Background Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities. Methods Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device. Results Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between PO-CUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities. Conclusions Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.Keywords Cardiac output Á Ultrasound Á Carotid doppler Á Pulmonary artery catheter Á Pulse contour analysis Á Point of care ultrasound Abstract Background La misurazione della gittata cardiaca (CO) in Unità di Terapia Intensiva (ICU) richiede dispositivi invasivi come il cateterismo dell'arteria polmonare (PA) o l'analisi dell'onda dell'impulso arterioso (PCA). Questo studio si propone di valutare l'accuratezza e la fattibilità dell'ecografia (POCUS) della carotide comune per stimare la CO in modo non invasivo e confrontarla con le modalità esistenti di misurazione della CO effettuate in maniera invasiva. Metodi I pazienti ricoverati in terapia intensiva chirurgica e cardiotoracica in un centro accademico, affiliato con l'università, nel corso di un periodo di quattro mesi, sottoposti a dispositivi di monitoraggio emodinamico invasivo sono stati inclusi in questo studio. E' stata eseguita l'ecografia dell'arteria carotide comune per misurare la CO ed i risultati sono stati confrontati con una tecnica invasiva. Risultati Medici di terapia intensiva e borsisti, utilizzando l'ecografia della carotide comune, hanno ottenuto le misurazioni della CO. Immagini del flusso Doppler e di volume sono state ottenute a livello della ghiandola tiroidea. Contemporaneamente è è stata registrata la CO mediante dispositivi invasivi. Il gruppo era costituito da 36 Ultrasound (2015) 18:127-133 DOI 10.1007 pazien...
Vigilance in preventing creatinine increases and ameliorating or removing potential causes should occur as soon as creatinine begins to rise to avoid worsening renal function, to reduce cost, and to improve patient outcome.
IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.
Background: Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear.Objective: To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation.Design: Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation.Main Outcome Measure: Mortality.Results: A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population.Conclusion: Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.
BackgroundHyperglycemia is a frequent and important metabolic derangement that accompanies severe sepsis and septic shock. Matrix-Metalloproteinase 9 (MMP-9) has been shown to be elevated in acute stress hyperglycemia, chronic hyperglycemia, and in patient with sepsis. The objective of this study was to examine the clinical and pathogenic link between MMP-9 and blood glucose (BG) levels in patients with early severe sepsis and septic shock.MethodsWe prospectively examined 230 patients with severe sepsis and septic shock immediately upon hospital presentation and before any treatment including insulin administration. Clinical and laboratory data were obtained along with blood samples for the purpose of this study. Univariate tests for mean and median distribution using Spearman correlation and analysis of variance (ANOVA) were performed. A p value ≤ 0.05 was considered statistically significant.ResultsPatients were grouped based on their presenting BG level (mg/dL): BG <80 (n = 32), 80–120 (n = 53), 121–150 (n = 38), 151–200 (n = 23), and > 201 (n = 84). Rising MMP-9 levels were significantly associated with rising BG levels (p = 0.043). A corresponding increase in the prevalence of diabetes for each glucose grouping from 6.3 to 54.1 % (p = 0.0001) was also found. As MMP-9 levels increased a significantly (p < 0.001) decreases in IL-8 (pg/mL) and ICAM-1 (ng/mL) were noted.ConclusionThis is the first study in humans demonstrating a significant and early association between MMP-9 and BG levels in in patients with severe sepsis and septic shock. Neutrophil affecting biomarkers such as IL-8 and ICAM-1 are noted to decrease as MMP-9 levels increase. Clinical risk stratification using MMP-9 levels could potentially help determine which patients would benefit from intensive versus conventional insulin therapy. In addition, antagonizing the up-regulation of MMP-9 could serve as a potential treatment option in severe sepsis or septic shock patients.
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