Pulmonary artery occlusion pressure estimation by transesophageal echocardiography: is simpler better?

The measurement of pulmonary artery occlusion pressure (PAOP) is important for estimation of left ventricular filling pressure and for distinction between cardiac and non-cardiac etiology of pulmonary edema. Clinical assessment of PAOP, which relies on physical signs of pulmonary congestion, is uncertain. Reliable PAOP measurement can be performed by pulmonary artery catheter, but it is possible also by the use of echocardiography. Several Doppler variables show acceptable correlation with PAOP and can be used for its estimation in cardiac and critically ill patients. Noninvasive PAOP estimation should probably become an integral part of transthoracic and transesophageal echocardiographic evaluation in critically ill patients. However, the limitations of both methods should be taken into consideration, and in specific patients invasive PAOP measurement is still unavoidable, if the exact value of PAOP is needed

Echocardiography alone or coupled with other hemodynamic devices?

Critical care echocardiography, either via transthoracic or transesophageal approaches, is the perfect tool for the hemodynamic evaluation of the patient with circulatory and respiratory failure and for proper adjustment of various therapeutic options (volume loading, vasoactive treatment, inotropic support, optimal ventilatory support). However, after initial therapy has been initiated or even after initial reevaluation of its effects, the hemodynamic situation can evolve, and repeated assessment of the hemodynamic condition at repeated intervals may be warranted. In addition to basic hemodynamic monitoring (arterial pressure, heart rate, eventually central venous pressure), echocardiography can be used for this purpose, alone or combined with other advanced invasive or minimally invasive hemodynamic devices. Conditions specific to the patient, organization of the intensive care unit and skills and/or activities of the physician influence the decision to combine echocardiography with other hemodynamic devices. The choice of the alternate hemodynamic device should be guided by the variables considered essential to be monitored as well as by a risk/benefit evaluation. In all cases, whatever the tools, the alternate hemodynamic device has to be totally mastered by intensivists and integrated into a clear therapeutic management. © 2011 Springer-Verlag Berlin Heidelberg.SCOPUS: ch.binfo:eu-repo/semantics/publishe

Fluid therapy: double-edged sword during critical care?

Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing

Fluid therapy: double-edged sword during critical care?

Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years.The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects.We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing