la tecnologia finger-cuff può trovare probabilmente una più appropriata applicazione in sala operatoria o in ambito più prettamente medico. La metodica rimane fortemente vincolata da una corretta lettura del dato pressorio che ci è parso fortemente suscettibile a una serie di variabili fisiopatologiche e ambientali. Per quanto riguarda il sistema PRAM, in relazione alla misura del CO confrontata sia con la TTE che con il metodo della termodiluizione transpolmonare, la sua applicazione ci sembra possa trovare spazio nel paziente critico, fornendo all’intensivista informazioni fondamentali sull’assetto emodinamico senza rischi aggiunti. Resta la necessità di ampliare le popolazioni di studio relative ai pazienti emodinamicamente più instabili e a quelli affetti da fibrillazione atriale per poter confermare i nostri risultati. Il sistema PRAM è operatore-dipendente: richiede di essere utilizzato da personale esperto, in grado di valutare la corretta lettura dell’onda di pressione

Cardiac Output Evaluation on Septic Shock Patients: Comparison between Calibrated and Uncalibrated Devices during Vasopressor Therapy

There are no reliable, non-invasive methods to accurately measure cardiac output (CO) in septic patients. MostCare (Vytech Health (TM), Vygon, Padova, Italy), is a beat-to-beat, self calibrated method for CO measurement based on continuous analysis of reflected arterial pressure waveforms. We enrolled 40 patients that were suffering from septic shock and requiring norepinephrine infusion to target blood pressure in order to to evaluate the level of agreement between a calibrated transpulmonary thermodilution device (PiCCO System, Pulsion Medical Systems, Feldkirchen, Germany) and the MostCare system in detecting and tracking changes in CO measurements related to norepinephrine reduction in septic shock patients,. PiCCO was connected to a 5 Fr femoral artery catheter and to a central venous catheter. System calibration was performed with 15 mL of cold saline injection over about 3 s. The MostCare device was connected to the artery catheter to analyze the arterial waveform. Before reducing norepinephrine infusion, the PiCCO system was calibrated, the MostCare waveform was optimized, and the values of the complete hemodynamic profile were recorded (T1). Norepinephrine infusion was then reduced by 0.03 mcg/Kg/min. After 30 min, a new calibration of PiCCO system and a new record on both monitors were performed (T2). Static measurements agreements were assessed using the Bland-Altman test, while trending ability was investigated using polar plot analysis. If volume expansion occurred, then related data were separately analyzed. At T1 mean the CO was 5.38 (SD 0.60) L/min, the mean difference was 0.176 L/min, the limits of agreement (LoA) was +1.39 and -1.04 L/min, and the percentage error (PE) was 22.6%; at T2 the mean CO was 5.44 (SD 0.73) L/min, the mean difference was 0.053 L/min, the LoA was +1.51 and -1.40, and the PE was 27%. After considering the volume expansion between T1 and T2, the mean CO at T1 was 5.39 L/min (SD 0.47), the LoA was +1.09 and -0.78 L/min, and the percentage error (PE) was 17%; at T2 the mean CO was 5.35 L/min (SD 0.81), the LoA was +1.73 and -1.52 L/min, and the PE was 30%. The polar plot diagram seems to confirm the trending ability of MostCare system versus the reference method. In septic patients, when the arterial waveform is accurate, MostCare and PiCCO transpulmonary thermodilution exhibit good agreement even after the reduction of norepinephrine and changes in vascular tone or volume expansion. MostCare could be a rapid to set, reliable, and useful tool to monitor hemodynamic variations in septic patients in emergency contexts where thermodilution methods or other advanced systems are not easily available

Low-Dose Cyclophosphamide versus Intermediate-High-Dose Cyclophosphamide versus Granulocyte Colony-Stimulating Factor Alone for Stem Cell Mobilization in Multiple Myeloma in the Era of Novel Agents: A Multicenter Retrospective Study

none14: The optimal stem cell (SC) mobilization strategy for patients with multiple myeloma (MM) remains a matter of debate. Possible approaches include low or high doses of cyclophosphamide (Cy), other chemotherapeutic agents, or granulocyte colony-stimulating factor (G-CSF) alone. The scope of the study was to compare low-dose Cy plus G-CSF versus intermediate-high-dose Cy plus G-CSF versus G-CSF alone for SC mobilization in MM, in terms of efficacy and safety. We retrospectively analyzed 422 MM patients undergoing SC mobilization in 6 Italian centers, including 188 patients who received low-dose Cy (LD-Cy group, defined as 2 g/m2), 163 patients who received intermediate-high-dose Cy (HD-Cy group, defined as ≥ 3 g/m2), and 71 patients who received G-CSF alone (G-CSF group). The median peak of circulating CD34+ cells was 77/µL in the LD-Cy group, 92/µL in the HD-Cy group, and 55/µL in the G-CSF group (P = .0001). The median amount of SCs collected was 9.1 × 106/kg, 9.7 × 106/kg, and 5.6 × 106/kg in the 3 groups, respectively (P = .0001). The rate of mobilization failure (defined as failure to collect ≥2 × 106/kg) was 3.7% in the LD-Cy group, 3.4% in the HD-Cy group, and 4.3% in the G-CSF group (P = .9). The target SC dose of at least 4 × 106/kg was reached in 90.4%, 91.1%, and 78.6% of the patients in these 3 groups, respectively (P = .014). The "on demand" use of plerixafor was higher in the G-CSF group (76%) compared with the LD-Cy group (19%) and the HD-Cy group (6%). In multivariate analysis, G-CSF mobilization and previous use of melphalan or radiotherapy were independently associated with failure to collect the target SC dose of ≥4 × 106/kg. No impacts of age, blood counts, or previous treatment with lenalidomide, bortezomib, or carfilzomib were observed. Our results suggest that LD-Cy may be considered for successful SC mobilization in patients with MM.noneZannetti, Beatrice Anna; Saraceni, Francesco; Cellini, Claudia; Fabbri, Elisabetta; Monaco, Federica; Guarini, Attilio; Laszlo, Daniele; Martino, Massimo; Olivieri, Attilio; Imola, Manuela; Tosi, Patrizia; Chiarucci, Martina; Zuffa, Eliana; Lanza, FrancescoZannetti, Beatrice Anna; Saraceni, Francesco; Cellini, Claudia; Fabbri, Elisabetta; Monaco, Federica; Guarini, Attilio; Laszlo, Daniele; Martino, Massimo; Olivieri, Attilio; Imola, Manuela; Tosi, Patrizia; Chiarucci, Martina; Zuffa, Eliana; Lanza, Francesc

BH3 mimetics in relapsed and refractory adult acute lymphoblastic leukemia: a Campus ALL real-life study

: Not available