BackgroundVariability of body weight (BW) and height calls for indexation of volumetric hemodynamic parameters. Extravascular lung water (EVLW) has formerly been indexed to actual BW (BWact) termed EVLW-index (EVLWI). In overweight patients indexation to BWact might inappropriately lower indexed EVLWIact. Several studies suggest indexation of EVLWI to predicted BW (EVLWIpred). However, data regarding association of EVLWIact and EVLWpred to mortality and PaO2/FiO2 are inconsistent. Two recent studies based on biometric database-analyses suggest indexation of EVLWI to height (EVLWIheight). Therefore, our study compared the association of un-indexed EVLW, EVLWIheight, EVLWpred and EVLWIact to PaO2/FiO2 and Oxygenation index (OI = mean airway pressure*FiO2*/PaO2).MethodsA total of 2119 triplicate transpulmonary thermodilutions (TPTDs; PiCCO; Pulsion Medical-Systems, Germany) were performed in 50 patients from the evaluation, and 181 patients from the validation groups. Correlations of EVLW and EVLWI to PaO2/FiO2, OI and ROC-AUC-analyses regarding PaO2/FiO2<200 mmHg (primary endpoint) and OI>10 were performed.ResultsIn the evaluation group, un-indexed EVLW (AUC 0.758; 95%-CI: 0.637-0.880) and EVLWIheight (AUC 0.746; 95%-CI: 0.622-0.869) provided the largest ROC-AUCs regarding PaO2/FiO2<200 mmHg. The AUC for EVLWIpred was smaller (0.713). EVLWIact provided the smallest AUC (0.685). This was confirmed in the validation group: EVLWIheight provided the largest AUC (0.735), EVLWIact (0.710) the smallest. In the merged data-pool, AUC was significantly greater for EVLWIheight (0.729; 95%-CI: 0.674–0.784) compared to all other indexations including EVLWIact (ROC-AUC 0.683, p = 0.007) and EVLWIpred (ROC-AUC 0.707, p = 0.015). The association of EVLW(I) was even stronger to OI compared to PaO2/FiO2. In the merged data-pool, EVLWIheight provided the largest AUC regarding “OI>10” (0.778; 95%-CI: 0.713–0.842) compared to 0.739 (95%-CI: 0.669–0.810) for EVLWIact and 0.756 (95%-CI: 0.688–0.824) for EVLWIpred.ConclusionsIndexation of EVLW to height (EVLWIheight) improves the association of EVLW(I) to PaO2/FiO2 and OI compared to all other indexations including EVLWIpred and EVLWIact. Also considering two recent biometric database analyses, EVLWI should be indexed to height.
In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.
We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.
Data provide no hint that haemodialysis prevents contrast-induced nephropathy. Therefore, postprocedural dialysis should be restricted to patients participating in clinical studies.
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