Goal-directed fluid management based on stroke volume variation and stroke volume optimization during high-risk surgery: a pilot multicentre randomized controlled trial

Introduction: Perioperative hemodynamic optimization has been shown to be useful to improve the postoperative outcome of patients undergoing major surgery. We designed a pilot study in patients undergoing major abdominal, urologic or vascular surgery to investigate the effects of a goal-directed (GD) fluid management based on continuous stroke volume variation (SVV) and stroke volume (SV) monitoring on postoperative outcomes. Methods: Fifty-two high-risk-surgical patients (ASA 3 or 4, arterial and central venous catheter in place, postoperative admission in ICU) were randomized either to a control group (Group C, n = 26) or to a goal-directed group (Group G, n = 26). Patients with cardiac arrhythmia or ventilated with a tidal volume <7 ml/kg were excluded. In Group G, SVV and SV were continuously monitored with the FloTrac™/Vigileo™ system (Edwards Lifesciences, USA) and patients were brought to and maintained on the plateau of the Frank-Starling curve (SVV <10% and SV increase <10% in response to fluid loading). During the ICU stay, organ dysfunction was assessed using the SOFA score and resource utilization using the TISS score. Patients were followed up to 28 days after surgery for infectious, cardiac, respiratory, renal, hematologic and abdominal complications. Results: Group G and Group C were comparable for ASA score, comorbidities, type and duration of surgery (275 vs. 280 minutes), heart rate, MAP and CVP at the start of surgery. However, Group G was younger than Group C (68 vs. 73 years, P < 0.05). During surgery, Group G received more colloids than Group C (1,589 vs. 927 ml, P < 0.05) and SVV decreased in Group G (from 9.0 to 8.0%, P < 0.05) but not in Group C. The number of postoperative wound infections was lower in Group G (0 vs. 7, P < 0.01). Although not statistically significant, the proportion of patients with at least one complication (46 vs. 62%), the number of postoperative complications per patient (0.65 vs. 1.40), the maximum ICU SOFA score (5.9 vs. 7.2), and the cumulative ICU TISS score (69 vs. 83) were also lower in Group G. ICU and hospital length of stay were similar in both groups. Conclusion: Although the two groups were not perfectly matched, this pilot shows that fluid management based on SVV and SV optimization decreases wound infections. It also suggests that such a GD strategy may decrease postoperative organ dysfunction and resource utilization. However, this remains to be confirmed by a larger study

Continuously assessed right ventricular end-diastolic volume as a marker of cardiac preload and fluid responsiveness in mechanically ventilated cardiac surgical patients

INTRODUCTION: Assessing cardiac preload and fluid responsiveness accurately is important when attempting to avoid unnecessary volume replacement in the critically ill patient, which is associated with increased morbidity and mortality. The present clinical trial was designed to compare the reliability of continuous right ventricular end-diastolic volume (CEDV) index assessment based on rapid response thermistor technique, cardiac filling pressures (central venous pressure [CVP] and pulmonary capillary wedge pressure [PCWP]), and transesophageal echocardiographically derived evaluation of left ventricular end-diastolic area (LVEDA) index in predicting the hemodynamic response to volume replacement. METHODS: We studied 21 patients undergoing elective coronary artery bypass grafting. After induction of anesthesia, hemodynamic parameters were measured simultaneously before (T1) and 12 min after volume replacement (T2) by infusion of 6% hydroxyethyl starch 200/0.5 (7 ml/kg) at a rate of 1 ml/kg per min. RESULTS: The volume-induced increase in thermodilution-derived stroke volume index (SVI(TD)) was 10% or greater in 19 patients and under 10% in two. There was a significant correlation between changes in CEDV index and changes in SVI(TD )(r(2 )= 0.55; P < 0.01), but there were no significant correlations between changes in CVP, PCWP and LVEDA index, and changes in SVI(TD). The only variable apparently indicating fluid responsiveness was LVEDA index, the baseline value of which was weakly correlated with percentage change in SVI(TD )(r(2 )= 0.38; P < 0.01). CONCLUSION: An increased cardiac preload is more reliably reflected by CEDV index than by CVP, PCWP, or LVEDA index in this setting of preoperative cardiac surgery, but CEDV index did not reflect fluid responsiveness. The response of SVI(TD )following fluid administration was better predicted by LVEDA index than by CEDV index, CVP, or PCWP

IAEA FUMAC BENCHMARK ON THE HALDEN, STUDISVIK AND QUENCH-L1 LOCA TESTS

The International Atomic Energy Agency (IAEA) sponsored the Coordinated Research Project (CRP) on Fuel Modeling under Accident Conditions (FUMAC) to coordinate and support research on nuclear fuel modelling under accident conditions in member countries. The focus of the FUMAC CRP (2015- 2018) has been on loss-of-coolant accidents (LOCA). Various institutions performed fuel performance simulations of selected experiments using different fuel performance codes (e.g., FRAPCONFRAPTRAN, TRANSURANUS, ALCYONE, DIONISIO, SOCRAT, FTPAC, BISON, RAPTA) and system codes (e.g SOCRATE, ATHLET). One of the results of the FUMAC CRP is a comprehensive code-to-code benchmark of selected results, and a comparison of simulations with experimental data as well. This paper represents an overview of the current state-of-the-art of nuclear fuel simulation capabilities for LOCAs and paves the way to further analyses and future developments. More precisely, we discuss the results of the simulation of a subset of the experiments considered in the FUMAC CRP, i.e., (i) the Halden LOCA tests (IFA-650.9/10/11, but only IFA-650.10 is in detail presented in this paper), (ii) the Studsvik LOCA test NRC-192, and (iii) rod 4 of the KIT QUENCH-L1 bundle test. These experiments, briefly presented in the paper, cover a wide range of conditions relevant for LOCA scenarios from different sources. The presented benchmark results are considered in more detail at the end of the LOCA transient (e.g., time of failure, cladding outer diameter, cladding oxidation thickness…). The experimental data are always included in the comparisons, when available. The results are also critically discussed, with the aim of identifying modelling developments required for the improvement of LOCA analyses. Finally, the outcome is complemented with an uncertainty and sensitivity analysis in a separate paper in this conference

Evaluation of a new arterial pressure-based cardiac output device requiring no external calibration

<p>Abstract</p> <p>Background</p> <p>Several techniques have been discussed as alternatives to the intermittent bolus thermodilution cardiac output (CO_PAC) measurement by the pulmonary artery catheter (PAC). However, these techniques usually require a central venous line, an additional catheter, or a special calibration procedure. A new arterial pressure-based cardiac output (CO_AP) device (FloTrac™, Vigileo™; Edwards Lifesciences, Irvine, CA, USA) only requires access to the radial or femoral artery using a standard arterial catheter and does not need an external calibration. We validated this technique in critically ill patients in the intensive care unit (ICU) using CO_PACas the method of reference.</p> <p>Methods</p> <p>We studied 20 critically ill patients, aged 16 to 74 years (mean, 55.5 ± 18.8 years), who required both arterial and pulmonary artery pressure monitoring. CO_PACmeasurements were performed at least every 4 hours and calculated as the average of 3 measurements, while CO_APvalues were taken immediately at the end of bolus determinations. Accuracy of measurements was assessed by calculating the bias and limits of agreement using the method described by Bland and Altman.</p> <p>Results</p> <p>A total of 164 coupled measurements were obtained. Absolute values of CO_PACranged from 2.80 to 10.80 l/min (mean 5.93 ± 1.55 l/min). The bias and limits of agreement between CO_PACand CO_APfor unequal numbers of replicates was 0.02 ± 2.92 l/min. The percentage error between CO_PACand CO_APwas 49.3%. The bias between percentage changes in CO_PAC(ΔCO_PAC) and percentage changes in CO_AP(ΔCO_AP) for consecutive measurements was -0.70% ± 32.28%. CO_PACand CO_APshowed a Pearson correlation coefficient of 0.58 (<it>p </it>< 0.01), while the correlation coefficient between ΔCO_PACand ΔCO_APwas 0.46 (<it>p </it>< 0.01).</p> <p>Conclusion</p> <p>Although the CO_APalgorithm shows a minimal bias with CO_PACover a wide range of values in an inhomogeneous group of critically ill patients, the scattering of the data remains relative wide. Therefore, the used algorithm (V 1.03) failed to demonstrate an acceptable accuracy in comparison to the clinical standard of cardiac output determination.</p

OECD/NEA Data Bank Scientific and Intergral Experiments Databases in Support of Knowledge Preservation and Transfer

The OECD/Nuclear Energy Data Bank was established by its member countries as an institution to allow effective sharing of knowledge and its basic underlying information and data in key areas of nuclear science and technology. The activities as regards preserving and transferring knowledge consist of the: — Acquisition of basic nuclear data, computer codes and experimental system data needed over a wide range of nuclear and radiation applications. — Independent verification and validation of these data using quality assurance methods, adding value through international benchmark exercises, workshops and meetings and by issuing relevant reports with conclusions and recommendations, as well as by organising training courses to ensure their qualified and competent use. — Dissemination of the different products to authorised establishments in member countries and collecting and integrating user feedback. Of particular importance has been the establishment of basic and integral experiments databases and the methodology developed with the aim of knowledge preservation and transfer. Databases established thus far include: — IRPhE – International Reactor Physics Experimental Benchmarks Evaluations, — SINBAD – a radiation shielding experiments database (nuclear reactors, fusion neutronics and accelerators), — IFPE – International Fuel Performance Benchmark Experiments Database, — TDB – The Thermochemical Database Project, — ICSBE – International Nuclear Criticality Safety Benchmark Evaluations [1], — CCVM – CSNI Code Validation Matrix of Thermal-hydraulic Codes for LWR LOCA and Transients [2]. This paper will concentrate on knowledge preservation and transfer concepts and methods related to some of the integral experiments and TDB

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment

Ein Beitrag zur integralen Beschreibung des Betriebsverhaltens von Brennstaeben in thermischen Reaktoren

With 65 refs.SIGLECopy held by FIZ Karlsruhe; available from UB/TIB Hannover / FIZ - Fachinformationszzentrum Karlsruhe / TIB - Technische InformationsbibliothekDEGerman