Pulmonary Artery Catheter Monitoring Research Articles

Pulmonary artery catheter monitoring in 2011

Hemodynamic monitoring has gained widespread acceptance in intensive care units. Despite ongoing debate regarding its safety and efficacy, monitoring with the pulmonary artery catheter (PAC) remains used for the management of severe heart failure and shock. To reanalyze using the most recently published literature in the field, the role of the PAC to manage critically ill patients with right ventricular failure, pulmonary hypertension and weaning failure from cardiac origin. The role of PAC as a gold standard to validate new cardiac output monitoring devices was also reported. Despite competition with less invasive hemodynamic monitoring devices or ultrasonic methods, the PAC remains a useful monitoring device in situations in which the knowledge of pulmonary artery pressure, pulmonary artery occlusion pressure and oxygenation parameters are needed. The proper use of PAC requires, however, a perfect knowledge of the numerous pitfalls and difficulties in interpretation of its measurements.

Mortality and Regional Oxygen Saturation Index in Septic Shock Patients: A Pilot Study

Peripheral muscle tissue oxygenation determined noninvasively using near-infrared spectroscopy may help to identify tissue hypoperfusion in septic patients. The aim of this study was to investigate regional oxygen saturation index (rSO2) in the brachioradialis (forearm) muscle by comparing measurements in healthy subjects and in intensive care unit (ICU) septic shock patients, and determine whether brachioradialis muscle rSO2 is associated with poor outcome in ICU septic shock patients. We conducted a prospective observational study in healthy volunteers (n = 50) and ICU septic shock patients (n=19). Brachioradialis (forearm) rSO2 measurements in healthy volunteers at rest and in ICU septic shock patients were compared. Pulmonary artery catheter monitoring was used in ICU patients. Significant differences in rSO2 were observed between healthy volunteers and ICU septic shock patients at ICU admission (68.7±4.9 vs. 55.0±13.0; p<0.001). When comparing septic shock survivors and nonsurvivors, significant differences were observed in rSO2 at baseline (64.5±8.9 vs. 47.5±10.7; p<0.01), 12 hours (67.3±9.6 vs. 45.0±14.9; p<0.01), and 24 hours (65.7±7.0 vs. 50.1±10.3; p<0.01). Lactate concentration was lower in survivors than nonsurvivors at 24 hours (12.0±7.5 mmol/L vs. 23.2±12.5 mmol/L; p<0.04). Cardiac index was greater in nonsurvivors than survivors at baseline (4.6+1.9 L/min/m vs. 3.0+0.9 L/min/m; p<0.05) and 12 h (3.9+0.5 L/min/m vs. 3.1+0.3 L/min/m; p<0.05). We observed that septic shock patients with forearm skeletal muscle rSO2≤60% throughout first 24 hours after ICU admission had significantly greater mortality rate than patients with forearm skeletal muscle rSO2>60% throughout this critical time.

Comparison of Nitrite Compounds and Carperitide for Initial Treatment of Acute Decompensated Heart Failure

Human atrial natriuretic peptides and nitrite compounds (NC) are infused for the initial management of acute heart failure (HF). However, there have been few studies comparing their hemodynamic effects.Fifty-two patients in acute decompensated HF (ADHF) who received carperitide (0.07 ± 0.05 µg/kg/minute, n = 23, group C) or NC (0.39 ± 0.24 µg/kg/minute, n = 29, group N) during the initial 24 hours in the intensive care unit between 1997 and 2007 were studied. We measured and compared hemodynamic parameters by pulmonary artery catheter monitoring before and after drug administration. Heart rate (HR), diastolic pulmonary artery pressure (DPAP), and central venous pressure (CVP) after the 24-hour administration were lower (HR: 92 ± 18 versus 79 ± 13 bpm, DPAP: 17 ± 6 versus 11 ± 5 mmHg, CVP: 6 ± 4 versus 3 ± 3 mmHg, P < 0.05, respectively) and the reduction of DPAP and systemic vascular resistance index were higher in group N than in group C. However, there was no significant difference regarding other indicators of preload and afterload. Although the serum B-type natriuretic peptide (BNP) level at discharge was lower in group N than group C (382 ± 434 versus 207 ± 201 pg/mL, P < 0.05), there was no significant difference in either the in-hospital reduction of BNP, the duration of hospitalization, or total cardiac events during 1-year follow-up.Although NC tended to improve the hemodynamics of ADHF more than carperitide, both drugs had a similar prognostic impact in patients with ADHF.

Hemodynamic Monitoring in Pigs Undergoing Orthotopic Abdominal Multivisceral Transplantation

Anesthesia for abdominal multivisceral transplantation (MVTx) is challenging. Surgical success depends on hemodynamic stability throughout organ removal from the donor and engraftment in recipients. The aim of the current study was to summarize our experience with anesthetic management including monitoring of hemodynamic changes in pigs during MVTx procedures. Materials and Methods Ten male pigs were randomly divided into two groups: donors and recipients for five MVTxs. A pulmonary artery catheter (PAC), transesophageal echocardiography (TEE), and pulse indicator continuous cardiac output (PiCCO) were used intraoperatively in recipients to monitor hemodynamic changes. Results Two recipients had cardiac arrest and died intraoperatively presumably due to hypovolemia. The data obtained by PAC and TEE from three successful cases showed huge changes in hemodynamics during the stages of organ removal and reperfusion after engraftment. Use of PiCOO in one of those three cases allowed successful fluid management, resulting in stable intraoperative hemodynamics. Conclusion The anesthetic management for MVTx surgery was improved by PAC, TEE, and PiCOO monitoring.

CENTRAL VENOUS PRESSURE VERSUS PULMONARY ARTERY CATHETER-DIRECTED SHOCK RESUSCITATION

Previously, we developed a protocol for shock resuscitation of severe trauma patients to reverse shock and regain hemodynamic stability during the first 24 intensive care unit (ICU) hours. Key hemodynamic measurements of cardiac output and preload were obtained using a pulmonary artery catheter (PAC). As an alternative, we developed a protocol that used central venous pressure (CVP) to guide decision making for interventions to regain hemodynamic stability [mean arterial pressure (MAP) >or= 65 mmHg and heart rate (HR) <or= 130 bpm]. Either protocol was available and required for traumatic shock resuscitation using bedside computerized clinical decision support to standardize decision making, and PAC was available if CVP-directed resuscitation was inadequate. We hypothesized that patients would be appropriately assigned to either protocol by trauma surgeon assessment of hemodynamic stability upon ICU admission. High-risk patients admitted to a level-1 trauma center ICU underwent resuscitation. Criteria were 1) major torso trauma, 2) base deficit (BD) >or= 6 mEq/L or systolic blood pressure < 90 mmHg, 3) transfusion of >or= 1 unit packed red blood cells (PRBC), or >or= age 65 years with two of three criteria. Patients with brain injury were excluded. Data were recorded prospectively. In 24 months ending July 31, 2006, of 193 patients, 114 (59%) were assigned CVP- directed resuscitation, and 79 (41%) were assigned PAC-directed resuscitation. A subgroup of 11 (10%) initially assigned CVP was reassigned PAC-directed resuscitation (7 +/- 2 h after start) due to hemodynamic instability. Crystalloid fluid and PRBC resuscitation volumes for PAC (8 +/- 1 L lactated Ringer's [LR], 5 +/- 0.4 units PRBC) were > CVP (5 +/- 0.4 L LR, 3 +/- 0.3 units PRBC) and similar to CVP - PAC protocol subgroup patients (9 +/- 2 L LR, 5 +/- 1 units PRBC). Intensive care unit (ICU) stay and survival rate for PAC (18 +/- 2 days, 75%) were similar to CVP - PAC (17 +/- 4 days, 73%) and worse than CVP protocol subgroup patients (9 +/- 1 days, 98%). Traumatic shock resuscitation is feasible using CVP as a primary hemodynamic monitor as part of a protocol that includes explicit definition of hemodynamic instability and where PAC monitoring is readily available. Computerized decision support provides a technique to implement complex protocol care processes and analyze patient response.

Current use of the pulmonary artery catheter

The pulmonary artery catheter is one of the most scrutinized monitors used in intensive care today. Pulmonary artery catheter use is declining due to limited demonstrated beneficial outcomes and the advancement of less invasive monitoring. This study discusses the current use of the pulmonary artery catheter and problems associated with its use including inaccuracy of measurements and data interpretation, inappropriately applied therapeutic interventions, inappropriate delays in applying interventions, and inappropriate patient selection. This overview presents current controversies surrounding the pulmonary artery catheter. It also discusses commonly used monitors and their lack of demonstrated benefits. In addition, data show that intensivists do not have sufficient knowledge to effectively use the pulmonary artery catheter. When utilized in a timely appropriate manner, pulmonary artery catheter monitoring may benefit a selected patient population. In summary, the pulmonary artery catheter monitor continues to be used for intensive care patients. To date, no single monitor is associated with an abundance of clear outcome benefits. There are some clinical data showing that the pulmonary artery catheter may still be useful when applied to the right patient population using appropriately timed therapies.

Pulmonary Artery versus Central Venous Catheter Monitoring in the Outcome of Patients Undergoing Bilateral Total Knee Replacement

Bilateral total knee replacement (BTKR) has been associated with a higher incidence of fat embolism (FES) compared to single knee replacement. Consequently, intraoperative monitoring with a pulmonary artery catheter (PAC) has been recommended. This study compares clinical outcome in BTKR patients monitored with central venous pressure versus PAC. A retrospective chart review of 249 consecutive patients undergoing BTKR, 132 of whom had PAC insertion versus 117 who had central line insertion, over a 1-year period were included in the study. Their medical records were reviewed for co-morbidities, baseline characteristics, and type of intraoperative monitoring. Need and duration for postoperative monitoring in the postoperative care, length of hospital stay (LOHS), signs of fat embolism, development of arrhythmias, and respiratory failure were all outcome measures. A total of four patients (1.6%) had FES as per Schonfeld criteria. One of these patients died within 48 h of surgery. They all had PAC monitoring intraoperatively. Pulmonary artery pressure (PAP) remained unchanged during surgery which raises doubt as to the clinical utility and advisability of the use of PAC's in this setting. There was no statistically significant difference in cardiac or pulmonary complications, or LOHS between the two groups. Central venous pressure monitoring appears to be sufficient in patients undergoing BTKR.

Applying logic to pulmonary artery catheter use

Mansour and colleagues recommend not routinely using the pulmonary artery catheter to guide hemodynamic management in the intensive care unit, because the perceived benefits are largely intangible [1]. Pulmonary artery catheter monitoring of the right ventricular ejection fraction (RVef) and of the right ventricular end-diastolic volume (EDV), however, reflects powerful yet underutilized relationships that assess right ventricular performance. Since the cardiac output equals the product of the RVef, the EDV and the heart rate, one can assess the RVef to EDV relations as direct measures of right ventricular performance. A series of RVef, EDV and heart rate combinations can give the same cardiac output (Figure ​(Figure1);1); monitoring or targeting cardiac output alone ignores this reality. For example, in hypovolemia the EDV is low and the RVef is increased, whereas in right ventricular failure the opposite is true. Furthermore, resuscitation from hypovolemia will increase the EDV and decrease the RVef [2], while reversal of cor pulmonale will decrease the EDV and increase the RVef. Figure 1 Right ventricular ejection fraction, right ventricular end-diastolic volume and heart rate relationship with cardiac output. CO, cardiac output; EDV, right ventricular end-diastolic volume; HR, heart rate; RVef, right ventricular ejection fraction. No monitoring device other than the pulmonary artery catheter can continually assess these variables. These concepts are often used in the cardiac surgery suite, but are rarely codified for diagnosis and management. Monitoring devices can improve outcome only if they are coupled to treatments that improve outcome. Applying the above logic to previously proposed treatment protocols, such as using the mixed venous oxygen saturation [3], may therefore be the first step toward defining pulmonary artery catheter utility [4].

Anaesthesia for non-cardiac surgery in a patient with Beckerʼs muscular dystrophy supported with a left ventricular assist device

The Section and Board of Anaesthesiology of the European Union of Medical Specialists aims (EUMS/UEMS) at harmonization of training of anaesthesiologists and at improvement of patient care throughout Europe. Pain medicine is considered to be an area of expertise in anaesthesiology although exclusivity is not claimed. The Section and Board has approved both a core syllabus for pain medicine to be part of the specialist training in anaesthesiology and an additional qualification in pain medicine following the completion of a 5 yr basic specialty training in anaesthesiology. These proposals were prepared by the Working Party on Pain Medicine of the Section and Board. It considers a multidisciplinary approach to pain to contribute to quality in care and has taken the initiative to set up a Multidisciplinary Joint Committee on Pain Medicine within the EUMS/UEMS, for which these guidelines define the area of expertise of anaesthesiology.

Evaluation of Invasive and Noninvasive Hemodynamic Monitoring in Trauma Patients

The aim of this study was to compare a recently developed and improved noninvasive hemodynamic monitoring system with the conventional invasive monitoring by pulmonary artery catheterization (PAC) in acute emergency trauma patients. In a large, university-run, inner city public hospital, we monitored 993 trauma patients noninvasively; 262 of these were simultaneously monitored with both noninvasive hemodynamic and invasive PAC monitoring. The noninvasive monitoring was begun shortly after admission to the emergency department and the invasive PAC monitoring was started in the operating room, or as soon as the patient arrived in the intensive care unit. Noninvasive monitoring included cardiac index (CI) by the IQ or Physio Flow bioimpedance device, together with mean arterial blood pressure, heart rate, pulse oximetry (SapO2), transcutaneous oxygen (PtcO2), and carbon dioxide (PtcCO2) tensions. We compared CI by simultaneous measurements with both invasive and noninvasive methods 907 times in 262 patients. The CI by thermodilution (CItd) correlated well with simultaneous measurements with the bioimpedance (CIbi), r2 = 0.915, r2 = 0.84, p < 0.001. The bias and precision of simultaneous measurements was -0.070 +/- 0.47 L/min/m2; agreement was considered satisfactory. In the initial resuscitation period of both monitoring systems, the CI, mean arterial blood pressure, SapO2, and tissue perfusion (reflected by invasive DO2 and VO2, and by noninvasive PtcO2/FiO2 ratio) were higher in survivors than in nonsurvivors, whereas heart rate values were higher in the nonsurvivors. We concluded that noninvasive hemodynamic monitoring provided a feasible, safe, inexpensive, accurate, continuous, on-line real-time graphic displays that are equivalent to the essential features of invasive pulmonary artery catheter monitoring.

Impact of Intraoperative Transesophageal Echocardiography During Noncardiac Surgery

The purpose of this study was to test if parameters measured by intraoperative transesophageal echocardiography (TEE) could be useful to evaluate the hemodynamic status of high-risk cardiovascular patients and if this information was sufficient to make changes in intraoperative management. Prospective clinical study. Single-university hospital. Ninety-eight patients undergoing noncardiac surgery. Every patient was assessed with a baseline examination of 2-dimensional, color, pulsed, and continuous Doppler images. Intraoperative changes in any of the evaluated and measured parameters led to a specific change according to the protocol. After continuous monitoring with TEE during surgery, all patients were assigned to 1 of the following groups: (1) TEE was of no use, (2) TEE-directed intraoperative management changes, (3) intraoperative TEE-directed changes in postoperative management, and (4) TEE successfully used as a substitute for pulmonary artery catheter monitoring. Two patients (2%) were assigned to group 1, 47 (48%) patients to group 2, 25 (25%) patients to group 3, and 24 (24%) patients to group 4. The most frequent modifications in intraoperative management were changes in drug therapy and fluid administration. Postoperative management changes were mostly made because of new diagnosis (14%) and new left ventricular wall motion abnormalities (9%). These results strongly suggest that objective measurements made by intraoperative TEE are effective in unveiling relevant clinical findings and useful information in high-risk patients undergoing noncardiac surgery.

Utilization and Infection Rates Associated with Pulmonary Artery Catheter Monitoring in an Intermediate Care Environment

Background: In early 2003, a nine-bed intermediate care heart failure unit was established at our hospital. The purpose of this unit was to allow heart failure physicians and nurses the opportunity to focus therapeutic protocols, diagnostic procedures and nursing competencies in one location to improve outcomes. We monitored utilization and infectious complications associated with pulmonary artery catheter (PAC) placement in this new intermediate care environment. Methods: Clinical and demographic data were prospectively collected on all PAC patients between April 23, 2003 and December 28, 2005.

The Pulmonary Artery Catheter: Gold Standard or Redundant Relic

Pulmonary artery catheter (PAC) technology has changed significantly and use has decreased over the last 20 years. Barriers to use include: (a) increased patient risk with placement; (b) ability to measure similar variables via less invasive measures; (c) increased cost; (d) inaccurate measurement leading to misuse of PAC-derived variables; (e) incorrect interpretation and clinical application; and (f) lack of proven benefit for patient management. Advances in technology have allowed for continuous trending of hemodynamic parameters measured via the PAC. Patient risk is similar to that of central line placement; however risks associated with pulmonary artery infarction and rupture are inherent to the PAC. Less invasive assessment of cardiac output equals that of the PAC, whereas pulmonary capillary wedge pressure and mixed venous oxygen saturation monitoring are unique features of the PAC. Effective use of PAC data will require ongoing standardized education. More studies are needed on the cost-effectiveness of PAC monitoring as well as outcome benefits. Much of the data available from the PAC can be obtained via less invasive methods. However, the PAC continues to be useful in specific situations and remains the gold standard for comparison of new technologies. This paper discusses use of the PAC during the past 2 decades and reviews studies affecting its use in clinical practice.

Evaluation and Monitoring of Patients with Acute Heart Failure Syndromes

Advanced heart failure (HF) is associated with frequent hospitalizations, poor quality of life, and increased mortality. Despite optimal medical management, readmission rates remain high and account for approximately two thirds of all costs related to HF management. Evaluation of patients with HF is critical for the appropriate selection and monitoring of therapy as well as for the prevention of recurrent hospitalizations. This evaluation can be complex and relies on integration of the bedside evaluation and information available from invasive and other noninvasive diagnostic techniques. The clinical examination remains the cornerstone of HF evaluation. Key features of the history and physical examination can be used to assign hemodynamic profiles based on the absence or presence of congestion and adequacy of perfusion. These hemodynamic profiles provide prognostic information and may be used to guide therapy. Direct measurement of hemodynamics may be helpful in patients in whom the physical examination is limited or discordant with symptoms. Although the pulmonary artery catheter (PAC) is not recommended during routine therapy of patients hospitalized with HF, it is reasonable to consider the use of PAC monitoring to adjust therapy in patients who demonstrate recurrent or refractory symptoms despite ongoing standard therapy adjusted according to clinical assessment. This is particularly relevant in centers with experience in hemodynamic monitoring for HF. B-type natriuretic peptide (BNP) testing has been shown to facilitate diagnosis of the etiology of dyspnea in the urgent setting for patients without a prior diagnosis of HF. Furthermore, BNP levels provide important prognostic information in patients with chronic HF, but serial BNP testing has not been validated as a guide to inpatient or outpatient management. Echocardiographic assessment can provide prognostic information about ventricular function and size as well as information about hemodynamic status. Development of validated and reproducible noninvasive techniques to monitor patients with acute HF will be an important step in maximizing interventions to improve outcomes in this patient population.

Kardiopulmonales Monitoring bei gastroenterologischen und renalen Notf�llen

Predominantly elderly and multimorbide patients require frequently intensive care observation and treatment due to acute gastrointestinal and renal disease. Manifest circulatory and rhythm instability, acute heart failure and severe metabolic or electrolyte derangements present indications for submission to a critical care unit. Stabilization of vital functions, control of specific therapeutic procedures (e. g. renal replacement therapy), and early recognition of secondary complications belong to the tasks of intensive care. Beyond a baseline monitoring available procedures comprises a broad spectrum from pulseoxymetrie to pulmonary artery catheter monitoring depending of the need of the individual patient.

The use of and preferences for the transesophageal echocardiogram and pulmonary artery catheter among cardiovascular anesthesiologists.

The pulmonary artery catheter (PAC), although widely used in anesthesia for cardiac and vascular surgery, remains controversial. Use of transesophageal echocardiography (TEE) by cardiovascular anesthesiologists may be a substitute or a preference compared with the PAC, but this has been incompletely investigated. An anonymous, cross-sectional survey was mailed to anesthesiologists in Canada and the United States. Anesthesiologists described their use of the PAC and TEE during cardiac and vascular surgery, along with their demographic characteristics. Two hundred sixty-five (77%) of 345 anesthesiologists responded. All had the PAC available for use, and 56% had TEE available. Only 23 (11% overall) reported having undergone echocardiography training, half of whom had completed fellowships. Both the PAC and TEE were more often used in cardiac valvular surgery (P = 0.0001) than in aortocoronary bypass or abdominal vascular surgery. Among all anesthesiologists, the PAC remained the preferred monitor in either cardiac or vascular surgery (P = 0.0001), although many indicated a preference for neither monitor. Among anesthesiologists with echocardiography training, TEE was preferred (P = 0.0004). We found that TEE was accessible to more than half of the surveyed anesthesiologists in cardiovascular surgery, but relatively few of them had completed formal training in its use. Only those with completed formal TEE training indicated a significant preference for TEE use and also used it frequently. Given the continuing controversy about the appropriate application of the PAC, concern about the appropriate application of TEE is prudent. The PAC remains the more frequently used and preferred monitor among cardiovascular anesthesiologists. A survey of anesthesiologists found that pulmonary artery catheter monitoring is currently more frequently used compared with transesophageal echocardiography during cardiac and vascular surgery.

Safe, highly selective use of pulmonary artery catheters in coronary artery bypass grafting: an objective patient selection method

Background. Routine versus selective use of pulmonary artery catheter (PAC) monitoring in coronary artery bypass grafting operations is a topic of significant debate. Accordingly, we retrospectively examined operative outcomes in 2,685 consecutive (1994 to 1998) coronary artery bypass grafting patients in whom PAC use was highly selective. Next, we developed a quantitative model of PAC use in terms of its multivariate predictors as a means of providing an objective criterion for patient PAC use selection. Methods. Safety of the implemented selective PAC use was assessed by comparisons to contemporaneous coronary artery bypass grafting outcome reported by The Society of Thoracic Surgeons’ national data. Continuous relations describing PAC use in terms of continuous univariate predictors were obtained using overlapping-range patient cohorts. Next, independent predictors of PAC use were derived by multivariate regression to best fit the categorical variable PAC (Yes = 1, No = 0). Model estimates were a continuous variable (PAC score) with values between 0 and 1. Results. Planned use of PAC was based on collective consideration of preoperative patient variables, and was not limited to low-risk or preserved ejection fraction patients. Planned and unplanned use of PAC was limited to 176 (planned, 6.6%) and 66 (unplanned, 2.4%) patients, respectively, whereas no PAC was used in 2,443 (91%). Overall patient characteristics and risk factors in this series were comparable to contemporaneous Society of Thoracic Surgeons data, and the incidence of operative deaths was 2.31% (n = 61; observed-to-expected [Society of Thoracic Surgeons risk] mortality = 0.73). Independent predictors of PAC use were ejection fraction, Society of Thoracic Surgeons risk, intraaortic balloon pump, congestive heart failure, reoperative surgery, and New York Heart Association class IV. Expectedly, PAC scores were substantially different for PAC (mean ± standard deviation, 0.37 ± 0.20; median, 0.38) and no PAC (0.14 ± 0.11; median, 0.10) patients ( p < 0.001). Area under the receiver operating characteristic curve derived for PAC score was relatively high (area, 0.85). Moreover, the corresponding summed sensitivity (0.68 to 0.91) and specificity (0.85 to 0.62) was maximized at 1.53 for PAC score between 0.15 and 0.31. Conclusions. Our results indicate that highly selective use of PAC in coronary artery bypass grafting can be accomplished safely, and it need not be limited to patients with preserved ejection fractions or low operative risk. Indeed, coronary artery bypass grafting without PAC may be preferable in the vast majority of patients as it reduces catheter-associated risks and resource utilization without incurring an increased operative risk. Also, pending further prospective confirmation, our analysis suggests that collective consideration of PAC use predictors to derive a PAC score provides an objective criterion to minimize unnecessary use of PAC with an acceptably low probability of error.

Evidence of Lung Injury During Reconstructive Surgery for Adult Spinal Deformities With Pulmonary Artery Pressure Monitoring

Observational analyses of 55 adult patients who underwent elective sequential anterior-posterior thoracolumbosacral surgical corrections for spinal deformities were used to evaluate the efficacy of pulmonary artery catheter monitoring. To demonstrate that during complex reconstructive surgery for spinal deformities, pulmonary artery catheter monitoring identifies a subset of patients with pulmonary injury and is essential in their management. Patients who undergo sequential anterior-posterior thoracolumbosacral surgical corrections for spinal deformities experience significant perioperative morbidity. Although the value of pulmonary artery catheter monitoring is controversial, its use in these procedures may help identify potential physiologic complications and improve surgical outcome. All patients were monitored with a pulmonary artery catheter during surgery until at least postoperative day 1. Outcome measurements included blood loss, vertebral levels fused, operative time, postoperative respiratory complications, and days in intensive care. Eight (8/55; 14.5%) patients according to pulmonary artery catheter monitoring demonstrated elevated pulmonary vascular resistance and noncardiac pulmonary edema. These patients had longer operative procedures with greater blood loss and had more postoperative respiratory complications. They were treated appropriately in intensive care and discharged without further complications. Pulmonary artery catheter monitoring of patients who undergo complex spinal fusion facilitates the identification of patients with pulmonary injury and is essential in the management of these patients in the postoperative period. It may, also, be a marker for embolic injury to the lung.

Hemodynamic-volumetric versus pulmonary artery catheter monitoring during anesthesia for liver transplantation

Hemodynamic-volumetric versus pulmonary artery catheter monitoring during anesthesia for liver transplantation

Locoregional neuraxial anesthesia and vascular surgery: the benefits

To assess the advantages of neuraxial blockade (NB) during and after vascular surgery and to confront them with the risk of epidural or spinal hematoma. NB may reduce the risk of thrombotic occlusion following lower extremity vascular reconstruction. This effect of NB may be attributed to reduced hypercoagulability, decreased peripheral resistance and increased graft flow. In patients under general anesthesia, only those authors using an aggressive perioperative management (pulmonary artery catheter monitoring, intensive care unit admission) were able to report grafts patency rates similar to those obtained with NB. NB facilitates the modulation of the hemodynamic and hormonal stress responses during the perioperative period. It also produces superior postoperative analgesia. Still, the impact of NB on cardiac morbidity following aortic reconstructive surgery remains open to debate. Only very few cases of epidural hematomas associated to NB following vascular surgery have been reported. They implicated patients who received either fibrinolytic medication, continuous heparin infusion, or both. Low molecular weight heparins may increase the risk or epidural hematoma and, should their administration become more frequent during vascular surgery, the safety of NB would then have to be reassessed. NB during vascular surgery is a safe and well-established practice. It offers many theoretical and demonstrated advantages. NB is particularly beneficial and economical for lower extremity vascular reconstruction. Still, NB may not be the best approach if the administration of fibrinolityc medication or prolonged heparin infusion is contemplated.