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Contains fulltext : 248807.pdf (Publisher’s version ) (Open Access) Thermodilution cardiac output monitoring, using a thermistor-tipped intravascular catheter, is used in critically ill patients to guide hemodynamic therapy. Often, these patients also need magnetic resonance imaging (MRI) for diagnostic or prognostic reasons. As thermodilution catheters contain metal, they are considered MRI-unsafe and advised to be removed prior to investigation. However, removal and replacement of the catheter carries risks of bleeding, perforation and infection. This research is an in vitro safety assessment of the PiCCO™ thermodilution catheter during 3 T Magnetic Resonance Imaging (3T-MRI). In a 3T-MRI environment, three different PiCCO™ catheter sizes were investigated in an agarose-gel, tissue mimicking phantom. Two temperature probes measured radiofrequency-induced heating; one at the catheter tip and one at a reference point. Magnetically induced catheter dislocation was assessed by visual observation as well as by analysis of the tomographic images. For all tested catheters, the highest measured temperature increase was 0.2 °C at the center of the bore and 0.3 °C under "worst-case" setting for the tested MRI pulse sequences. No magnetically induced catheter displacements were observed. Under the tested circumstances, no heating or dislocation of the PiCCO™ catheter was observed in a tissue mimicking phantom during 3T-MRI. Leaving the catheter in the critically ill patient during MRI investigation might pose a lower risk of complications than catheter removal and replacement.

Contains fulltext : 229420.pdf (Publisher’s version ) (Closed access)

Background Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. Methods Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature—a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. Results Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached “strong agreement,” 20 “weak agreement,” and 2 had “no agreement.” Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. Conclusions These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.

In 2001, the Surviving Sepsis Campaign (SSC) began to develop evidence-based guidelines and recommendations for the resuscitation and management of patients with sepsis. With the 2016 edition, the Society of Critical Care Medicine and European Society of Intensive Care Medicine recommended a separate task force be dedicated to guideline formulation for children. The objective of the “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children” is to provide guidance for the care of infants, children, and adolescents with septic shock and other sepsis-associated organ dysfunction. Recommendations are intended to guide “best practice” rather than to establish a treatment algorithm or to define standard of care and cannot replace the clinician's decision-making capability when presented with a patient's unique set of clinical variables.

Contains fulltext : 230013.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS: The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS: A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research. 01 februari 2020

Item does not contain fulltext AIM: Comparing the effects of different vasopressors in septic shock patients is hampered by high heterogeneity and the fact that current guidelines dictate the use of norepinephrine. Herein, we studied the effects of three vasopressor agents, norepinephrine, phenylephrine, and vasopressin, on the macro- and microcirculation during experimental human endotoxemia, a standardized, controlled model of systemic inflammation in humans in vivo. METHODS: We performed a randomized controlled study in which 40 healthy male volunteers were assigned to a 5-h infusion of either 0.05 mug/kg/min norepinephrine (n = 10), 0.5 mug/kg/min phenylephrine (n = 10), 0.04 IU/min vasopressin (n = 10), or saline (n = 10), starting 1 h before intravenous administration of 2 ng/kg lipopolysaccharide (LPS). The macrocirculation was monitored using arterial catheter-derived parameters with additional blood pressure waveform contour analysis (PCA) until 4.5 h following LPS administration. Sublingual microcirculatory density and flow were assessed using a handheld video microscope until 6 h post-LPS. RESULTS: LPS administration affected all macrocirculatory and microcirculatory parameters. The LPS-induced decrease in blood pressure and systemic vascular resistance (SVR) was refractory to low-dose norepinephrine and phenylephrine, and to a lesser extent, to vasopressin. Only vasopressin exerted effects on PCA parameters compared with placebo, by mitigating the LPS-induced decrease in diastolic blood pressure by stabilizing SVR and cardiac output. The endotoxemia-induced decreased indices of microvascular flow and density were not influenced by vasopressor therapy. CONCLUSIONS: In a highly controlled model of systemic inflammation in humans in vivo, a 5-h infusion of various vasopressors revealed distinctive effects on macrohemodynamic variables without affecting the sublingual microcirculation.

Item does not contain fulltext The administration of beta-blockers in patients with sepsis is a trending topic in intensive care medicine since the landmark study by Morelli and colleagues, showing a striking decrease in 28-day mortality compared to standard care. While the available evidence suggests that the use of beta-blockers in septic shock is safe, the effects on hemodynamics are controversial. In this paper, we review the effect of beta-blockade in septic shock on hemodynamics from animal models to critically ill patients.

Contains fulltext : 168747.pdf (Publisher’s version ) (Open Access) Increased extravascular lung water (EVLW) may contribute to respiratory failure in neonates. Accurate measurement of EVLW in these patients is limited due to the lack of bedside methods. The aim of this pilot study was to investigate the reliability of the transpulmonary ultrasound dilution (TPUD) technique as a possible method for estimating EVLW in a neonatal animal model. Pulmonary edema was induced in 11 lambs by repeated surfactant lavages. In between the lavages, EVLW indexed by bodyweight was estimated by TPUD (EVLWItpud) and transpulmonary dye dilution (EVLWItpdd) (n = 22). Final EVLWItpud measurements were also compared with EVLWI estimations by gold standard post mortem gravimetry (EVLWIgrav) (n = 6). EVLWI was also measured in two additional lambs without pulmonary edema. Bland-Altman plots showed a mean bias between EVLWItpud and EVLWItpdd of -3.4 mL/kg (LOA +/- 25.8 mL/kg) and between EVLWItpud and EVLWIgrav of 1.7 mL/kg (LOA +/- 8.3 mL/kg). The percentage errors were 109 and 43 % respectively. The correlation between changes in EVLW measured by TPUD and TPDD was r2 = 0.22. Agreement between EVLWI measurements by TPUD and TPDD was low. Trending ability to detect changes between these two methods in EVLWI was questionable. The accuracy of EVLWItpud was good compared to the gold standard gravimetric method but the TPUD lacked precision in its current prototype. Based on these limited data, we believe that TPUD has potential for future use to estimate EVLW after adaptation of the algorithm. Larger studies are needed to support our findings.

Contains fulltext : 153476.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To define near-normal values of extravascular lung water indexed to body weight in children. DESIGN: Prospective multicenter observational study. SETTING: Medical/surgical PICUs of 5 multinational hospitals. PATIENTS: Fifty-eight children with a median age of 4 years (range 1 month to 17 year) with heterogeneous PICU admission diagnoses were included. Extravascular lung water measurements from these children were collected after resolution of their illness. Obtained values were indexed to actual body weight and height and subsequently related to age. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Extravascular lung water indexed to body weight correlated with age (r2 = 0.7) and could be categorized in three-age groups consisting of significantly different median extravascular lung water indexed to body weight values (5th-95th percentile): less than 1 year, 9-29 mL/kg; 1-5 years, 7-25 mL/kg; and 5-17 years, 5-13 mL/kg. Extravascular lung water indexed to height did not correlate to age and resulted in an age-independent near-normal value of less than 315 mL/m. CONCLUSIONS: Younger children have higher values of extravascular lung water indexed to actual body weight. Age categorized near-normal values of extravascular lung water indexed to body weight are presented for possible clinical use. Furthermore, we suggest to index extravascular lung water to height, which seems to be age independent.

Item does not contain fulltext OBJECTIVES: To summarize the physiologic principles underlying the hemodynamic monitoring using the PiCCO device (Pulsion, Munich, Germany) incorporating the transpulmonary thermodilution technique, the pulse contour cardiac output, and estimation of the arterial pressure variation method. Analysis and review of the current literature. DESIGN: A MEDLINE-based literature search using the key words transpulmonary thermodilution, pulse contour analysis, cardiac output, animal models, and child. MEASUREMENTS AND MAIN RESULTS: The bias and precision of cardiac output measured by transpulmonary thermodilution are reliable. The reproducibility for repeated measurements is approximately 5% and the percentage error is approximately 15%. Transpulmonary thermodilution may adequately track changes in cardiac output in animals submitted to hypovolemic conditions and during volume loading. Conversely, data from experimental and clinical studies suggest that continuous monitoring of cardiac output using pulse contour analysis requires careful interpretation because periodic recalibration with transpulmonary thermodilution is necessary. Transpulmonary thermodilution-derived static indicator of cardiac preload (global end-diastolic volume, intrathoracic blood volume) may be more sensitive than conventional measurements of vascular filling pressure. However, the value of stroke volume variation or pulse pressure variation have not been evaluated in pediatric patients. Further studies are needed to determine whether theoretical assumptions underlying the measurement of extravascular lung water are valid in children. CONCLUSIONS: The PiCCO device may be a useful adjunct for hemodynamic monitoring in critically ill children. Further studies are needed to clarify the reliability and clinical value of pulse contour method and extravascular lung water measurement.

Contains fulltext : 69467.pdf (Publisher’s version ) (Closed access) OBJECTIVE: This study was undertaken to validate the transpulmonary thermodilution cardiac output measurement (CO(TPTD)) in a controlled newborn animal model under various hemodynamic conditions with special emphasis on low cardiac output. DESIGN: Prospective, experimental, pediatric animal study. SETTING: Animal laboratory of a university hospital. SUBJECTS: Twelve lambs. INTERVENTIONS: We studied 12 lambs under various hemodynamic conditions. Cardiac output was measured using the transpulmonary thermodilution technique with central venous injections of ice-cold saline. An ultrasound transit time perivascular flow probe around the main pulmonary artery served as the standard reference measurement (CO(UFP)). During the experiment, animals were resuscitated from hemodynamic shock using fluid boluses. Cardiac output measurements were performed throughout the experiment. MEASUREMENTS AND MAIN RESULTS: The correlation coefficient between CO(TPTD) and CO(UFP)was .97 (95% confidence interval .94-.98, p < .0001). Bland-Altman analysis showed a mean bias of 0.19 L/min with limits of agreement of -0.04 and 0.43 L/min (12.0% and +/-14.7%, respectively). The correlation coefficient between changes in CO(TPTD) and CO(UFP) during volume loading was .95 (95% confidence interval .91-.96, p < .0001). There was a significant correlation between changes in global end-diastolic volume and changes in stroke volume (r = .59) but not between changes in central venous pressure and changes in stroke volume (r = .03). CONCLUSIONS: The transpulmonary thermodilution technique is a reliable method of measuring cardiac output in newborn animals. It is also capable of tracking changes in cardiac output.

Contains fulltext : 70798.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To measure the effect of intense neuromuscular blockade (NMB) on oxygen consumption (VO(2)) in deeply sedated and mechanically ventilated children on the first day after complex congenital cardiac surgery. DESIGN: Prospective clinical interventional study. SETTING: Pediatric intensive care unit of an university medical centre. MEASUREMENTS AND RESULTS: Nine mechanically ventilated and sedated children (weight 2.8-8.7 kg) were included. All children were treated with vasoactive drugs. The level of sedation was quantified using the comfort score, Ramsay score and bispectral index (BIS). The intensity of NMB was quantified using acceleromyography and VO(2) was measured using indirect calorimetry. Analgo-sedation using various intravenous agents was targeted at a deep level (comfort score < 18, BIS < 60 and Ramsay score > 4). NMB was achieved by intravenous administration of rocuronium. All measurements were conducted before, during and after recovery from a period of intense NMB. Baseline values were VO(2) 6.1 ml/(kg min) (SD 1.3), comfort score 13 (SD 0.7), BIS 42.5 (SD 14.2), mean blood pressure 54.0 mmHg (SD 10.5), mean heart rate 129.9 bpm (SD 28.9) and mean core temperature 36.7 degrees C (SD 0.5). There were no significant differences in VO(2) or other parameters between baseline, during NMB and the recovery phase. CONCLUSION: Neuromuscular blocking agents do not reduce oxygen consumption in deeply sedated and mechanically ventilated children after congenital cardiac surgery.

Contains fulltext : 137171.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The measurement of extravascular lung water using the transpulmonary thermodilution technique enables the bedside quantification of the amount of pulmonary edema. Children have higher indexed to body weight values of extravascular lung water compared with adults. Transpulmonary thermodilution measurements of extravascular lung water in children have not yet been validated. The purpose of this study was to validate the extravascular lung water measurements with the transpulmonary thermodilution method over a wide range of lung water values in a pediatric animal model. DESIGN: Experimental animal intervention study. SETTING: Animal laboratory at the Radboud University Nijmegen, The Netherlands. SUBJECTS: Eleven lambs. INTERVENTION: Pulmonary edema was induced using a surfactant washout model. MEASUREMENTS AND MAIN RESULTS: Between the lavages, extravascular lung water index was estimated using transpulmonary single and double indicator dilution. Two additional lambs were used to estimate extravascular lung water index in lungs without pulmonary edema. The final extravascular lung water index results were compared with the extravascular lung water index estimations by postmortem gravimetry (EVLWIG). The results were analyzed using both correlation and Bland-Altman statistics. Extravascular lung water index by transpulmonary thermodilution (EVLWITPTD) correlated significantly with either EVLWIG (r = 0.88) or with extravascular lung water index by transpulmonary double indicator dilution (EVLWITPDD) (r = 0.98). The mean bias with EVLWIG was 12.2 mL/kg (limits of agreement +/- 10.9 mL/kg) and with EVLWITPDD 2.4 mL/kg (limits of agreement +/- 3.8 mL/kg). The percentage errors were 41% and 14%, respectively. The bias became more positive when the mean of EVLWITPTD and EVLWIG increased (r = 0.72; p = 0.003). CONCLUSIONS: EVLWITPTD was significantly correlated to the postmortem gravimetric gold standard, although a significant overestimation was demonstrated with increasing pulmonary edema.

Item does not contain fulltext OBJECTIVE: Mechanical ventilation causes cyclic changes in the heart's preload and afterload, thereby influencing the circulation. However, our understanding of the exact physiology of this cardiopulmonary interaction is limited. We aimed to thoroughly determine airway pressure distribution, how this is influenced by tidal volume and chest compliance, and its interaction with the circulation in humans during mechanical ventilation. DESIGN: Intervention study. SETTING: ICU of a university hospital. PATIENTS: Twenty mechanically ventilated patients following coronary artery bypass grafting surgery. INTERVENTION: Patients were monitored during controlled mechanical ventilation at tidal volumes of 4, 6, 8, and 10 mL/kg with normal and decreased chest compliance (by elastic binding of the thorax). MEASUREMENTS AND MAIN RESULTS: Central venous pressure, airway pressure, pericardial pressure, and pleural pressure; pulse pressure variations, systolic pressure variations, and stroke volume variations; and cardiac output were obtained during controlled mechanical ventilation at tidal volume of 4, 6, 8, and 10 mL/kg with normal and decreased chest compliance. With increasing tidal volume (4, 6, 8, and 10 mL/kg), the change in intrathoracic pressures increased linearly with 0.9 +/- 0.2, 0.5 +/- 0.3, 0.3 +/- 0.1, and 0.3 +/- 0.1 mm Hg/mL/kg for airway pressure, pleural pressure, pericardial pressure, and central venous pressure, respectively. At 8 mL/kg, a decrease in chest compliance (from 0.12 +/- 0.07 to 0.09 +/- 0.03 L/cm H2O) resulted in an increase in change in airway pressure, change in pleural pressure, change in pericardial pressure, and change in central venous pressure of 1.1 +/- 0.7, 1.1 +/- 0.8, 0.7 +/- 0.4, and 0.8 +/- 0.4 mm Hg, respectively. Furthermore, increased tidal volume and decreased chest compliance decreased stroke volume and increased arterial pressure variations. Transmural pressure of the superior vena cava decreased during inspiration, whereas the transmural pressure of the right atrium did not change. CONCLUSIONS: Increased tidal volume and decreased chest wall compliance both increase the change in intrathoracic pressures and the value of the dynamic indices during mechanical ventilation. Additionally, the transmural pressure of the vena cava is decreased, whereas the transmural pressure of the right atrium is not changed.

Item does not contain fulltext INTRODUCTION: Nexfin (Edwards Lifesciences, Irvine, CA) allows for noninvasive continuous monitoring of blood pressure (ABPNI) and cardiac output (CONI) by measuring finger arterial pressure (FAP). To evaluate the accuracy of FAP in measuring ABPNI and CONI as well as the adequacy of detecting changes in ABP and CO, we compared FAP to intra-arterially measured blood pressure (ABPIA) and transpulmonary thermodilution(COTD) in post cardiac surgery patients during a fluid challenge (FC). METHODS: Twenty sedated patients post cardiac surgery were included, and 28 FCs were performed. Measurements of ABP and CO were simultaneously collected before and after an FC, and we compared CO and blood pressure. RESULTS: Finger arterial pressure was obtainable in all patients.When comparing ABPNI with ABPIA, bias was2.7 mm Hg (limits of agreement [LOA], +/- 22.2), 4.9 mm Hg (LOA, +/- 13.6), and 4.2 mm Hg (LOA, +/-13.7) for systolic,diastolic, and mean arterial pressure, respectively. Concordance between changes in ABPNI and ABPIA was 100%.Mean bias between CONI and COTD was -0.26 (LOA, +/- 2.2), with a percentage error of 38.9%. Concordance between changes in CONI vs COTD and was 100%. CONCLUSION: Finger arterial pressure reliably measures ABP and adequately tracks changes in ABP. Although CONI is not interchangeable with COTD, it follows changes in CO closely.

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Contains fulltext : 119288.pdf (Publisher’s version ) (Closed access) 01 juli 2013

Extravascular lung water (EVLW) reflects the amount of pulmonary edema and can be measured at the bedside using the transpulmonary thermodilution method (TPTD) incorporated in the PiCCO device (Pulsion, Germany). Currently, normal values of EVLW for the use in children are unavailable. This study was designed to collect near-normal values of EVLW in children after recovery from critical illness.

Dear Editor, In a recent article by Giraud et al. [1] the effect of a left-to-right shunt on the transpulmonary thermodilution (TPTD) curve and the subsequent calculation of extravascular lung water (EVLW) and intrathoracic blood volume (ITBV) are described. The authors conclude that a left-to-right shunt generates recirculation of thermal indicator, which induces a change in the dilution curve. Although we support their observation their explanation may lead to confusion. The transpulmonary thermodilution method must fulfill the following conditions: (1) constant blood flow, (2) no or minimal loss of indicator between injection and detection point, (3) complete mixing of the indicator with blood, and (4) the indicator must pass the detection point only once [2]. To satisfy condition 4, the dilution curve is interrupted at the downslope part based upon a specific algorithm to prevent the effects of recirculation [3]. Subsequently the curve is extrapolated from the interrupted point to the baseline in order to calculate the area under the curve [4]. The cases described by Giraud et al. both had a left-to-right shunt (ventricular septal defect (VSD) and aorto-cava fistula (ACF)). The (pulmonary) “recirculation” that occurs in a left-to-right shunt is an extra “short” circuit. The observed TPTD curve is the result of a delay in delivery of the indicator to the systemic circulation and will subsequently show a lower initial peak, followed by a slow re-approximation to the baseline. Unfortunately the authors do not provide the values of the mean transit time (MTt) and downslope time (DSt), but these numbers are easily deduced from Fig. 1 on page 1,084 [1]. The recalculations are explained in Table 1 and show that the left-to-right shunt induces an increase of both time intervals. The increase of the DSt (51%) is twice the increment of the MTt (25%). Recirculation of the indicator passing the detecting point for a second time is excluded by the fact that true recirculation will not occur before approximately 60 s (≈2 × MTt in the normal situation). This is long after the interruption of the downslope part. Table 1 Recalculations for case 1 Increment of the DSt and, to a lesser extent, of the MTt can also be observed in the presence of a large volume of lung water. Both situations are the consequence of delayed delivery of indicator to the systemic circulation. In conclusion it can be stated that a left-to-right shunt induces an increase in DSt and, to a lesser extent, MTt as a consequence of delayed delivery of indicator to the systemic circulation because of the presence of an extra circuit. This phenomenon should not be confused with true recirculation.

Contains fulltext : 80712.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Measurement of extravascular lung water (EVLW) may be useful in the treatment of critically ill children and can be performed at the bedside using the transpulmonary thermodilution technique (TPTD). There are currently no data to verify the accuracy of these measurements in (small) children. We compared the results of TPTD measurement with the clinical gold standard transpulmonary double indicator dilution (TPDD) measurement in young children. DESIGN: Prospective clinical study in children. SETTING: Catheterization laboratory of a university hospital. PATIENTS AND METHODS: Twelve children (

Contains fulltext : 50966.pdf (Publisher’s version ) (Closed access)

Contains fulltext : 109912.pdf (Publisher’s version ) (Closed access) 01 maart 2012

Intermittent cardiac output measurement using the transpulmonary thermodilution (TPTD) method is considered to be the gold standard in young children but a validated continuous cardiac output technique is not available in these patients. We compared the continuous pulse contour cardiac output (PCCO) measurements with the TPTD method in critically ill children.

Purpose The aim of the present study was to explain why extravascular lung water index (EVLWI) is higher and why global end-diastolic blood volume index (GEDVI) is lower in young children when measured with the PiCCO system (Pulsion, Munich, Germany). Materials and Methods We pooled available data from literature from children concerning organ weight derived from autopsy studies and computed tomographic lung measurements. These data include age, height, body weight, body surface area (BSA), and lung and heart weights. For standard, age-dependent weight and height, we used published data from the World Health Organization. From the available data, we calculated the lung weight–to–body weight ratio, the heart weight–to–BSA ratio, and the end-diastolic volume–to–BSA ratio. We compared these ratios to body growth and development. Results Lung weight develops more slowly and with less magnitude than does body weight. In addition, the (relatively) greater lung weight in younger children results in a higher amount of pulmonary blood volume. This explains the higher EVLWI in young children. End-diastolic blood volume and heart weight increase faster and are more pronounced compared with BSA. This explains the lower GEDVI in young children. We propose correction factors for comparing EVLWI and GEDVI with adult reference values. Conclusions Extravascular lung water index is higher and GEDVI is lower in young children because of changing organ-to-body weight relationships during growth.

Cardiac output (CO) can be measured using the transpulmonary thermodilution (TPTD) technique. TPTD is considered to be the gold standard in pediatric patients. We studied the influence of high levels of EVLW on the reliability of CO measurement using the TPTD technique in a pediatric animal model.

The present study compared measurements of cardiac output by an arterial pressure-based cardiac output (APCO) analysis method with measurement by intermittent thermodilution cardiac output (ICO) via pulmonary artery catheter in a clinical setting.The multicenter, prospective clinical investigation enrolled patients with a clinical indication for cardiac output monitoring requiring pulmonary artery and radial artery catheters at two hospitals in the United States, one hospital in France, and one hospital in Belgium. In 84 patients (69 surgical patients), the cardiac output was measured by analysis of the arterial pulse using APCO and was measured via pulmonary artery catheter by ICO; to establish a reference comparison, the cardiac output was measured by continuous cardiac output (CCO). Data were collected continuously by the APCO and CCO technologies, and at least every 4 hours by ICO. No clinical interventions were made as part of the study.For APCO compared with ICO, the bias was 0.20 l/min, the precision was +/- 1.28 l/min, and the limits of agreement were -2.36 l/m to 2.75 l/m. For CCO compared with ICO, the bias was 0.66 l/min, the precision was +/- 1.05 l/min, and the limits of agreement were -1.43 l/m to 2.76 l/m. The ability of APCO and CCO to assess changes in cardiac output was compared with that of ICO. In 96% of comparisons, APCO tracked the change in cardiac output in the same direction as ICO. The magnitude of change was comparable 59% of the time. For CCO, 95% of comparisons were in the same direction, with 58% of those changes being of similar magnitude.In critically ill patients in the intensive care unit, continuous measurement of cardiac output using either APCO or CCO is comparable with ICO. Further study in more homogeneous populations may refine specific situations where APCO reliability is strongest.

Arterial finger blood pressure can be measured continuously and non-invasively using the Finapres method. There are numerous studies on the absolute blood pressure levels and tracking of blood pressure changes in adults [1]. The accuracy and precision of Finapres are according to the standards of the Association for the Advancement of Medical Instrumentation. Recently BMEYE developed finger cuffs specifically designed for the pediatric population. We present the first feasibility study comparing the blood pressure measurements of a pediatric prototype device (PFINAP) with intra-arterial blood pressure (IAP) in critically ill children.

Introduction Extravascular lung water index (EVLWI) can be measured at the bedside using the transpulmonary thermodilution technique (TPTD). The goal of this study was to compare EVLWI values with a chest x-ray score of pulmonary edema and markers of oxygenation in critically ill children. Methods This was a prospective observational study in a pediatric intensive care unit of a university hospital. We included 27 critically ill children with an indication for advanced invasive hemodynamic monitoring. No specific interventions for the purpose of the study were carried out. Measurements included EVLWI and other relevant hemodynamic variables. Blood gas analysis, ventilator parameters, chest x-ray and TPTD measurements were obtained within a three-hour time frame. Two radiologists assessed the chest x-ray and determined a score for pulmonary edema. Results A total of 103 measurements from 24 patients were eligible for final analysis. Mean age was two years (range: two months to eight years). Median cardiac index was 4.00 (range: 1.65 to 10.85) l/min/m2. Median EVLWI was 16 (range: 6 to 31) ml/kg. The weighted kappa between the chest x-ray scores of the two radiologists was 0.53. There was no significant correlation between EVLWI or chest x-ray score and the number of ventilator days, severity of illness or markers of oxygenation. There was no correlation between EVLWI and the chest x-ray score. EVLWI was significantly correlated with age and length (r2 of 0.47 and 0.67 respectively). Conclusions The extravascular lung water index in critically ill children does not correlate with a chest x-ray score of pulmonary edema, nor with markers of oxygenation.