Central Venous Pressure Monitoring Research Articles

CVP in elderly patients with severe diseases: a comparative study of two different measurement approaches

Objective To compare the value of central venous pressure (CVP) measured by peripherally inserted central catheters (PICC) and centrally inserted central catheters (CICC) in elderly patients with severe diseases. Methods Paired design and self-controlled was applied in the research. CVP was measured by 2 different measurement approaches in patients with PICC and CICC simultaneously. The sample size was calculated by the enumeration method through the accuracy estimation of consistency evaluation of quantitative measurement, and the required number was 70. Results Among the 70 collected samples, the mean values of the measured CVP by PICC and CICC were (7.995±3.435) cmH2O and (7.743±3.277) cmH2O; no statistically significant difference was observed (t=1.622, P=0.109) . The pearson's linear correlation coefficient of the CVP measured by 2 different measurement approaches was 0.926 (P<0.000 1) . A linear regression model through the origin of the CVP measured by 2 different measurement approaches was fitted with the linear regression equation of CVPPICC=1.023 CVPCICC (R2=0.978) ; and the 95%CI of the prediction line contained the reference line. The Bland-Altman plot showed that 64 samples fell within limits of agreement (LoA) , LoA was -2.300-2.804, with a consistent rate of 91.43%. All the plots out of the LoA did not exceeded the 95% CI. Conclusions The CVP measured by CICC and PICC exhibit high consistency. Therefore, PICC can be used to replace the CICC in the CVP monitoring. Key words: Central venous pressure; Centrally inserted central catheter; Peripherally inserted central catheter; Patients with severe diseases

Monitoring of central venous pressure and stroke volume variation in a case with a ruptured brain arteriovenous malformation and Fontan circulation

BackgroundPatients with complex congenital heart disease increasingly undergo noncardiac surgeries because of advancements in surgical techniques and medical management. In Fontan circulation, maintaining an adequate transpulmonary gradient is essential for preserving both pulmonary blood flow and cardiac output. However, intraoperative circulatory monitoring of Fontan patients has not been established.Case presentationA 17-year-old girl required an emergency craniotomy for ruptured arteriovenous malformation. She had a surgical history of bidirectional Glenn operation and Fontan palliation for her congenital hypoplastic left heart syndrome and double outlet right ventricle. We performed general anesthesia with continuous monitoring of central venous pressure (CVP) and stroke volume variation (SVV). Transesophageal echocardiography was not conducted because of difficulty in manipulating the probe due to the patient’s position and surgical setting. After incision of the dura, approximately 1700 ml of rapid blood loss from the arteriovenous malformation was observed in 30 min. In this period, CVP decreased from 15 to 5 mmHg or less. In contrast, there was only a slight rise in SVV from 5 to 8%. We rapidly administered fluid and then transfused blood, and CVP gradually recovered to 10–15 mmHg. During the surgery, circulatory collapse was not observed. The patient was transferred to the intensive care unit under sedation and controlled ventilation.ConclusionsCVP decreased sharply, whereas SVV rose only slightly during acute bleeding in the present case. CVP monitoring may have been useful for the management of an acute bleeding case with a Fontan circulation but SVV may not have been reliable. As more patients with a Fontan circulation undergo noncardiac surgeries, appropriate circulatory monitoring in these patients should be further investigated.

Incidence of central venous catheter hub contamination

PurposeTo investigate microorganisms causing central venous catheter contamination and how this contamination differs across different catheter metrics. Materials and methodsAfter obtaining IRB approval and informed consent, 830 cultures were prospectively obtained from 45 ICU patients with central venous catheter or peripherally inserted central catheter. Bacterial colonies were identified by mass spectrometry. ResultsBacterial contamination of central catheter hubs occurred 44% of the time in this study in the ICU setting. Coagulase-positive staphylococci cultures had higher median (±interquartile range) CFUs (12±232) versus coagulase-negative (3±10) and other bacteria (1±3; P<0.001). Bacterial contamination was associated with various metrics. Higher incidence (P<0.05) of coagulase-positive staphylococci cultures was associated with hub-only connections (a “hub” being a female connection; 10.9% vs. 7.9% male connections), connections without a manifold (1lumen device that mixes multiple infusions together; 9.7% vs. 0% with manifold); and central venous pressure monitoring connections (25.8% vs. 7.1% without). Internal jugular sites (10.0% vs. 2.7% femoral, 6.2% PICC, P=0.031) and medial lumens of triple lumen catheters (11.9% vs. 5.6% distal, 7.0% proximal, P=0.049) had increased incidence of higher bacteria loads (>15 CFUs). ConclusionsThis study found a high incidence of central access catheter hub bacterial contamination, which correlated with positive blood cultures in 2 of 3 total bacteremia cases identified in the 45 patients.

Protocol Adherence for Severe Sepsis and Septic Shock Management in the Emergency Department; a Clinical Audit.

Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans' lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines. This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21. 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically. The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents' adherence to current standard guidelines regarding severe sepsis and septic shock.

A Retrospective Study on the Compliance with Surviving Sepsis Campaign Guideline in Patients with Sepsis Admitted to Intensive Care Unit in Hong Kong

The global incidence of sepsis is increasing due to earlier recognition, but mortality from sepsis still remains high. Local data on the management according to the Surviving Sepsis Campaign Care Bundle is still lacking. Hence, this study looks at the epidemiology, patient characteristics and management of septic patients admitted to intensive care unit (ICU) in a regional hospital in Hong Kong. Clinical records of all patients admitted to ICU of Tseung Kwan O Hospital from 1st January to 30th June, 2014 were screened. There were 108 patients who fulfilled the inclusion criteria, corresponding to incidence of 32%. There were 62% males with a mean age of 63.6 years. Most patients (34.3%) were diagnosed in emergency department and the majority (46%) were transferred to ICU within 3 h of diagnosis, whereas 44% were transferred >6 h after diagnosis and 10% were transferred between 3-6 h. Most common source of infection was respiratory (26%), followed by blood (15.7%) and urinary tract (7%). Three-hour bundle compliance: measurement of lactate (0%), blood culture before antibiotics (56%), administration of antibiotics (100%) and administration of intravenous fluids volume to 30 ml/kg (21%). Six-hour bundle compliance: Vasopressor use (89%), central venous pressure monitoring (68%), central venous oxygen saturation measurement (0%). The hospital mortality rate was 26.8%. In conclusion, mortality of sepsis is high. Relentless effort is needed to boost the adherence to Sepsis Care Bundle, especially the measurement of serum lactate. Protocols, checklists, education and simulation training are possible means to improve the quality of care and clinical outcome of septic patients.

Maternal patent ductus arteriosus with bidirectional shunt: Obstetric anaesthesia and its challenges.

Sir, During pregnancy and peripartum period, the physiological changes are poorly tolerated by a patient with bidirectional shunt and severe pulmonary hypertension.[1] We describe a case of 27-year-old primigravida at 32 weeks of gestation who presented with respiratory distress, pre-eclampsia and platelet count of 64 × 109/L. She was a known case of uncorrected congenital PDA with severe pulmonary hypertension and Eisenmenger syndrome. With an interdisciplinary approach, high-risk consent was taken for the emergency caesarean section because of worsening maternal condition, after explaining the high incidence of maternal morbidity and mortality to the family. Pre-operatively, she had tachycardia, hypertension and tachypnoea with an oxygen saturation of 82% on room air, which improved to 89%–92% with oxygen supplementation. Arterial blood gas also showed hypoxaemia and metabolic acidosis, with pH 7.40, PaCO2 22, PaO2 42.00, bicarbonate 16.10, base excess – 5.1 and SaO2 80.70%. In the operating room, right radial artery and right internal jugular vein were cannulated for blood pressure and central venous pressure monitoring, respectively. General anaesthesia with rapid sequence induction and cricoid pressure was instituted using fentanyl, etomidate and succinylcholine. Spinal anaesthesia was not given because of the low platelet count. Soon after induction of anaesthesia, the patient developed supraventricular tachyarrhythmia, followed spontaneously by bradycardia and reverted to normal sinus rhythm in few seconds. This may have been due to sympathetic response to laryngoscopy and intubation, although a higher dose of fentanyl was given at induction to avoid this. A live baby boy was delivered, with Apgar score of 7 at 1 min and 8 at 5 min. During the maintenance phase, she was initially given 100% O2 to maintain oxygen saturation, which was tapered down to 50% and supplemented with 50% air during the procedure. According to the echocardiogram findings, she had severe pulmonary hypertension. She was given milrinone (inodilator) and glyceryl trinitrate infusions, titrated according to response from 0.3–0.6 μg/kg/min, and 0.5–8 μg/kg/min, respectively. At the end of surgery, the trachea was extubated after fulfilling the criteria. During transfer from the operating room, she suddenly developed primary postpartum haemorrhage with a blood loss of approximately 1.5 L, for which immediately 1 unit packed cell was transfused. The surgeon requested general anaesthesia to perform balloon tamponade, which was provided with facemask and sevoflurane 2%–3%. The patient was shifted to cardiac care unit, where she deteriorated from the 2nd post-operative day and inspite of the best possible care provided, patient died on the 4th post-operative day. She experienced sudden cardiac arrest, cardiopulmonary resuscitation was performed but she never revived. The cause of death could not be ascertained. The most probable diagnosis was pneumonia as she had a fever, increasing total leucocyte count, tachypnoea, increased oxygen requirement and pulmonary infiltrate on chest X-ray. She may have aspirated during inhalational anaesthesia by facemask that was given for balloon tamponade, or she may have had a community-acquired infections, leading to severe sepsis and acute respiratory distress syndrome. This could have further worsened the pulmonary hypertension resulting in pulmonary hypertensive crisis and cardiac arrest. Another possible cause could be massive pulmonary embolism resulting in sudden death which is also a common cause of mortality in such patients.[2] The pregnancy induced hypercoagulable state further increases the risk of thromboembolic events in patients with Eisenmenger syndrome, and hence prophylactic anticoagulation is recommended. Unfortunately, our patient never received anticoagulation at any stage, though she was considered high risk for thromboembolic episodes. Haemodynamic disturbance with major fluid shifts occurring after delivery can also be considered as cause of death in such patients. Vigilance is mandated in fluid management as postpartum autotransfusion may expose these patients to fluid overload and heart failure.[3] Pregnancy is contraindicated in women with Eisenmenger syndrome,[4] It is a significant cause of mortality, typically from heart failure or thromboembolic events.[5] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Crystalloid Coload vs Colloid Coload following Spinal Anesthesia for Elective Cesarean Delivery: The Effects on Maternal Central Venous Pressure

ABSTRACTIntroductionSpinal anesthesia is widely used in the management of uncomplicated cesarean section. Maternal hypotension is the commonest serious problem which decreases uterine blood flow causing fetal hypoxia, acidosis, and neonatal depression. Fluid administration before start of the surgery (preloading) with crystalloid is found to be ineffective due to rapid redistribution of fluids in various tissue spaces. A “coload” given at the time of spinal anesthesia may be more effective. Most studies have concentrated on noninvasive systolic blood pressure (SBP) measurements to evaluate the effect of such regimens. We used central venous pressure (CVP) measurement technique in parturients receiving rapid administration of crystalloid or colloid solution at the time of initiation of anesthesia (coload). We hypothesized that a colloid coload compared with a crystalloid coload would produce a larger sustained increase in volume and therefore reduce vasopressor requirements.Materials and methodsWe recruited healthy term women scheduled for elective cesarean delivery under spinal anesthesia for this randomized study. Baseline heart rate, baseline mean arterial blood pressure (MAP), and CVP were recorded. At the time of spinal injection, subjects were allocated to receive a rapid 1 L coload of either polymerized gelatin 3.5% (Haemaccel) or Hartmann (crystalloid) solution. The primary outcome CVP was compared between groups, as were secondary outcomes: phenylephrine dose and maternal hemodynamics data.ResultsMaternal demographics, surgical times, and American Society of Anesthesiologists (ASA) were similar between groups. Baseline parameters were similar in all the three groups. Heart rate increased from the baseline in all the three groups; however, mean heart rate was highest in crystalloid group. Mean arterial blood pressure decreased in all the three groups from baseline; however, highest fall was recorded in crystalloid group. The incidence of hypotension was 66.66% in crystalloid group as compared with 36.66% in colloid group. Crystalloid group patients received 6.33 ± 4.54 mg of ephedrine as compared with 2.40 ± 2.82 mg in colloid group. Thus, the incidence of hypotension and ephedrine consumption was significantly higher in crystalloid group as compared with colloid group. We found statistically significant differences in the mean preoperative CVP reading (p &lt; 0.05) between the two groups, the mean CVP reading in crystalloid group being slightly lower. With preloading, similar CVP readings were obtained in both groups. The fall in CVP during subarachnoid blockade was also not significant. The CVP began to fall with the establishment of the block until the delivery of the baby after which it was found to rise. The predelivery CVP was significantly lower than preoperative CVP in both groups—the fall being significantly more in crystalloid group.ConclusionIn our study, the results showed statistically significant decrease in volume requirement, when colloid coload is used than crystalloid coload using CVP monitor as a guide. Colloid coloading is effective and superior to crystalloid coloading for prevention of maternal hypotension in cesarean section.How to cite this articleSivanna U. Crystalloid ColoadvsColloid Coload following Spinal Anesthesia for Elective Cesarean Delivery: The Effects on Maternal Central Venous Pressure. J Med Sci 2017;3(4):95-101.

Simultaneous peripheral and central venous pressure monitoring for evaluating cardiac preload in critically ill patients

Simultaneous peripheral and central venous pressure monitoring for evaluating cardiac preload in critically ill patients

Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors

Background/Aims: Despite the development of strategies to minimize blood loss during hepatectomy challenges remain. Our aim was to determine whether low positive airway pressure (PAP) without positive end-expiratory pressure (PEEP) could minimize blood loss during hepatectomy. Methods: Forty-one living liver donors who underwent extended left lobectomy or right lobectomy between December 2012 and November 2013 were retrospectively analyzed. In the standard PAP group (n = 18), tidal volume was 8-10 ml/kg, respiratory rate was 10-12/min and PEEP was maintained at 5 cm H₂O. In the low PAP group (n = 23), tidal volume was reduced to 5 ml/kg, respiratory rate was increased to 15/min and PEEP maintained at 0 cm H₂O. Low central venous pressure (CVP) was maintained during surgery in all cases. Results: The low PAP group had significantly less blood loss (p = 0.0075) and shorter operation time (p = 0.0303) than the standard PAP group. In multiple regression analysis, ventilation mode and median CVP were found to be determining factors for blood loss. In no case did the ventilation mode affect perioperative management. Conclusions: Low PAP without PEEP is a safe mechanical ventilation mode that might help minimize blood loss along with CVP monitoring during hepatectomy.

Optimal transducer levels for central venous pressure and pulmonary artery occlusion pressure monitoring in supine and prone positions in pediatric patients

Background: This study was performed to investigate optimal central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) transducer levels in supine and prone positions in pediatric patients. Methods: Chest tomography images of 213 children aged ≤ 10 years were reviewed. Distances from the back to the uppermost blood level of both atria and their ratios to the largest anteroposterior (AP) diameter of the thorax were calculated for the supine position. For the prone position, same distances and ratios were calculated from the anterior chest. Subgroup analysis was performed to evaluate if there were significant differences in each ratio according to age. Results: In the supine position, the ratio of the uppermost blood level of the right atrium (RA) and left atrium (LA) to the largest AP diameter of the thorax was 80-85% and 60-65%, respectively. The ratio of the most posterior blood level of the RA and LA to largest AP diameter of thorax was 45-50% and 55-60%, respectively, from the anterior chest in the prone position. Subgroup differences in each ratio were within the range of 5%. Conclusions: In pediatric patients, CVP and PAOP transducers should be differently placed according to supine and prone positions. The influence of age was minimal on the level of each transducer. Keywords: Central venous pressure; Position; Transducer

Intraoperative Pleth Variability Index Is Linked to Delayed Graft Function After Kidney Transplantation.

Delayed graft function (DGF) is an early postoperative complication of kidney transplantation (KT) predisposing to acute rejection and lower graft survival. Intraoperative arterial hypotension and hypovolemia are associated with DGF. Central venous pressure (CVP) is used to estimate volemia but its reliability has been criticized. Pleth variability index (PVI) is a hemodynamic parameter predicting fluid responsiveness. The aim of this study was to examine the relationship between intraoperative PVI and CVP values and the occurrence of DGF. This was a prospective, noninterventional, observational, single-center study. All consecutive patients with KT from deceased donors were included. Recipients received standard, CVP, and PVI monitoring. Intraoperative hemodynamic parameters were recorded from recipients at 5 time points during KT. Forty patients were enrolled. There was a poor correlation between PVI and CVP values (r2= 0.003; P= .44). Immediate graft function and DGF patients had similar hemodynamic values during KT, with the exception of PVI values, which were significantly higher in the DGF group. In particular, a PVI >9% before unclamping of the renal artery was the only predictive parameter of DGF in our multivariate analysis (P= .02). This study suggests that PVI values >9% during KT are associated with the occurrence of DGF.

Reference Levels for Central Venous Pressure and Pulmonary Artery Occlusion Pressure Monitoring in the Lateral Position

To investigate reference levels for central venous pressure or pulmonary artery occlusion pressure monitoring in a lateral position. Retrospective observational study. A tertiary university hospital. A total of 204 adults who underwent chest computed tomography scan in the 90° lateral position from November 2006 to February 2015. None. Distances from the mid-sternum to the uppermost and lowermost blood levels of both atria were measured. Ratios of the distance from the bottom of the thorax to the uppermost and the lowermost blood levels of both atria to the largest diameter of the thorax were calculated. There were significant differences between the distances from the mid-sternum to the uppermost and the lowermost blood levels of the right atrium and those of the left atrium in the right and left lateral positions, respectively. There were significant differences in the uppermost (3.3±0.1 cm; 95% confidence interval [CI] 3.1-3.5) and the lowermost (4.4±0.1 cm; 95% CI 4.2-4.7) blood levels of the right atrium between the right and left lateral positions. Although the uppermost (1.5±0.1 cm; 95% CI 1.3-1.8) and the lowermost (0.4±0.1 cm; 95% CI 0.2-0.6) blood levels of the left atrium between the right and left lateral positions showed differences, their extent was smaller than the right atrium. The uppermost and the lowermost blood levels of the right atrium lay lower than those of the left atrium in the 90° right lateral position. In contrast, in the 90° left lateral position, the uppermost and the lowermost blood levels of the right atrium lay higher than those of the left atrium. When monitoring the central venous pressure and pulmonary artery occlusion pressure with patients in the lateral position, changes in the blood level of both atria should be considered when releveling the reference transducer.

Impact of the Royal Australasian College of Physicians' clinical examination preparation on basic physician trainee assessment of jugular venous pressure

Australian internal medicine trainees undergo intensive training in preparation for the Royal Australasian College of Physicians (RACP) clinical examination. Trainees preparing for the 2013 RACP clinical examination assessed the jugular venous pressure (JVP) of patients, with central venous pressure monitoring in the intensive care unit before and after the exam. RACP clinical examination preparation was associated with improvements of trainees' ability to identify JVP that were not elevated, although the JVP examination was performed marginally as a diagnostic test. Ongoing training might further improve this skill.

Early goal-directed therapy for severe sepsis and septic shock: A living systematic review

Studies and meta-analyses conflict regarding the use of early goal-directed therapy (EGDT) for septic shock. We sought to clarify the conflict by performing a living systematic review and meta-regression. MethodsWe performed a meta-analysis and explored heterogeneity with meta-regression. We conformed with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and qualified strength of evidence with a Grading of Recommendations Assessment, Development and Evaluation profile. ResultsOverall, EGDT did not significantly reduce mortality compared with usual care (relative risk, 0.85; 95% confidence interval, 0.67-1.08); however, heterogeneity was substantial (I2=64%; 95% confidence interval, 12%-85%). Illness severity did not correlate with mortality reduction; however, there were significant correlations with control rate mortality and the strategy employed by the control group. Benefit was confined to trials with a control mortality greater than 35%. Compared with monitoring of lactate clearance and central venous pressure, EGDT mortality was higher. ConclusionThe benefit of EGDT is evident in populations with high mortality, in line with reported global mortality rates. In settings with low mortality the recent trials challenge the need for 6-hour goals; however, most patients in these trials met 3-hour resuscitation goals as defined by the Surviving Sepsis Campaign. In settings with higher mortality, EGDT or normalization of lactate/central venous pressure may be viable therapeutic options.

Does glycemic level affect neurologic outcomes during cardiopulmonary bypass?

Perioperative hyperglycaemia, aggravated by cardiopulmonary bypass (CPB), is associated with adverse outcomes. Increased potential for stroke in these patients may be improved by different interventions. Blood glucose level changes as an intrinsic response to both stress and extrinsic sources; might affect early mortality and morbidity. In this study, we tried to identify a relationship existence between cerebral arterial oxygen saturation (rSO2) and blood glucose levels, and thus; evaluate changes in rSO2 caused by changes in blood glucose levels measured at predetermined time points of CPB. Forty six patients with American Society of Anaesthesiologists (ASA) physical status at least III and even IV, undergoing elective open cardiac surgery were prospectively studied. Preparation for surgery, anaesthesia and perioperative vital data monitoring (five-channel) ECG, pulse oximetry, capnography, nasopharynx and rectal temperature, invasive arterial blood pressure, central venous pressure and near-infrared spectroscopy (NIRS) monitoring were done in the same standardised way for each patient. The Mini-Mental State Examination (MMT) questionnaire was used for these patients before and 24 hours after the operation to assess neurologic adverse effects. NIRS values and blood glucose levels were sampled at the following stages of the intervention: the reference level (T0) was obtained immediately after cannulation of the arterial system and before anaesthesia; the second sample (T1) was taken 20 min after anaesthesia was introduced; the third sample (T3) was taken after 20 min of the aortic cross-clamp; the fourth sample (T4) was taken 20 min after the removal of the aortic cross-clamp; and the final sample (T5) was obtained 24 h after the surgery. No statistically signifi;cant relationship was found between changes in rSO2 and changes in blood glucose levels before surgery, after anaesthesia, ischemia, reperfusion, and surgery, in either diabetic or non-diabetic patients. Our findings showed increase in blood glucose levels and decrease in rSO2 as expected in ischemia and reperfusion periods of bypass. There was no significant difference between preoperative and postoperative MMT values of diabetic and non-diabetic patients. Cerebral oxygen saturation measured by NIRS may be a useful monitorization in open cardiac surgery. Our fndings suggests that hyper/hypoglycemia during surgery did not reflect changes in cerebral oxygenation, thus neurologic outcomes when other variables remained constant. Further studies using this approach in different surgeries and patient groups are needed.

A retrospective analysis of liver resection performed without central venous pressure monitoring

BackgroundStudies have suggested that blood loss can be reduced during liver resection by monitoring and maintaining low central venous pressure (CVP) through fluid restriction or other means, but such a strategy carries risks to the patient including those inherent to central venous catheterization. We sought to characterize fluid management and blood loss during liver resections done without CVP monitoring. MethodsRetrospective data were extracted from electronic anesthesia records for 993 liver resections. For 135 resections, between 2011 through 2013, where a documentation template was used that recorded fluid administration prior to hepatic inflow occlusion, multivariate analysis was performed to test for an association between pre-clamp fluid volumes administered and blood loss and other adverse outcomes. ResultsThe median estimated blood loss was 300 mL and overall rate of transfusion was 8.6%. There was no statistically significant association between crystalloid volume administered prior to inflow clamping (median 900 mL) and blood loss, mortality or length of stay in the subset of patients with supplemental fluid data. ConclusionLiver resection can be performed safely without either CVP monitoring or non-invasive continuous cardiac output monitoring. Additionally, there was no disadvantage to a practical approach to fluid administration prior to inflow clamping during liver resections in the absence of CVP monitoring with regard to blood loss or short-term outcomes.

Central Venous Pressure Monitoring; Introduction of a New Device.

Hemodynamic monitoring is needed in up to 58% of patients presented to the emergency department. Central venous pressure (CVP) monitoring is generally useful to assess general volume status. There are several methods of CVP measurement, which can be categorized as invasive and non-invasive. CVP manometer and electronic transducer are among the invasive methods and direct observation, ultrasonography and plethysmography are examples of non-invasive ones. All the mentioned methods have some negative points and shortcomings. Here we introduce a new device that can facilitate CVP measurement and provide physicians with further data that can be helpful regarding decision making and patient management.

Optimal level of the reference transducer for central venous pressure and pulmonary artery occlusion pressure monitoring in supine, prone, and sitting position.

To guarantee accurate measurement of central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP), proper positioning of a reference transducer is a prerequisite. We investigated ideal transducer levels in supine, prone, and sitting position in adults. Chest computed tomography images of 113 patients, taken in supine or prone position were reviewed. For supine position, distances between the back and the uppermost blood level of both atria and their ratios to the largest anteroposterior (AP) diameter of thorax were calculated. For prone position, same distances and ratios were calculated from the anterior chest. For sitting position, distances between the mid-sternoclavicular joint and the most cephalad blood level of both atria and their ratios to the sternal length were calculated. The ratio of the uppermost blood level of right atrium (RA) and left atrium (LA) to the largest AP diameter of thorax was 0.81±0.04 and 0.59±0.03 from the back in supine position. That calculated from the anterior chest in prone position was 0.54±0.03 and 0.46±0.03. The ratio of the most cephalad blood level of RA and LA to the sternal length was 0.70±0.10 and 0.68±0.09 from the mid-sternoclavicular joint in sitting position, which corresponded to the upper border of 4th rib. Optimal CVP transducer levels are at four-fifths of the AP diameter of thorax in supine position, at a half of that in prone position, and at upper border of the 4th sternochondral joint in sitting position. PAOP transducer levels are similar in prone and sitting position, except for supine position which is at three-fifths of the AP diameter of thorax.

Recent advances in liver disease.

Recent advances in liver disease.

Application of PICC on central venous pressure monitoring : a Meta-analysis

Objective To identify the difference in the central venous pressure measured via two different approaches. Methods We had searched the databases including PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), VIP Database and Wanfang Database, and Google Scholar was used for supplement search. All the experimental studies with self-control design that investigated the difference in the central venous pressure measured via two different approaches from the database foundation of until 2014 were included. The literature exclusion and data collection were performed independently by two investigators. The literature quality was evaluated by the 2nd edition of quality assessment of diagnostic accuracy studies tool (QUADAS-2). All the studies enrolled were assigned to high-quality and low-quality groups for subsequent stratified meta-analysis. Results A total of 8 studies involving 273 samples were entered in the final analysis. Pooled analyses from all studies revealed a statistically significant difference between the two approaches (P=0.002), and the pooled deviation is 0.436 (95% CI: 0.166-0.707). Conclusions Consideration of minor difference between the two approaches showed by meta-analysis, peripherally-inserted central catheter (PICC) remains feasible to measure central venous pressure. The consistency of the two approaches used for measuring central venous pressure requires further validation by large-scale clinical trials. Key words: Meta-analysis; Central venous pressure(CVP); Peripherally inserted central catheter(PICC)