In this SV-guided bleeding and fluid resuscitation model, both ScvO2 and dCO2 correlated well with changes in SV, but only the dCO2 returned to its baseline, normal value, while ScvO2 remained significantly lower than at baseline. These results suggest that dCO2 may be a good hemodynamic endpoint of resuscitation, while ScvO2 is not strictly a hemodynamic parameter, but rather an indicator of the balance between oxygen delivery and consumption.
Early response of PCT in the first 24 hours of commencing empirical antimicrobials in critically ill patients may help the clinician to evaluate the appropriateness of therapy.
BackgroundRecruitment maneuvers are often used in critical care patients with hypoxemic respiratory failure. Although continuous positive airway pressure/pressure support (CPAP/PS) ventilation is a frequently used approach, but whether lung recruitment also improves oxygenation in spontaneously breathing patients has not been investigated yet. The primary objective was to analyze the effect of recruitment maneuver on oxygenation in patients ventilated in CPAP/PS mode.MethodsFollowing baseline measurements PEEP was increased by 5 cmH2O. Recruitment maneuver was applied for 40 s with 40 cmH2O of PS. Measurements of the difference in PaO2/FiO2 and airway parameters measured by the ventilator were recorded immediately after recruitment then 15 and 30 min later. Thirty patients ventilated in CPAP/PS mode with a PEEP ≥5 cmH2O were enrolled in this prospective, observational study if their PaO2/FiO2 ratio was <300 mmHg or required an FiO2 >0.5.ResultsFollowing recruitment maneuver patients were considered as non-responders (NR, n = 15) if difference of PaO2/FiO2 <20% and responders (R, n = 15) if difference of PaO2/FiO2 ≥20%. In the NR-group, PaO2/FiO2 decreased non-significantly from baseline: median [interquartile], PaO2/FiO2 = 176 [120–186] vs. after recruitment: 169 [121–182] mmHg, P = 0.307 while in the R-group there was significant improvement: 139 [117–164] vs. 230 [211–323] mmHg, P = 0.01. At the same time points, dead space to tidal volume ratio (Vds/Vte) significantly increased in the NR-group Vds/Vte = 32 [27–37] vs. 36 [25–42]%, P = 0.013 but no significant change was observed in the R-group: 26 [22–34] vs. 27 [24–33]%, P = 0.386.ConclusionRecruitment maneuver improved PaO2/FiO2 ratio by ≥20% in 50% of patients ventilated in CPAP/PS mode.
Purpose of reviewTo discuss the pathophysiological rationale of advanced hemodynamic monitoring in the critically ill and also to highlight the importance of a multimodal, individualized approach.
Recent findingsThere are several clinical studies and animal experiments evaluating, which hemodynamic endpoint should be the best target during fluid management. Recent systematic reviews and meta-analyses also investigated the effects of advanced hemodynamic endpoints targeted hemodynamic management on outcome mainly in high-risk surgical patients. Although most of these studies report positive results, this knowledge does not seem to affect our everyday practice. According to large international surveys, most physicians still rely on inappropriate indices. One of the reasons could be that target values applied in these studies can be misleading in the individual patient. Therefore, we describe the concept of an individualized approach, in which normalizing the components of oxygen delivery are put in the context of the patients' individual response by evaluating components of oxygen consumption, and organ perfusion.
SummaryAdvanced hemodynamic monitoring-based management provides a number of benefits, which could be better tailored for the patients' actual needs by putting this into a multimodal, individualized approach.
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