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ITU Journal Club:. Dr. Clinton Jones. ST4 Anaesthetics. Haemodynamic monitoring: “ optimise tissue oxygenation and help prevent multiorgan failure “. Central Haemodynamic monitoring: PAC LIDCO PICCO ODM USCOM TTE TOE CVP. Peripheral Haemodynamic monitoring: Microcirculation
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ITU Journal Club:Dr. Clinton Jones.ST4 Anaesthetics.Haemodynamic monitoring:“optimise tissue oxygenation and help prevent multiorganfailure “Central Haemodynamic monitoring:
  • PAC
  • LIDCO
  • PICCO
  • ODM
  • USCOM
  • TTE
  • TOE
  • CVP
  • Peripheral Haemodynamic monitoring:
  • Microcirculation
  • Gastric tonometry
  • Sublingual capnography
  • Tissue oximetry
  • Mixed venous or central venous oxygen saturations.
  • 2009 JICS Debate: CO monitoring in ITUIntensivists shouldn’t use CO monitoring:
  • It doesn’t make patients better.
  • All monitoring offers patients risk for no clear benefit.
  • Distracting and delays or prevents effective interventions – outcome from sepsis is time related.
  • Expensive
  • No evidence exists to show clinicians interpret data and alter clinical therapy correctly.
  • EGDT in sepsis works and does not require measurement of CO.
  • Debate continues:Intensivists should use cardiac output monitoring:
  • Fluid resuscitation and inotropic support is always performed with specific aims in mind.
  • Patient & physician specific early goal directed therapy.
  • To prevent excessive use of fluids and inotropes and subsequent harmful effects.
  • Cochrane Review: Pulmonary artery catheters for adult patients in intensive care (Review) 2013 The Cochrane Collaboration. Rajaram SS, Desai NK, Kalra, Gajera M et al. 2013, Issue 2. Does the use of PAC in ICU lead to increased mortality, hospital or ICU LOS and cost?Objective:To provide an up-to-date assessment of the effectiveness of a PAC on:Primary outcomes:
  • All types of hospital mortality (28 days, 30 days, 60 days or ICU mortality).
  • Secondary outcomes:
  • LOS in ICU
  • LOS in hospital
  • Cost of hospital care
  • Search Methods:
  • Cochrane Central Register of Controlled Trials
  • MEDLINE (1954 – 2012)
  • EMBASE (1980 – 2012)
  • CINAHL (1982 – 2012)
  • Liaised with industry
  • Contacted key people in the field of critical care
  • Selection criteria:
  • Included all RCT’s conducted in adults (16 years and over) ICU’s, comparing management with and without a PAC.
  • Screened titles, abstracts and then full texts from an electronic search.
  • Two authors independently reviewed reports. Final reports included in paper after consensus agreement.
  • Domains for potential risk of bias were identified and assessed:
  • Selection bias
  • Performance bias
  • Detection bias
  • Attrition bias
  • Reporting bias
  • Data Collection:
  • Included 13 RCT’s.
  • Total number of patients 5686.
  • All patients admitted to ICU and randomised to PAC or control group (+/- CVC line).
  • RESULTSCombined Mortality:n=5686, p = 0.73, RR 1.01LOS:
  • General ICU LOS
  • 4 studies with n=2723 assessed.No significant difference detected.
  • ICU LOS: High risk surgery
  • Heterogeneity high and meta-analysis not appropriate.
  • Hospital LOS
  • Overall 9 studies reported hospital LOS.2 studies, n=1689.Management with vs without PAC (p=0.30).Cost:
  • 4 studies collected data on cost.
  • All conducted in US.
  • Only total costs was analysed in this review.
  • Cost for PAC group was demonstrated higher than for CVC group.
  • However only 2 studies qualified for analysis (n=191) and no significant differences was shown.
  • Quality of Evidence:
  • Mortality outcome is robust.
  • Hospital and ICU LOS is high.
  • Cost analysis low.
  • Conclusions:
  • Current evidence is a review of all available RCTs to date.
  • Use of PAC does not increase mortality, ICU LOS or hospital LOS.
  • Shock reversal, improvement in organ dysfunction and less vasopressor use are outcome measures needed to be studied.
  • Further research assessing PAC with goal directed therapy protocols is required.
  • Implications for practice:
  • PAC is a safe diagnostic and monitoring tool, not a treatment intervention.
  • Prior to reintroducing PAC further training is needed.
  • Further studies are needed to determine optimal PAC management protocols for specific ICU patients.
  • Early insertion of PAC in the management of sepsis may offer the greatest benefit – further study required.
  • PAC haemodynamicsare best assessed in combination with the inclusion of clinical indices of perfusion.
  • Future Research:
  • In light of the findings of this paper it should now be possible to examine protocol specific management with a PAC in selected groups of critically ill patients against appropriate controls.
  • Many Thanks.Any questions?
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