Pulse Indicator Continuous Cardiac Output Research Articles

Comparison of effect of norepinephrine and terlipressin on patients with ARDS combined with septic shock: a prospective single-blind randomized controlled trial

To approach the effect of different vasopressor on hemodynamics, volume responsiveness, fluid volume balance, renal function and prognosis in patients with acute respiratory distress syndrome (ARDS) complicated with septic shock. A prospective single-blind randomized controlled trial was conducted. ARDS patients with septic shock admitted to the Department of Critical Care Medicine of Jiangxi Provincial People's Hospital from January 1st, 2015 to May 1st, 2016 were enrolled. The patients satisfied ARDS Berlin diagnostic criteria, over 15 years old, needing vasopressor after fluid resuscitation were enrolled. The patients were divided into norepinephrine group (NE group) and terlipressin group (TP group) by randomise number table derived by computer. Patients in TP group were given terlipressin (0.01-0.04 U/min) with an intravenous pump, while those of NE group were given norepinephrine (> 1 μg/min) with an intravenous pump, and the target mean arterial pressure (MAP) was maintained at 65-75 mmHg (1 mmHg = 0.133 kPa). Hemodynamics and extravascular lung water index (EVLWI) were monitored by pulse indicator continuous cardiac output (PiCCO). The volume responsiveness of patient was evaluated by passive leg raising (PLR) test, and cardiac index (CI) change (ΔCI ≥ 10%) served as positive volume responsiveness. The differences in hemodynamics, EVLWI, oxygenation index (OI), lactate clearance rate (LCR), rate of positive volume responsiveness, urinary output, fluid volume balance, renal function, and prognostic indicators were compared between the two groups. Fifty-seven patients with ARDS complicated with septic shock were enrolled, with 26 patients in NE group, and 31 patients in TP group, the baseline data in both groups was balanced with comparability. Compare with NE group, 48-hour and 72-hour heart rate (HR) in TP group was significantly slowed (bpm: 82.1±6.8 vs. 87.6±7.4, 81.3±6.1 vs. 85.6±8.3, both P < 0.05), 72-hour central venous pressure (CVP) was significantly decreased (mmHg: 9.4±2.6 vs. 10.9±3.0, P < 0.05), but no significant difference was found in HR, MAP, CVP, CI, EVLWI, OI and LCR at other time points between the two groups. 48-hour and 72-hour positive volume responsiveness rate in TP group were significantly increased as compared with those of NE group (74.2% vs. 46.2%, 64.5% vs. 38.5%, both P < 0.05), urinary output on the 2nd day (mL/24 h: 2 342.8±704.1 vs. 1 944.6±684.3) and fluid volume balance (mL: -319.7±54.8 vs. -169.6±27.2) were significantly decreased (both P < 0.05). There was no significant difference in positive volume responsiveness rate, urine output, fluid volume balance, and the level of serum creatinine at other time points between the two groups. There was no statistically significant difference in the following features between TP group and NE group: duration of mechanical ventilation (days: 8.41±2.97 vs. 9.67±3.56), length of intensive care unit (ICU) stay (days: 12.84±4.47 vs. 14.77±5.01), total length of hospital stay (days: 19.34±7.37 vs. 21.07±8.41), and 28-day mortality (29.0% vs. 30.8%, all P > 0.05). Compared with norepinephrine, terlipressin for ARDS patients with septic shock is more conducive to restrict fluid load, improve the renal perfusion and increase urine output. However, in both groups there was no significant difference in the efficiency of stabilizing hemodynamics, shortening the duration of mechanical ventilation, reducing ICU or hospital days and decreasing 28-day mortality.

A case of pulse indicator continuous cardiac output guided treatment in a myocardial infarction patient complicating heart failure and severe pneumonia

A case of pulse indicator continuous cardiac output guided treatment in a myocardial infarction patient complicating heart failure and severe pneumonia

The influence of continuous veno-venous hemofiltration on cardiac output value monitored by transpulmonary thermodilution technique in critical patients

To investigate the influence of continuous veno-venous hemofiltration (CVVH) on cardiac output (CO) value and parameters of hemodynamics monitored by transpulmonary thermodilution technique in critical patients. A prospective cohort study was conduced. Sixty-two critical patients admitted to intensive care unit (ICU) of Zunyi Medical College Affiliated Hospital from January 2011 to October 2015 were enrolled. All of the patients received CVVH through femoral vein puncture catheter. The CO value was monitored before CVVH operation, immediately after CVVH operation (8?centigrade normal saline was injected immediately after the output of blood from the arterial end), 5 minutes after operation, the time at the sudden interruption (press pause key after 10 minutes of operation) and resumed immediately, 15 minutes and 30 minutes after operation by pulse-indicated continuous cardiac output (PiCCO) with transpulmonary thermodilution method. The changes in heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), and blood temperature were observed at all time points. From CVVH before start to 5 minutes thereafter, CO values were not significantly changed in patients, fluctuating in 6.96 (7.33, 8.67)-6.98 (6.43, 7.45) L/min. When CVVH was suddenly interrupted, CO value was immediately increased to the peak 8.04 (7.36, 8.77) L/min, which showed statistically significant difference as compared with other time points (all P < 0.01). Immediately after the CVVH recovery from interruption, the CO value dropped to 4.71 (4.14, 7.26) L/min, and it was significantly lower than those at other time points (all P < 0.01). With the CVVH recovery, the patients' CO value was gradually restored to the stable operation ahead of interruption [4.71 (4.14, 7.26)-6.85 (6.08, 7.26) L/min]. During CO monitoring, HR, MAP, CVP and blood temperature of the patients were at the same level, and no significant changes were founded. CVVH interruption of immediate PiCCO monitoring CO value were significantly increased, immediately after the CVVH recovery the CO value were significantly reduced, and the normal operation of CVVH did not affect the CO value monitoring. Hemodynamics and blood temperature of all patients were stable during CVVH.

Measurement of brachial artery velocity variation and inferior vena cava variability to estimate fluid responsiveness

To investigate the accuracy and feasibility of brachial artery peak velocity variation (ΔVpeakbrach) and inferior vena cava variability (VIVC) as indicators of fluid responsiveness in critically ill patients. A single-center prospective observation was conducted. The patients on mechanical ventilation with spontaneously breathing admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from June 2013 to August 2015 were enrolled. The patients were diagnosed as severe sepsis or sepsis shock. The peak velocity in brachial artery and diameter of the inferior vena cava at the end of inspiration and expiration was measured by bedside portable ultrasonic machine, and then ΔVpeakbrach and VIVC were calculated. The hemodynamic parameters were collected at baseline and after volume expansion (VE). The stroke volume (SV) was measured by pulse-indicated continuous cardiac output (PiCCO). Patients were classified as responders or non-responders according to the variation of SV (ΔSV) increased ≥ 15% or not after VE. Receiver operating characteristic curve (ROC) was plotted to evaluate the sensitivity and specificity of ΔVpeakbrach and VIVC in predicting volume responsiveness. Among 58 patients after VE, 32 patients were defined as responders and the rest 26 were defined as non-responders.There were no differences in gender, age, acute physiology and chronic health evaluation II (APACHE II) score, dose of vasoactive agent, ventilator parameters and infection site. Compared with baseline hemodynamic parameters, heart rate (HR) was decreased (bpm: 95±18 vs. 103±21), and systolic blood pressure (SBP) was increased [mmHg (1 mmHg = 0.133 kPa): 92±8 vs. 80±7] after VE in responders; central venous pressure (CVP) was increased after VE in non-responders (mmHg: 11±4 vs. 8±3, all P < 0.05). The ΔVpeakbrach [(15.4±4.3)% vs. (11.2±3.5)%] and VIVC [(18.6±4.1)% vs. (14.3±3.6)%] in responders were significantly increased as compared with those of non-responders (both P < 0.05). The area under ROC curve (AUC) of ΔVpeakbrach for predicting volume responsiveness was 0.816. When the cut-off value of ΔVpeakbrach was ≥ 13.3%, the sensitivity was 71.9%, and the specificity was 80.8%. AUC of VIVC for predicting volume responsiveness was 0.733. When the cut-off value of VIVC was ≥ 19.25%, the sensitivity was 53.1%, and the specificity was 88.5%. ΔVpeakbrach and VIVC are reliable indicators for predicting volume responsiveness in critical patients.

Hepatic Perfusion Alterations in Septic Shock Patients

Background:Early goal-directed therapy (EGDT) has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients.Methods:A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients’ characteristics were compared before treatment (T0), immediately after EGDT (T1), and 24 h after EGDT (T2). This study is registered at ClinicalTrials.org, NCT02060773.Results:Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients; therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate (ICG-PDR) and 15-min retention rate (R15) at T0 (11.9 ± 5.0%/min and 20.0 ± 13.2%), T1 (11.4 ± 5.1%/min and 23.6 ± 14.9%), and T2 (11.0 ± 4.5%/min and 23.7 ± 15.3%) (all P > 0.05). Both of the alterations of ICG-PDR and R15 showed no differences at T0, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected (P > 0.05).Conclusion:There were no hepatic perfusion improvements after EGDT in the early phase of patients with septic shock.Trial Registration:Clinicaltrials.gov NCT02060773 (https://clinicaltrials.gov/ct2/show/NCT02060773).

High Serum sTREM-1 Correlates With Myocardial Dysfunction and Predicts Prognosis in Septic Patients

ObjectiveThis study aimed to evaluate the predictive and prognostic value of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in patients with myocardial dysfunction induced by severe sepsis and septic shock. Materials and MethodsA total of 84 patients with severe sepsis and septic shock were enrolled between May 2013 and December 2014.The patients were monitored by pulse indicator continuous cardiac output system and divided into myocardial depression group (cardiac function index [CFI] < 4.1/minute, n = 37) and nonmyocardial depression group (CFI ≥ 4.1/minute, n = 47 ). Additionally, the patients were divided into survival group (n = 40) and nonsurvival group (n = 44) based on 28-day mortality. Hemodynamic parameters and serum sTREM-1, B-type natriuretic peptide (BNP) and cardiac troponin I (cTnI) levels were collected on days 1, 3 and 5 after admission to intensive care unit. Results(1) The serum values of sTREM-1, BNP and cTnI in myocardial depression group were higher than those in nonmyocardial depression group (P < 0.01); and CFI, cardiac index, stroke volume, global ejection fraction and left ventricular contractility index (dpmax) in myocardial depression group were lower than those in nonmyocardial depression group on day 1 (P < 0.05); (2) serum sTREM-1 negatively correlated with left ventricular ejection fraction, CFI, cardiac index, global ejection fraction and dpmax, and it positively correlated with BNP and cTnI (P < 0.01); (3) the area under the receiver operating characteristics curve for sTREM-1 in the prediction of myocardial depression was 0.671 with a sensitivity of 83.8% and a specificity of 46.8% when cutoff point was 174.5ng/mL, the power of predicting septic depression for sTREM-1 was lower than that of BNP; logistic regression analysis showed that serum sTREM-1 was not an independent predictor of septic myocardial depression; the area under the receiver operating characteristics curve was 0.773 for sTREM-1 in predicting outcome with a sensitivity of 86.4% and a specificity of 80% when cutoff point was 182.3ng/mL, the power of predicting prognosis for sTREM-1 was superior to those of BNP and cTnI; (4) there was a decrease trend for sTREM-1 levels and an increasing trend for CFI in the survival group (P < 0.05). ConclusionsMyocardial dysfunction is common in patients with severe sepsis and septic shock and high serum levels of sTREM-1 correlates with myocardial dysfunction to some extent but is not an independent predictor, which more importantly showed prognostic value for septic shock outcome.

Joint effects of hydroxyethyl starch and furosemide on acute lung injury induced by paraquat in swine

Objective To discuss the jointly therapeutic effects of 6% hydroxyethyl starch 130/ 0.4 (voluven) and furosemide on acute lung injury induced by paraquat (PQ) in swine. Methods The ALI/ARDS models were established with 20% PQ (20 mL) intraperitoneal injection in 18 healthy female piglets and randomly divided into three groups: voluven group (A) , furosemide group (B) and voluven +furosemide group (C) (n=6 in each group). The heart rate (HR) , mean arterial pressure (MAP) , extravascular lung water index (ELWI) , pulmonary vascular permeability index (PVPI) , partial pressure of carbon dioxide (PaCO2) and oxygenation index (PaO2/FiO2) among the three groups were carefully measured by PICCO (pulse indicator continuous cardiac output) before modeling (baseline) , just after modeling (t0) , and 2 h (t2) , 4 h (t4) , 6 h (t6) and 8 h (t8) after trearment. Needle biopsies of lung tissue were made before modeling and at t0 and t8 and prepared for microscopy observation after Hematoxylin- eosin staining method (HE staning). Repeated measurement data were compared among repeated measures by the ANOVA and the difference between groups was compared by one-wey ANOVA. Results (1) The HR and MAP of all animals increased obviously while the oxygenation index declined significantly at modeling just made (t0) compared to those before modeling (all P 0.05). (2) The ELWI and PVPI of all animals increased obviously at modeling just made (t0) compared to those before modeling (all P <0.05). The ELWI and PVPI were decreased after treatment. And at the same time, the ELWI and PVPI of A and B groups were significantly lower than those of C group after treatment (all P <0.05). (3) The alveolar tissue showed obviously injured changes at modeling just made (t0). The injury was relieved 8h after trearment, which was most markedly in group C. Conclusions With the combination of 6% hydroxyethyl starch 130/ 0.4 and furosemide administered, the acute lung injury induced by paraquat poisoning can be effectively relieved, promoting gas exchange, and improve oxygenation. Key words: Paraquat; Acute lung injury; 6% hydroxyethyl starch 130/ 0.4; Furosemide; Pulse indicates continuous cardiac output monitoring; Extravascular lung water index; Pulmonary vascular permeability index; Oxygenation index

Prognostic value of Picco monitoring combined with plasma microRNA-150 detection in septic shock patients

To assess the prognostic value of pulse indicator continuous cardiac output (Picco) monitoring combined with plasma microRNA-150 detection in septic shock patients. Clinical data of 48 patients with septic shock admitted in General Intensive Care Unit (GICU), Shanghai First People's Hospital Songjiang Branch Affiliated to Shanghai Jiaotong University from August 2012 to August 2014 were analyzed retrospectively. The plasma levels of microRNA-150 in 48 patients at admission were assayed by qRT-PCR; and Picco monitoring was performed to record hemodynamic changes. The correlation of microRNA-150 or Picco parameters with prognosis of patients was assessed by univariate analysis and multivariate logistic analysis. Spearman correlation test showed the relationship between microRNA-150 and Picco parameters. Finally, the clinical value of combining microRNA-150 with Picco monitoring to predict the outcome of septic shock patients was analyzed by ROC curves. Twenty-three patients survived and 25 died in 28 d after admission in GICU. Compared with survival patients, microRNA-150 was significantly lower in fatal patients (t=-10.32, P<0.05). Univariate analysis showed that low microRNA-150 level was a risk factor for poor prognosis(OR=2.176,95% CI:1.121-4.223, P<0.05). Compared with fatal cases, the cardiac index of survival patients was higher, while EVLWI and PVPI were lower. MicroRNA-150 level was positively correlated with cardiac index (r=0.712, P<0.05), negatively correlated with EVLWI and PVPI (r=-0.622 and-0.689, both P<0.05). ROC curves showed a satisfactory diagnostic efficiency of combining microRNA-150 with Picco monitoring. Lower microRNA-150 may indicate a poor prognosis, and Picco monitoring combined with microRNA 150 detection may improve the prognostic efficiency in septic shock patients.

Investigation on the predictive value of the dynamic changes of EVLWI and PVPI on the prognosis of ARDS patients

To investigate the dynamic changes of extra vascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) on the prognosis of acute respiratory distress syndrome (ARDS), and predict the risk factors affecting prognosis of ARDS. 70 patients meeting ARDS Berlin definition, who were admitted to the ICU from July 2012 to July 2014, were analyzed with a prospective method. The patients were divided into a survival group and a death group according to their survival situation in 28 days. EVLWI (EVLWI1-EVLWI4), PVPI (PVPI1-PVPI4), DeltaEVLWI (subtracting EVLWI day 4 from day 1), and DeltaPVPI (subtracting PVPI day 4 from day 1) of the two groups of patients from the 1st day to the 4th day were monitored by the pulse indicator continuous cardiac output (PiCCO). Parameters including the acute physiology and chronic health evaluation (APACHE II) score, sequential organ failure assessment (SOFA) score, EVLWI, PVPI, DeltaEVLWI, DeltaPVPI, oxygenation index (OI), CVP, the number of organ dysfunction were compared between the two groups. Univariate analysis and multivariate logistic regression were used to analyze the independent risk factors associated with prognosis. Receiver operating characteristic curve (ROC curve) was drawn to evaluate the prediction performance of those risk factors in the prognosis of ARDS. Comparison of EVLWI and PVPI between the survival group and the death group of ARDS patients at different time points: EVLWI and PVPI showed no statistical difference from the 1st day to the 2nd day after admission, but those two parameters in the death group were higher than those in the survival group form the 3rd day to the 4th day after admission (P<0.01). The comparison of the dynamic changes of EVLWI and PVPI within the two groups: the EVLWI and PVPI in the survival group declined gradually from 1st day to 4th day after treatment, but that changing trend in the death group showed no statistical difference. DeltaEVLWI and DeltaPVPI changes in the survival group were higher than in the death group (P<0.01). They were independent risk factors of patients 28-day prognosis (P<0.05). ROC curve and 28-day survival curve showed that the area under ROC curve of DeltaPVPI predicting prognosis of patients with ARDS was 0.812, when the optimal cut off value was 1.2, and the median survival period in DeltaPVPI>1.2 group was longer than that in the Delta PVPI≤1.2 group. The continuous dynamic observation of EVLWI and PVPI changes is better than that of a single detection. DeltaEVLWI and DeltaPVPI are independent risk factors and can be used as an auxiliary indicator for the prognosis of patients with ARDS.

The influence of continuous venovenous hemofiltration on parameter measurement by the transpulmonary thermodilution technique

To evaluate the influence of continuous venovenous hemofiltration (CVVH) on measurement of transpulmonary thermodilution parameters. A prospective observational study was conducted. Fifty-six patients who received CVVH and hemodynamic monitoring at the same time admitted to the Department of Critical Care Medicine of Tianjin Third Central Hospital from July 2012 to July 2014 were enrolled. In all the patients, the dialysis catheter was inserted through the femoral vein, and transpulmonary thermodilution measurements were performed by pulse indicator continuous cardiac output (PiCCO) monitoring technology at the same time. Mean arterial pressure (MAP), central blood temperature, cardiac index (CI), global end-diastolic volume index (GEDVI), intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI) were measured before CVVH, immediately after CVVH, and 30 minutes after CVVH, respectively. Results In the 56 patients, there were 36 males and 20 females, (66 ± 16) years of old, height of (172 ± 6) cm, body weight of (68 ± 10) kg. The acute physiology and chronic health evaluation II (APACHE II) scores was 26 ± 6. After CVVH, the central blood temperature was gradually decreased, and blood temperature at 30 minutes after CVVH was significantly lower than that before CVVH (degrees C : 37.17 ± 1.06 vs. 37.57 ± 1.26, P < 0.01). There were no significant changes in MAP and EVLWI before and after CVVH the MAP was (89 ±20), (86 ± 16), (90 ± 17) mmHg ( 1 mmHg = 0.133 kPa) at three time points respectively, and EVLWI was (9.4 ± 3.2, (9.3 ± 3.0), (9.4 ± 2.9) mL/kg, respectively. After CVVH, CI, GEDVI and ITBVI showed a gradual downward tendency. Compared with those before CVVH, the decline of CI, GEDVI, and ITBVI immediately after CVVH was not statistically significant [CI (mL x s (-1) x m(-2): 62.18 ± 24.34 vs 63.85 ± 21.84, GEDVI (mL/m2): 705 ± 103 vs 727 ± 100, ITBVI (mL/m2): 881 ± 129 vs 908 ± 125, all P > 0.05]. CI, GEDVI, ITBVI at 30 minutes after CVVH were significantly decreased [CI mL x s(-1) x m(-2)): 57.84 ± 20.50 vs 63.85 ± 21.84, GEDVI (mL/m2): 681 ± 106 vs. 727 ± 100, ITBVI (mL/m2): 851 ± 133 vs. 908 ± 125, all P < 0.05]. CVVH was associated with a decline of 6.01 mL x s(-1) x m(-2) at 30 minutes after CVVH [95% confidence interval (95% CI)) = -10.67 to -1.50, P = 0.011]. The declines of GEEDVI and ITBVI were observed with 46 mL/m2 (95% CI = -81 to - 11, P = 0.014), 57 mL/m2 (95% CI = -101 to -13, P = 0.014) respectively 30 minutes after CVVH. CVVH had no significant effect on the transpulmonary thermodilution measurement of CI, GEDVI, ITBVI and EVLWI. Thirty minutes after the start of CVVH, CI, GEDVI was decreased significantly, but had no effect on EVLWI.

The clinical effects of pulse indicator continuous cardiac output in goal-optimized fluid management on patients with acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

Objective To investigate the clinical effects of the pulse indicator continuous cardiac output (PiCCO) in goal-optimized fluid management on patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with respiratory failure. Methods A total of 71 AECOPD patients with respiratory failure who were hospitalized in department of Critical Care Medicine in our hospital were selected from October 2010 to September 2013. The PiCCOtechnology was applied to monitor intrathoracic blood volume index (ITBI) and extravascular lung water index (ELWI). We compared the relationship of ELWI with ITBI and oxygenation index, and a simple correlation analysis was used for statistical analysis. Results A significantly negative correlation was found between ELWl and oxygenation index (r=–0.743, P<0.01). ELWI=14 ml/kg was defined as the cutoff value for the subgroup analysis. A negative correlation still was found between ELWI and oxygenation index in the subgroup with ELWI<14 ml/kg, but it had no significant difference (r=–0.533, P=0.080), while a significantly negative correlation was found in the subgroup with ELWI≥14 ml/kg (r=–0.961, P<0.01). There was no significant correlation between ELWI and ITBI (r=0.477, P=0.072). ITBI=1 000 ml/m2 was defined as the cutoff value for the subgroup analysis. There is no significant correlation between ELWI and ITBI in the subgroup with ITBI<1 000 ml/m2 (r=0.338, P=0.116), but in the subgroup with ITBI≥1 000 ml/m2, a significantly positive correlation between ELWI and ITBI was found (r=0.677, P<0.01). Conclusions The results suggest that when ELWI is higher than 14 ml/kg, ELWI becomes an important influencing factor for oxygenation, which can be decreased to improve oxygenation in patients with AECOPD, and when ITBI≥1 000 ml/m2, ITBI can be reduced by decreasing ELWI. PiCCO has an important clinical significance on a goal-optimized fluid management in AECOPD patients with respiratory failure. Key words: Cardiac output; Pulmonary disease, chronic obstructive Respiratory failure; Fluid management

Clinical feature of severe hand, foot and mouth disease with acute pulmonary edema in pediatric patients

To explore the clinical feature of severe hand, foot and mouth disease (HFMD) in pediatric patients, and to observe the hemodynamic changes in those with acute pulmonary edema. A prospective observation study was conducted. Thirty-five severe HFMD pediatric patients with acute pulmonary edema admitted to the intensive care unit (ICU) and Department of Pediatric of First People's Hospital of Foshan from May 2008 to September 2014 were enrolled. The clinical features were thoroughly investigated. Hemodynamic data were monitored by pulse-indicated continuous cardiac output (PiCCO) in 5 cases, and the changes in PiCCO parameters were observed at ICU admission (0 hour), and 24, 48, 96 hours after treatment. Thirty-five patients who met the diagnostic standard of severe HFMD were enrolled, including 22 male and 13 female, aged from 7 months to 4 years. Six patients were younger than 1 year, 13 1-2 years, 12 2-3 years, and 4 patients 3-4 years old. The most common time of occurrence of pulmonary edema was 3-4 days after the onset of the disease. Fever and central nervous system symptoms were found in all the patients, and examination of the cerebral spinal fluid (CSF) revealed non-bacterial inflammatory changes. PiCCO results showed a tendency of lowering of heart rate (HR), systemic vascular resistance index (SVRI), and extravascular lung water index (EVLWI) after the treatment, and the values obtained at 96 hours were significantly lower than those at 0 hour [HR (bpm): 119.0±14.7 vs. 200.8±19.7, SVRI (kPa×s×L(-1)×m(-2)): 148.9±14.6 vs. 209.6±58.7, EVLWI (mL/kg): 10.5±1.9 vs. 34.8±10.8, P<0.05 or P<0.01], global end-diastolic volume index (GEDVI) was also gradually decreased without significant differences among all the time points, together with a tendency of increase in stroke volume index (SI) and cardiac index (CI). The values of the parameters at 96 hours were significantly higher than those at 0 hour [SI (mL/m2): 38.5±6.5 vs. 17.4±2.8, CI (mL×s(-1)×m(-2)): 75.0±8.0 vs. 55.5±8.5, both P<0.01]. Left atrium was found to be enlarged, and left ventricular systolic function decreased in two patients by cardiac ultrasonic. Four out of 35 patients died, and functional disability of extremities was found in 1 patient. Other patients were cured and discharged without any sequelae. Severe HFMD complicated by acute pulmonary edema is a perilous condition in children, accompanied commonly by pathologic changes in central nervous system and systolic dysfunction of left ventricle. According to the results with PiCCO monitoring, HFMD patients suffering from acute pulmonary edema may be of cardiac origin in addition to neurogenic origin.

Central venous pressure in combination with visual left ventricular ejection fraction as an indicator of fluid responsiveness in patients with septic shock

Objective To investigate the value of central venous pressure(CVP) combined with visual left ventricular ejection fraction(LVEF)as an indicator of fluid responsiveness in patients with septic shock. Methods A retrospective analysis of 83 patients with septic shock receiving fluid challenge was conducted. The hemodynamic changes were evaluated with the pulse indicator continuous cardiac output (PiCCO) monitor, and all the patients were divided into two groups: the responded group(△CI% ≥ 15%)and the unresponded group(△CI < 15%), according to the change in CI(△CI%). Those patients were divided into several subgroups, including low CVP group(CVP < 8 mmHg) and high CVP group(CVP ≥ 8 mmHg), low LVEF group(LVEF < 50%) and high LVEF group(LVEF ≥ 50%), according to the initial value of CVP and LVEF. The changes in hemodynamic variables were compared before and after fluid challenge in each subgroup. The ability of CVP and visual LVEF was evaluated to predict fluid responsiveness with receiver operating characteristic curves. Results Fifty three (63.9%)patients responded to the fluid challenge, and lower CVP and higher LVEF patients were more frequency in responded group. The threshold value of 8 mmHg CVP for prediction of fluid responsiveness revealed the area under the curve (AUC) of 0.646(P=0.219), and 50% visual LVEF revealed AUC of 0.729(P=0.023). CVP in combination with visual LVEF for prediction of fluid responsiveness showed an AUC of 0.817 (P=0.001) with a sensitivity of 76.3% and a specificity of 88.2%. Conclusions Visual LVEF alone and combined with CVP can be used as an indicator of fluid responsiveness in patients with septic shock. Key words: Central venous pressure; Heart ventricles/US; Ventricular function, left; Stroke volume; Shock/DI/PP; Hemodynamics

Hemodynamic Changes in Patients Undergoing Pericardiectomy.

To observe the hemodynamic changes in patients undergoing pericardiectomy at different operational stages. Totally 16 consecutive patients receiving radical pericardiectomy were enrolled in this observational study. Hemodynamic variables were monitored continuously by pulse-indicated continuous cardiac output(PiCCO)system. Totally,three sets of intraoperative hemodynamic parameters were obtained at three different stages of pericardiectomy. During the pericardiectomy,the cardiac index[CI,(1.9±0.6),(2.7±0.6),(3.0±0.5)L·min(-1)·m(-2);P<0.05]and stroke volume index[SI,(22.5±8.7),(29.9±8.5),(30.1±8.5)dyn·s·cm(-5)·m(2);P<0.05]showed significant improvement,whereas central venous pressure[CVP,(17.1±5.0),(13.3±3.9),(12.3±3.0)mmHg;P<0.05]decreased significantly. Global end-diastolic volume index[GEDVi,(533±156),(580±153),(559±144)ml·m(-2);P<0.05]increased and stroke volume variation[SVV,(15.6±6.1)%,(10.8±4.2)%,(9.4±5.4)%;P<0.05]decreased intra-operatively. The majority of the above-mentioned hemodynamic improvements occurred after the resection of pericardium over the left ventricular outflow tract(LVOT). PiCCO system can serve as a reliable,less invasive hemodynamic monitoring method during pericardiectomy. Resection of the pericardium over the LVOT is the most important step of the pericardiectomy.

Correlation of severity classification of acute respiratory distress syndrome by the Berlin definition with extra vascular lung water index and pulmonary vascular permeability index

To explore the correlation of severity classification of acute respiratory distress syndrome (ARDS) by the Berlin definition with extra vascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). A total of 70 cases with ARDS at intensive care unit of our hospital from July 2012 to July 2014 were divided into three groups of mild (n = 20), moderate (n = 30) and severe (n = 20) according to the Berlin definition. The scores of acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) within 24 h of admission were recorded. And the values of EVLWI and PVPI of three groups from Day 1-4 were monitored by pulse indicator continuous cardiac output (PiCCO). Receiver operating characteristic (ROC) curve was drawn for these parameters and the area under curve was compared. Meanwhile blood gas was analyzed and oxygenation index (OI) calculated. And the correlations of EVLWI and PVPI with OI were analyzed. Comparisons of EVLWI, PVPI and OI were made for three groups at different timepoints: As the severity of ARDS aggravated, EVLWI and PVPI of three groups increased significantly at any timepoint while OI decreased sharply (P < 0.05). EVLWI and PVPI declined gradually from Day 1-4 in mild ARDS group (P < 0.05), PVPI declined dramatically (P < 0.05) while EVLWI showed no obvious change in moderate ARDS group (P > 0.05). There was no sharp decline of EVLWI or PVPI in severe ARDS group (P > 0.05). And OI increased significantly from Day 1-4 in three groups (P < 0.01). The area under ROC curve (AUC) for PVPI in evaluating the prognosis of three groups was 0.594, 0.643, 0.723 and 0.816 respectively. PVPI > 2.95 at Day 4 of admission was used as the best threshold value for judging prognosis. And the sensitivity was 70% and specificity 92%. OI had negative correlation with EVLWI and PVPI in three groups from Day 1-4 [(r = -0.685, P = 0.000) and (r = -0.631, P = 0.000)]. Both EVLWI and PVPI reflect adequately the severity of ARDS by the Berlin definition. And the dynamic trend of PVPI is superior to that of EVLWI.

Improved sepsis bundles in the treatment of septic shock: a prospective clinical study

BackgroundSepsis bundles can decrease mortality in patients with severe sepsis or septic shock. However, current methods of measuring pressure, such as central venous pressure, are inadequate. This study investigated the effect of improved sepsis bundles informed by pulse-indicated continuous cardiac output. MethodsWe compared the outcome of treatment with sepsis bundles informed by either conventional pressure measurements or pulse-indicated continuous cardiac output. Patients in 2 groups received fluid resuscitation, standard antibiotics, and oxygen therapy. ResultsA total of 105 patients with septic shock were randomly divided into 2 groups: the conventional sepsis bundle group (n = 52) or the improved sepsis bundle group (ISBG, n =53). The ISBG significantly reduced the mean Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment scores. Significantly fewer ISBG-treated patients received vasoactive drugs compared to conventional sepsis bundle group–treated patients. In addition, patients in the ISBG exhibited a significantly increased arterial blood lactate clearance rate and required less total fluid resuscitation and a shorter duration of mechanical ventilation and stay in the intensive care unit. ConclusionsPulse-indicated continuous cardiac output–directed sepsis bundles can reduce the severity of septic shock, provide more accurate fluid resuscitation, and reduce the duration of mechanical ventilation and stay in the intensive care unit.

Significance of extravascular lung water in fluid management for patients with acute exacerbation of chronic obstructive pulmonary disease

Objective To explore the correlations of extravascular lung water index (ELWI), oxygenation index and intrathoracic blood volume index (ITBI) in patients with acute exacerbation chronic obstructive pulmonary disease (AECOPD) and examine the significance of ELWI in fluid management. Methods A total of 63 hospitalized AECOPD patients with respiratory failure were recruited from our hospital from October 2010 to April 2013. Pulse indicator continuous cardiac output (PiCCO) technology was employed to monitor ITBI and ELWI. We compared the relationship of ELWI, ITBI and oxygenation index. And simple correlation analysis was used for statistical processing. Results Significant negative correlation existed in ELWI and oxygenation index (r=-0.741, P<0.01). ELWI 14 ml/kg was defined as a cutoff value for subgroup analysis. A negative correlation existed between ELWI and oxygenation index in the subgroup with ELWI<14 ml/kg, but there was no significant difference (r=-0.524, P=0.080); in the subgroup with ELWI≥14 ml/kg, there was significant negative correlation (r=-0.952, P<0.01). No significant correlation existed between ELWI and ITBI (r=0.477, P=0.072). ITBI 1 000 ml/m2 was defined as a cutoff value for subgroup analysis. No significant difference existed in the subgroup with ITBI<1 000 ml/m2(r=0.332, P=0.117). However, significant positive correlation existed in the subgroup with ITBI≥1 000 ml/m2 (r=0.677, P<0.01). Conclusion Excessive extravascular lung water is an important factor for acute exacerbation of COPD leading to respiratory failure. Key words: Extravascular lung water; Pulmonary disease, chronic obstructive; Fluid management

Value of extravascular lung water lndex in assessment of prognosis of elderly patients with combined septic shock and pulmonary capillary leakage

Objective To investigate the value of extravascular lung water index(EVLWI) in assessment of prognosis of elderly patients with combined septic shock and pulmonary capillary leakage. Methods Totally 34 elderly patients with septic shock and pulmonary capillary leakage in our hospital from Jan. 2011 to Dec. 2012 were selected. Cardiac index (CI), global end diastolic volume index (GEDI), systemic vascular resistance index (SVRI), pulmonary vascular permeability index (PVPI) and EVLWI were detected by pulse-indicator continuous cardiac output (PiCCO) technology for 3 days. Based on the actual body weight (ABW) and predicted body weight (PBW), the actual extravascular lung water index and predicted extravascular lung water index were calculated. Peak airway pressure (Ppeak), plateau pressure (Pplat), mean airway pressure (Pm), tidal volume (VT), positive end expiratory pressure (PEEP), oxygen concentration (FiO2) and static lung compliance (Cst) were monitored, the arterial partial pressure of oxygen (PaO2) was detected by blood gas analysis, and the PaO2/FiO2 (P/F) and oxygenation index (OI) were calculated. Chest X-ray, lung injury score (LIS) were conducted. The correlations of EVLWI to actual body weight (EVLWIa) and predicted body weight(EVLWIp) with P/F, Cst and LIS were analyzed. The predictive value of EVLWIa and EVLWIp in the prognosis in elderly patients with septic shock and pulmonary capillary leakage was assessed. Results At day 1, non-survivors had higher levels of SOFA score and lactate level than survivors (both P 0.05. Multiple logistic regression analysis showed that SOFA, EVLWa and EVLWp were independent predictive risk factors for mortality in elderly patients with septic shock and pulmonary capillary leakage. The areas under the receiver operating characteristic curve (ROC) of SOFA, EVLWIa and EVLWIp for predicting the prognosis were 0.769, 0.832 and 0.855 respectively. With 11.96ml/kg as the cutoff point of EVLWIp, the sensitivity and specificity of EVLWIp predicting the survival of patients was 94.4% and 61.5% respectively. Conclusions Extravascular lung water can predict the prognosis and reflect the severity of lung injury in elderly patients with septic shock and pulmonary capillary leakage. Compared with EVLWIa, the EVLWIp has a better correlation with lung injury and a higher predictive value for survival. Key words: Extra vascular lung water; Infection; Shock; Prognosis; Capillary leak syndrome

Increased cardiac index attenuates septic acute kidney injury: a prospective observational study.

BackgroundThe relationship between cardiac output and septic acute kidney injury (AKI) remains unclear. The purpose of this study was to assess the association between the cardiac index (CI) and the renal outcomes in patients with septic shock.MethodsA one-year prospective cohort study was performed in the surgical and medical ICU of a teaching hospital in Nanjing, China. Twenty-nine septic shock patients who required early goal-directed fluid resuscitation were consecutively included. Pulse indicator continuous cardiac output (PiCCO) device was used to measure hemodynamic parameters before and after early goal-directed therapy (EGDT). Based on CI changes after EGDT, patients were assign to the CI increased group or the CI constant group, respectively. The incidence of poor renal outcome, which was defined as AKI on admission without recovery in following three days or new onset AKI within 28 days, was recorded. We investigated whether an increased CI was associated with a better renal outcome.ResultsAfter EGDT, there were 16 patients in the CI increased group and 13 patients in the CI constant group. The incidence of poor renal outcome was lower in CI increased group than in the CI constant group (6% vs. 62%; P = 0.003) with a relative risk of 0.10. The logistic regression showed that the CI percent change was associated with renal outcome, with an odd ratio of 0.003 (P = 0.056) after adjustment of possible confounding factors. The CI percent change would predict a good renal outcome (AU ROC 0.739, P = 0.012) with moderate accuracy (sensitivity 75% and specificity 89%) when using a 10% cut-off value from Youden index. The CI percent change was also positively correlated with creatinine clearance (CCr) after EGDT (ρ = 0.548; P = 0.002).ConclusionsThe increased CI after EGDT was a protective factor for kidney in patients with septic shock. A CI increased above 10% could be potentially used to predict development and reversibility of AKI in septic shock patients.Trial registrationClinicaltrials.gov:NCT01862588 (May 13, 2013).

The effect of anticoagulant therapy on coagulation and inflammation markers in sepsis patients and its significance

To study the effect of anticoagulant therapy with low molecular weight heparin (LMWH) on coagulation and inflammation markers in sepsis patients. A prospective randomized controlled trial ( RCT ) was conducted. Eighty-seven patients suffering from septic shock undergoing mechanical ventilation in Department of Critical Care Medicine of Subei People's Hospital from June 2012 to September 2014 were enrolled. The hemodynamic changes before and after PLR were monitored by pulse indicated continuous cardiac output ( PiCCO ) and PVI monitoring. Responsive group: positive fluid response was defined as an increase in cardiac index ( CI )≥10% after PLR. Unresponsive group: negative fluid response was defined as an increase in CI<10% after PLR. The hemodynamic parameters, including heart rate ( HR ), mean arterial pressure ( MAP ), central venous pressure ( CVP ), stroke volume variation ( SVV ), CI and PVI, and the changes in cardiac parameters (ΔHR, ΔMAP, ΔCVP, ΔSVV, ΔCI, and ΔPVI ) before and after PLR were determined. The relations between hemodynamic parameters and their changes with ΔCI were analyzed by the Pearson analysis. The role of the parameters for volume responsiveness prediction was evaluated by receiver operating characteristic ( ROC ) curves. There were no significant differences in values of all parameters, including CD62p, D-dimmer, IL-6, TNF-α, and APACHE II score at 1 day of treatment. The values of all parameters in observation group were gradually decreased. CD62p at 3 days of treatment and D-dimmer, IL-6, TNF-α, and APACHE II score at 5 days of treatment were significantly lower than those at 1 day of treatment. The values in the control group were decreased at first and then increased, as D-dimmer, IL-6 and TNF-α were significantly higher on the 5th day than those at 1 day of treatment. Compared with control group, CD62p, D-dimmer, IL-6, TNF-α and APACHE II score on the 7th day of treatment were significantly lowered in observation group [CD62 (μg/L): 22.64±2.88 vs. 31.52±2.81, D-dimmer (g/L): 1.32±0.46 vs. 4.79±0.82, IL-6 (ng/L): 5.84±1.87 vs. 49.64±3.12, TNF-α (ng/L): 21.04±3.15 vs. 130.58±6.26, APACHE II score: 9.71±2.02 vs. 14.17±2.38, all P < 0.05]. Correlation analysis showed that in observation group, CD62p, D-dimmer, IL-6, and TNF-α were positively correlated with APACHE II score (r value was 0.907, 0.868, 0.880, 0.693, respectively, all P=0.000). The incidence of MODS in observation group was significantly lower than that in the control group [26.7% (8/30) vs. 46.7% (14/30), χ (2)=3.943, P = 0.028]. LMWH, which was given early in sepsis, can significantly down-regulate the expression of CD62p, D-dimmer, IL-6 and TNF-α, and reduce the incidence of MODS. Some indicators regarding coagulation and inflammation can be used as supplementary indicators to severity scores, and it may be able to improve the accuracy of scoring systems for sepsis.