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BACKGROUND: Cardiac output (CO) is rarely monitored during surgery, and arterial pressure remains the only hemodynamic parameter for assessing the effects of volume expansion (VE). However, whether VE-induced changes in arterial pressure accurately reflect changes in CO has not been demonstrated. The authors studied the ability of VE-induced changes in arterial pressure and in pulse pressure variation to detect changes in CO induced by VE in the perioperative period. METHODS: The authors studied 402 patients in four centers. Hemodynamic variables were recorded before and after VE. Response to VE was defined as more than 15% increase in CO. The ability of VE-induced changes in arterial pressure to detect changes in CO was assessed using a gray zone approach. RESULTS: VE increased CO of more than 15% in 205 patients (51%). Areas under the receiver operating characteristic curves for VE-induced changes in systolic, diastolic, means, and pulse pressure ranged between 0.64 and 0.70, and sensitivity and specificity ranged between 52 and 79%. For these four arterial pressure-derived parameters, large gray zones were found, and more than 60% of the patients lay within this inconclusive zone. A VE-induced decrease in pulse pressure variation of 3% or more allowed detecting a fluid-induced increase in CO of more than 15% with a sensitivity of 90% and a specificity of 77% and a gray zone between 2.2 and 4.7% decrease in pulse pressure variation including 14% of the patients. CONCLUSION: Only changes in pulse pressure variation accurately detect VE-induced changes in CO and have a potential clinical applicability. [ABSTRACT FROM AUTHOR]

In the present review we will describe and discuss the physiological and technological background necessary in understanding the dynamic parameters of fluid responsiveness and how they relate to recent softwares and algorithms' applications. We will also discuss the potential clinical applications of these parameters in the management of patients under general anesthesia and mechanical ventilation along with the potential improvements in the computational algorithms. [ABSTRACT FROM AUTHOR]

Different minimally invasive haemodynamic monitoring techniques are commercially available today and in the recent years they have proved adequate in replacing the pulmonary artery catheter under certain clinical conditions.Moreover, several of these techniques provide additional new parameters primarily related to preload assessment.Therefore, in order to be used in daily clinical practice, the diversity of minimally invasive haemodynamic monitoring requires knowledge of the different techniques, the different parameters provided by the devices and their clinical validity. The aim of the present article is to review the most widely used minimally invasive cardiac output monitoring techniques; emphasize the new parameters available for preload assessment;and propose a modular stepwise monitoring concept. [ABSTRACT FROM AUTHOR]

Introduction: In the treatment of patients with chronic pain, whole-body electrostatic therapy using the Elosan Cabin C1 has been proposed as an adjunctive therapy. So far, data on the use of this cabin are limited. Promising results with a significant reduction in pain scores have been obtained in a small group of patients. However, treatment with Elosan Cabin C1 has not been the subject of evaluation in a larger patient population. The aim of this study was to investigate the efficacy and adverse effects of electrostatic treatment in such a population., Methods: Prospective, multi-center, observational clinical trial conducted in daily practice in a large adult ambulatory population with chronic pain. Each patient received eight weekly Elosan C1 treatment sessions for up to 9 weeks. Treatment was added to an established conservative pain management. Pain scores (visual analog scale (VAS) 0-100, primary outcome) and sleep quality (seven-point Likert scale, secondary outcome) were assessed before, during, and at the end of the treatment period; quality of life (SF-12: Physical Component Summary = PCS, Mental Component Summary = MCS; secondary outcome) was assessed before and at the end of the treatment period. Subgroup analyses were performed for sex, age, duration of pain, initial pain location, pain entity, and pain medication at the start of treatment., Results: A total of 192 patients were enrolled, 143 patients (74.5%) had a complete set of 8 treatment sessions. A reduction in pain scores from 68 ± 14 points to 47 ± 22 points was observed (p < 0.001), 65% of patients (responders) had a reduction of > 15 points. Female patients had a significantly better response than male patients with a higher number of responders (76% vs. 38%; p < 0.001). Patients with a pain history < 1 year had a significantly better response than patients with a pain history > 1 year. The Physical Component Summary (PCS) increased from 36 ± 11 to 41 ± 11 (+ 18%, p < 0.001) and the Mental Component Summary (MCS) from 41 ± 7 to 43 ± 7 (+ 6%, p = 0.3). Overall sleep quality improved significantly from 4.6 ± 1.7 to 3.73 ± 1.7 points (p < 0.001), with a higher proportion of responders in the female group (37 vs. 18%; p < 0.034). No serious adverse events were observed during treatment., Conclusions: Electrostatic therapy with Elosan Cabin C1 may be a useful and effective adjunct therapy for patients with chronic pain. The results suggest that female patients and those with a recent history of pain experience the greatest benefit., Trial Registration: NCT04818294 (clinicaltrials.gov)., (© 2023. The Author(s).)

Background: In Switzerland, details of current anaesthesia practice are unknown. However, they are urgently needed to manage anaesthesia drug supply in times of drug shortages due to the pandemic., Methods: We surveyed all Swiss anaesthesia institutions in April 2020 to determine their annual anaesthesia activity. Together with a detailed analysis on anaesthetic drug use of a large, representative Swiss anaesthesia index institution, calculations and projections for the annual need of anaesthetics in Switzerland were made. Only those drugs have been analysed that are either being used very frequently or that have been classified critical with regard to their supply by the pharmacy of the index institution or the Swiss Federal Office of Public Health., Results: The response rate to our questionnaire was 98%. Out of the present 188 Swiss anaesthesia institutions, 185 responded. In Switzerland, the annual number of anaesthesias was 1'071'054 (12'445 per 100'000 inhabitants) with a mean anaesthesia time of 2.03 hours. Teaching hospitals (n = 54) performed more than half (n = 572'231) and non-teaching hospitals (n = 103) provided almost half of all anaesthesias (n = 412'531). Thereby, private hospitals conducted a total of 290'690 anaesthesias. Finally, office-based anaesthesia institutions with mainly outpatients (n = 31) administered 86'292 anaesthesias. Regarding type of anaesthesia provided, two thirds were general anaesthesias (42% total intravenous, 17% inhalation, 8% combined), 20% regional and 12% monitored anaesthesia care. Projecting for example the annual need for propofol in anaesthesia, Switzerland requires 48'573 L of propofol 1% which corresponds to 5'644 L propofol 1% per 100'000 inhabitants every year., Conclusions: To actively manage anaesthesia drug supply in the context of the current pandemic, it is mandatory to have a detailed understanding of the number and types of anaesthesias provided. On this basis, the Swiss annual consumption of anaesthetics could be projected and the replenishment organized., Competing Interests: The authors have declared that no competing interests exist.

Background: Continuous non-invasive cardiac output devices using digital photoplethysmography (PPG) are widely available for bedside use, but their interchangeability with reference methods has not yet been evaluated in a systematic review and patient data meta-analysis., Methods: A systematic review and meta-analysis of studies comparing non-invasive cardiac output monitoring using PPG with the invasive bolus thermodilution method was performed. With ethical approval, all published studies from the PUBMED, Embase, Scopus, Web of Science, and Google Scholar databases from January 1, 2010 to January 1, 2018 were included. From these analysed studies, individual patient data were interpreted using the interchangeability methods for both absolute values and changes in cardiac output measurements., Results: Ten studies comparing PPG and bolus thermodilution in the operating room and intensive care settings were included. The interchangeability rate (95% CI) was 37% (24-48) (n=1350 pairs of measurements). The interchangeability rate was poorer with the CNAP device (CNSystems, Graz, Austria) [18% (17-20)] than with the Clearsight (Edwards Lifesciences, Irvine, CA) device [33% (31-34), P<0.0001], for patients receiving norepinephrine [19% (17-20) vs. 33% (32-34), P<0.0001], and for patients with low mean arterial pressure (<65mmHg) [26% (23-29) vs. 30% (29-31), P<0.0001]. Among the 1009 comparisons of the changes in cardiac output between both methods, 561 (56%) were interpretable with a trend interchangeability rate at 24% (12-36)., Conclusions: Cardiac output measurements using PPG were not interchangeable with bolus thermodilution in regard to both absolute values and changes in cardiac output measurements, and should be used with caution in clinical practice., Trial Registration: PROSPERO ID CRD42018089513., (Copyright © 2019 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Postoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and reducing postoperative short-term and long-term survival. Optimal management of perioperative intravenous fluids and inotropic drugs may reduce infection rates and improve outcomes from surgery. Previous small trials of cardiac-output-guided haemodynamic therapy algorithms suggested a modest reduction in postoperative morbidity. A large definitive trial is needed to confirm or refute this and inform widespread clinical practice., Methods: The Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial is a multicentre, international, parallel group, open, randomised controlled trial. 2502 high-risk patients undergoing major elective gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intravenous fluid combined with low-dose inotrope infusion, or usual care. The trial intervention will be carried out during and for 4 hours after surgery. The primary outcome is postoperative infection of Clavien-Dindo grade II or higher within 30 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation; however, outcome assessors will be blinded when feasible. Participant recruitment started in January 2017 and is scheduled to last 3 years, within 50 hospitals worldwide., Ethics/dissemination: The OPTIMISE II trial has been approved by the UK National Research Ethics Service and has been approved by responsible ethics committees in all participating countries. The findings will be disseminated through publication in a widely accessible peer-reviewed scientific journal., Trial Registration Number: ISRCTN39653756., Competing Interests: Competing interests: MRE has received an honorarium for lecturing for Edwards Lifesciences and is Chief Investigator of the NIHR-funded FLO-ELA trial of cardiac output-guided haemodynamic therapy in patients undergoing emergency abdominal surgery. MPWG reports serving as Medical Advisory Board, Sphere Medical Ltd; Director, EBPOM Social Enterprise; Director, Oxygen Control Systems Ltd; Director, EBPOM USA. UK NIHR CRN National Specialty Lead for Anaesthesia, Perioperative Medicine and Pain. Joint Editor-in-Chief, Perioperative Medicine. MGM reports personal fees from Deltex Medical, personal fees from Edwards Lifesciences, personal fees from Baxter, grants from Smiths Medical, outside the submitted work. In addition, MGM has a patent ’QUENCH' (clinical hydration solutions limited) a patient hydration device (issued). MS reports grants from Edwards Lifesciences, during the conduct of the study; grants from Medtronic, grants from AMOMED, grants from Edwards Lifesciences, grants from Gettinge Group, outside the submitted work. TDP reports grants from Australian and New Zealand College of Anaesthetists, during the conduct of the study. LE reports personal fees from Cogstate, outside the submitted work. DAM reports personal fees from Edwards Lifesciences, outside the submitted work. JR-M reports personal fees from Edwards Lifesciences, during the conduct of the study; personal fees and non-financial support from Edwards Lifesciences, from Fresenius Kabi, from Deltex Medical, outside the submitted work. RMP holds research grants, and has given lectures and/or performed consultancy work for Nestle Health Sciences, BBraun, Medtronic, Glaxo Smithkline, Intersurgical, and Edwards Lifesciences, and is a member of the Associate editorial board of the British Journal of Anaesthesia. RMP is supported in part by an NIHR Professorship. The OPTIMISE II trial is adopted by the UK Perioperative Medicine Clinical Trials Network. DNW is supported in part by a New Investigator Award from the Canadian Institutes of Health Research and a Merit Award from the Department of Anesthesia at the University of Toronto., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Functional hemodynamic parameters such as stroke volume and pulse pressure variation (SVV and PPV) have been shown to be reliable predictors of fluid responsiveness in mechanically ventilated patients. Today, different minimally- and non-invasive hemodynamic monitoring systems measure functional hemodynamic parameters. Although some of these parameters are described by the same name, they differ in their measurement technique and thus may provide different results. We aimed to test the performance of seven functional hemodynamic parameters simultaneously in the same clinical setting., Methods: Hemodynamic measurements were done in 30 cardiac surgery patients that were mechanically ventilated. Before and after a standardized intravenous fluid bolus, hemodynamics were measured by the following monitoring systems: PiCCOplus (SVV PiCCO , PPV PiCCO ), LiDCO rapid (SVV LiDCO , PPV LiDCO ), FloTrac (SVV FloTrac ), Philips Intellivue (PPV Philips ) and Masimo pulse oximeter (pleth variability index, PVI). Prediction of fluid responsiveness was tested by calculation of receiver operating characteristic (ROC) curves including a gray zone approach and compared using Fisher's Z-Test., Results: Fluid administration resulted in an increase in cardiac output, while all functional hemodynamic parameters decreased. A wide range of areas under the ROC-curve (AUC's) was observed: AUC-SVV PiCCO  = 0.91, AUC-PPV PiCCO  = 0.88, AUC-SVV LiDCO  = 0.78, AUC-PPV LiDCO  = 0.89, AUC-SVV FloTrac  = 0.87, AUC-PPV Philips  = 0.92 and AUC-PVI = 0.68. Optimal threshold values for prediction of fluid responsiveness ranged between 9.5 and 17.5%. Lowest threshold values were observed for SVV LiDCO , highest for PVI., Conclusion: All functional hemodynamic parameters tested except for PVI showed that their use allows a reliable identification of potential fluid responders. PVI however, may not be suitable after cardiac surgery to predict fluid responsiveness., Trial Registration: NCT02571465 , registered on October 7th, 2015 (retrospectively registered).

Objective: The aim of this study was to analyze the accuracy, precision, and trending ability of the following 4 pulse wave analysis devices to measure continuous cardiac output: PiCCO 2 ([PCCO]; Pulsion Medical System, Munich, Germany); LiDCO Rapid ([LCCO]; LiDCO Ltd, London, UK); FloTrac/Vigileo ([FCCO]; Edwards Lifesciences, Irvine, CA); and Nexfin ([NCCO]; BMEYE, Amsterdam, The Netherlands)., Design: Prospective, observational clinical study., Setting: Intensive care unit of a single-center, teaching hospital., Participants: The study comprised 22 adult patients after elective coronary artery bypass surgery., Interventions: Three measurement cycles were performed in all patient durings their immediate postoperative intensive care stay before and after fluid loading. Hemodynamic measurements were performed 5 minutes before and immediately after the administration of 500 mL colloidal fluid over 20 minutes., Measurements and Main Results: PCCO, LCCO, FCCO, and NCCO were assessed and compared with cardiac output derived from intermittent transpulmonary thermodilution (ICO). One hundred thirty-two matched sets of data were available for analysis. Bland-Altman analysis using linear mixed effects models with random effects for patient and trial revealed a mean bias ±2 standard deviation (%error) of -0.86 ± 1.41 L/min (34.9%) for PCCO-ICO, -0.26 ± 2.81 L/min (46.3%) for LCCO-ICO, -0.28 ± 2.39 L/min (43.7%) for FCCO-ICO, and -0.93 ± 2.25 L/min (34.6%) for NCCO-ICO. Bland-Altman plots without adjustment for repeated measurements and replicates yielded considerably larger limits of agreement. Trend analysis for all techniques did not meet criteria for acceptable performance., Conclusions: All 4 tested devices using pulse wave analysis for measuring cardiac output failed to meet current criteria for meaningful and adequate accuracy, precision, and trending ability in cardiac output monitoring., (Copyright © 2017. Published by Elsevier Inc.)

Objective: During assisted ventilation and spontaneous breathing, functional haemodynamic parameters, including stroke volume variation (SVV) and pulse pressure variation (PPV), are of limited value to predict fluid responsiveness, and the passive leg raising (PLR) manoeuvre has been advocated as a surrogate method. We aimed to study the predictive value of SVV, PPV and PLR for fluid responsiveness during weaning from mechanical ventilation after cardiac surgery., Methods: Haemodynamic variables and fluid responsiveness were assessed in 34 patients. Upon arrival at the intensive care unit, measurements were performed during continuous mandatory ventilation (CMV) and spontaneous breathing with pressure support (PSV) and after extubation (SPONT). The prediction of a positive fluid responsiveness (defined as stroke volume increase >15% after fluid administration) was tested by calculating the specific receiver operating characteristic (ROC) curves., Results: A significant increase in stroke volumes was observed during CMV, PSV and SPONT after fluid administration. There were 19 fluid responders (55.9%) during CMV, with 22 (64.7%) and 13 (40.6%) during PSV and SPONT, respectively. The predictive value for a positive fluid responsiveness (area under the ROC curve) for SVV was 0.88, 0.70 and 0.56; was 0.83, 0.69 and 0.48 for PPV; was 0.72, 0.74 and 0.70 for PLR during CMV, PSV and SPONT, respectively., Conclusion: During mechanical ventilation, adequate prediction of fluid responsiveness using SVV and PPV was observed. However, during spontaneous breathing, the reliability of SVV and PPV was poor. In this period, PLR as a surrogate was able to predict fluid responsiveness better than SVV or PPV but was less reliable than previously reported., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient's coagulation status by glass bead-activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot., Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation., Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = -14.7%). Comparing S2 and S1, the glass bead-activated tests showed mean percentage differences of -18.9% (gbACTs), +37.4% (CR), and -3.7% (PF)., Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2., (© The Author(s) 2016.)

Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.

Septic shock is a serious medical condition. With increased concerns about invasive techniques, a number of non-invasive and semi-invasive devices measuring cardiac output (CO) have become commercially available. The aim of the present study was to determine the accuracy, precision and trending abilities of the FloTrac and the continuous pulmonary artery catheter thermodilution technique determining CO in septic shock patients. Consecutive septic shock patients were included in two centres and CO was measured every 4 h up to 48 h by FloTrac (APCO) and by pulmonary artery catheter (PAC) using the continuous (CCO) and intermittent (ICO) technique. Forty-seven septic shock patients with 326 matched sets of APCO, CCO and ICO data were available for analysis. Bland and Altman analysis revealed a mean bias ±2 SD of 0.0 ± 2.14 L min(-1) for APCO-ICO (%error = 34.5 %) and 0.23 ± 2.55 L min(-1) for CCO-ICO (%error = 40.4 %). Trend analysis showed a concordance of 85 and 81 % for APCO and CCO, respectively. In contrast to CCO, APCO was influenced by systemic vascular resistance and by mean arterial pressure. In septic shock patients, APCO measurements assessed by FloTrac but also the established CCO measurements using the PAC did not meet the currently accepted statistical criteria indicating acceptable clinical performance.

Background: The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations., Methods: This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe., Results: Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III-V, 768 patients [16.2 %]; p < 0.01) and central venous catheter (ASA I and II, 874 patients [11.8 %]; ASA III-V, 1463 patients [30.9 %]; p < 0.01). In elective surgery, 990 patients (10.8 %) were exposed to cardiac output monitoring, in urgent surgery 252 patients (11.7 %) and in emergency surgery 173 patients (19.8 %). A central venous catheter was used in 1514 patients (16.6 %) undergoing elective, in 480 patients (22.2 %) undergoing urgent and in 349 patients (39.9 %) undergoing emergency surgery. Nine hundred sixty patients (7.9 %) were monitored using arterial waveform analysis, 238 patients (2.0 %) using oesophageal Doppler ultrasound, 55 patients (0.5 %) using a pulmonary artery catheter and 44 patients (2.0 %) using other technologies. Across nations, cardiac output monitoring use varied from 0.0 % (0/249 patients) to 27.5 % (19/69 patients), whilst central venous catheter use varied from 5.6 % (7/125 patients) to 43.2 % (16/37 patients)., Conclusions: One in ten patients undergoing major surgery is exposed to cardiac output monitoring whilst one in five receives a central venous catheter. The use of both technologies varies widely across Europe., Trial Registration: ClinicalTrials.gov Identifier: NCT01203605. Date of registration: 15.09.2010.

Background: In critically ill patients with significant pulmonary hypertension (PH), close perioperative cardiovascular monitoring is mandatory, considering the increased morbidity and mortality in this patient group. Although the pulmonary artery catheter is still the standard for the diagnosis of PH, its use to monitor cardiac output (CO) in patients with PH is decreasing as a result of increased morbidity and possible influence of tricuspid regurgitation on the measurements. However, continuous CO measurement methods have never been evaluated under PH regarding their agreement and trending ability. In this study, we evaluated the influence of acute PH and different CO states on transpulmonary thermodilution (TPTD) and calibrated pulse contour analysis (PiCCO; both assessed with PiCCO plus™), intermittent pulmonary artery thermodilution (PATD), and continuous thermodilution (CCO) compared with a modified Fick method (FICK) in an animal model., Methods: Nine healthy pigs were studied under anesthesia. PH of 25 and 40 mm Hg (by administration of the thromboxane analog U46619), CO decreases, and CO increases were induced to test the different CO measurement techniques over a broad range of hemodynamic situations. Before each step, a new baseline data set was collected. CO values were compared using Bland-Altman analysis; trending abilities were assessed via concordance and polar plot analysis. The influence of pulmonary pressure on CO measurements was analyzed using linear mixed models., Results: A mean bias of -0.26 L/min with prediction intervals of -0.88 to 1.4 L/min was measured between TPTD and FICK. Their concordance rate was 100% (94%-100% confidence interval), and the mean polar angle -3° with radial limits of agreement of ±28° indicated good trending abilities. PATD compared with FICK also showed good trending ability. Comparisons of PiCCO and CCO versus FICK revealed low agreement and poor trending results with concordance rates of 84% (71%-93%) and 88% (74%-95%), mean polar angles from -17° and -19°, and radial limits of agreement of ±45° and 40°. Pulmonary pressures influenced only the difference between FICK and PiCCO, as assessed by linear mixed models., Conclusions: TPTD compared with FICK was able to track all changes induced during the study period, including those by PH. It yielded better agreement than PATD both compared with FICK. PiCCO and CCO were not mapping all changes correctly, and when used clinically in unstable patients, regular controls with intermittent techniques are required. Acute pharmacologically induced PH did influence the difference between FICK and PiCCO.

The present study evaluated transpulmonary thermodilution (TPTD) and pulse contour cardiac output (PCCO) both measured by the PiCCO Plus™ monitor (Pulsion Medical Systems, Munich, Germany) against pulmonary artery thermodilution (PATD) in cats as a hemodynamic model for small children. A wide range of cardiac outputs (CO) was simultaneously measured. Accuracy and trending abilities were critically evaluated. Three cats were studied under isoflurane anesthesia and 160 CO measurements were performed with 3 mL ice-cold 5 % dextrose with PATD and TPTD. The results were compared with the PCCO measurement before the bolus measurement. Cardiac output was manipulated from 32 to 224 mL/kg/min by dobutamine, dopamine, phenylephrine, medetomidine and increased concentrations of isoflurane. Bland-Altman analysis, concordance and polar plot analysis were performed to assess accuracy and trending ability. TPTD was measuring constantly higher than PATD with a mean bias of 73 mL/kg/min and limits of agreement of 34-112 mL/kg/min, a concordance rate of 94 % and a mean polar angle of -5° with radial limits of agreement (RLOA) of 33°. Concordance rate of the PCCO versus PATD was 82 % with a mean polar angle of -10° and RLOA of 46° and versus TPTD 90 % with a mean polar angle of -6° and RLOA of 46°. Both tested methods constantly overestimated simultaneous PATD measurements. The small size, low flows and the relative short catheter not reaching the abdominal aorta may explain that. However TPTD tracked changes accurately opposed to a poor trending ability of the PCCO measurement.

Objectives: The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points., Design: A prospective, observational clinical study., Setting: A teaching hospital, single center., Participants: Consecutive patients undergoing cardiac surgery (N = 300)., Interventions: Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure., Measurements and Main Results: Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding., Conclusions: Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The benefit of the post-anaesthesia care unit (PACU) with respect to an early detection of postoperative complications is beyond dispute. From a patient perspective, prevention and optimal management of pain, nausea and vomiting (PONV) are also of utmost importance. The aims of the study were therefore to prospectively measure pain and PONV on arrival to the PACU and before discharge and to determine the relationship of pain and PONV to the length of stay in the PACU., Methods: Postoperative pain was assessed over 30 months using a numeric rating scale on admittance to the PACU and before discharge; in addition, PONV was recorded. Statistical analysis was done considering gender, age, American Society of Anesthesiologists (ASA) classification, surgical speciality, anaesthesia technique, duration of anaesthesia, intensity of nursing and length of stay., Results: Data of 12,179 patients were available for analysis. The average length of stay in the PACU was 5.7 ± 5.9 h, whereas regular PACU patients stayed for 3.2 ± 1.9 h and more complex IMC patients stayed for 15.1 ± 6.0 h. On admittance, 27% of patients were in pain and the number decreased to 13% before discharge; 3% experienced PONV. Risk factors for increased pain determined by multivariate analysis were female gender; higher ASA classification; general, cardiac and orthopaedic surgery and prolonged case duration. In more complex IMC patients, pain scores were higher on arrival but dropped to similar levels before discharge compared to regular PACU patients. Female gender and postoperative pain were risk factors for postoperative vomiting. Pain and PONV on arrival correlated with length of stay in the PACU. Pain- or PONV-free patients stayed almost half of the time in the PACU compared to patients with severe pain or vomiting on arrival., Conclusions: The majority of PACU patients had good pain control, both on admittance and before discharge, and the overall incidence of PONV was low. Managing patients in the PACU could achieve a significant reduction of pain and PONV. The level of pain and presence of PONV on admittance to the PACU correlate with and act as predictors for increased length of PACU stay.

Purpose of Review: Advanced hemodynamic monitoring is indispensable for adequate management of patients undergoing major surgery. This article will summarize minimally invasive hemodynamic monitoring technologies and their potential use in thoracic anesthesia., Recent Findings: According to their inherent principle, currently available technologies can be classified into four groups: bioimpedance and bioreactance, applied Fick's principle, pulse wave analysis and Doppler. All devices measure stroke volume and cardiac output. Functional hemodynamic variables and volumetric parameters have been integrated in some devices. Two major indications can be identified: the 'hemodynamically unstable' patient and the patient 'at risk' for hemodynamic instability. Although there is evidence for the first indication, pre-emptive hemodynamic therapy or perioperative hemodynamic optimization for the patient 'at risk' is still an issue of ongoing debate. There is a growing body of evidence that this approach can positively influence patients' outcome with less postoperative complications in selected patient groups., Summary: Many different minimally invasive hemodynamic monitoring devices have been developed and clinically introduced in the last years. They offer the advantage of being less invasive and easier to use. However, these techniques have several limitations and data are scarce in patients undergoing thoracic anesthesia, preventing their widespread use so far.

Background: A new calibrated pulse wave analysis method (VolumeView™/EV1000™, Edwards Lifesciences, Irvine, CA, USA) has been developed to continuously monitor cardiac output (CO). The aim of this study was to compare the performance of the VolumeView method, and of the PiCCO2™ pulse contour method (Pulsion Medical Systems, Munich, Germany), with reference transpulmonary thermodilution (TPTD) CO measurements., Methods: This was a prospective, multicentre observational study performed in the surgical and interdisciplinary intensive care units of four tertiary hospitals. Seventy-two critically ill patients were monitored with a central venous catheter, and a thermistor-tipped femoral arterial VolumeView™ catheter connected to the EV1000™ monitor. After initial calibration by TPTD CO was continuously assessed using the VolumeView-CCO software (CCO(VolumeView)) during a 72 h period. TPTD was performed in order to obtain reference CO values (COREF). TPTD and arterial wave signals were transmitted to a PiCCO2™ monitor in order to obtain CCO(PiCCO) values. CCO(VolumeView) and CCO(PiCCO) were recorded over a 5 min interval before assessment of CO(TPTD). Bland-Altman analysis, %(errors), and concordance (trend analysis) were calculated., Results: A total of 338 matched sets of data were available for comparison. Bias for CCO(VolumeView)-CO(REF) was -0.07 litre min(-1) and for CCO(PiCCO)-CO(REF) +0.03 litre min(-1). Corresponding limits of agreement were 2.00 and 2.48 litre min(-1) (P<0.01), %(errors) 29 and 37%, respectively. Trending capabilities were comparable for both techniques., Conclusions: The performance of the new VolumeView™-CCO method is as reliable as the PiCCO2™-CCO pulse wave analysis in critically ill patients. However, an improved precision was observed with the VolumeView™ technique. CLINICALTRIALS.GOV IDENTIFIER: NCT01405040.

Introduction: Transpulmonary thermodilution is used to measure cardiac output (CO), global end-diastolic volume (GEDV) and extravascular lung water (EVLW). A system has been introduced (VolumeView/EV1000™ system, Edwards Lifesciences, Irvine CA, USA) that employs a novel algorithm for the mathematical analysis of the thermodilution curve. Our aim was to evaluate the agreement of this method with the established PiCCO™ method (Pulsion Medical Systems SE, Munich, Germany, clinicaltrials.gov identifier: NCT01405040) METHODS: Seventy-two critically ill patients with clinical indication for advanced hemodynamic monitoring were included in this prospective, multicenter, observational study. During a 72-hour observation period, 443 sets of thermodilution measurements were performed with the new system. These measurements were electronically recorded, converted into an analog resistance signal and then re-analyzed by a PiCCO2™ device (Pulsion Medical Systems SE)., Results: For CO, GEDV, and EVLW, the systems showed a high correlation (r(2) = 0.981, 0.926 and 0.971, respectively), minimal bias (0.2 L/minute, 29.4 ml and 36.8 ml), and a low percentage error (9.7%, 11.5% and 12.2%). Changes in CO, GEDV and EVLW were tracked with a high concordance between the two systems, with a traditional concordance for CO, GEDV, and EVLW of 98.5%, 95.1%, and 97.7% and a polar plot concordance of 100%, 99.8% and 99.8% for CO, GEDV, and EVLW, respectively. Radial limits of agreement for CO, GEDV and EVLW were 0.31 ml/minute, 81 ml and 40 ml, respectively. The precision of GEDV measurements was significantly better using the VolumeView™ algorithm compared to the PiCCO™ algorithm (0.033 (0.03) versus 0.040 (0.03; median (interquartile range), P = 0.000049)., Conclusions: For CO, GEDV, and EVLW, the agreement of both the individual measurements as well as measurements of change showed the interchangeability of the two methods. For the VolumeView method, the higher precision may indicate a more robust GEDV algorithm., Trial Registration: clinicaltrials.gov NCT01405040.

Introduction: Morbid obesity and its consequences are considered risk factors for adverse outcome in trauma, although the pathophysiologic mechanisms are incompletely understood. The aim of this study was to compare initial resuscitation, treatment, and short-term outcome of severely injured patients by body mass index (BMI)., Methods: A total of 1,084 severely injured patients with an injury severity score of 16 or greater were enrolled between 1996 and 2009 and grouped according to BMI. Their course of treatment and in-hospital outcome were analyzed by univariate and multivariate comparison., Results: Of these patients, 603 (55.6%) were of normal weight with a BMI between 18.5 and 24.9, 361 (33.3%) had BMI values between 25 and 29.9, and 90 patients (8.3%) were obese (BMI ≥ 30). Thirty patients (2.8%) had BMI levels below 18.5. All groups were comparable with respect to injury severity, initial resuscitation, and time to ICU admission. There was a tendency towards higher mortality in obese patients (mortality 24.4%) and also overweight patients (mortality 18.8%) when compared with patients with a normal BMI (mortality 16.6%). Obese patients showed the highest mortality on day 0 (8.9% vs. 2.8% in the normal-weight group, P = 0.023), mostly due to persistent shock (6.7%). When corrected for BMI, obese patients are provided significantly lower volumes of intravenous fluids during the initial resuscitation period., Conclusion: In contrast to the mostly American literature, only a low percentage of trauma patients at a European trauma center are obese. These patients are at risk of higher mortality from persistent hemorrhagic shock in the initial phase after trauma, which may potentially be related to relative hypovolemia during the resuscitation period. In the later course of treatment, no significant differences exist with respect to specific complications, hospital stay, or in-hospital mortality.

The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.

The variety of minimally invasive cardiac output (CO) monitoring devices is growing rendering it difficult to keep track of new developments. In this article technical principles, limitations and validation procedures considering new aspects are reviewed. An integrated approach for their use is proposed since no single device can comply with all clinical needs. CO should be interpreted in combination with clinical information and other hemodynamic parameters. It's evident that not the monitor per se, but only the protocol / therapy based on the hemodynamic data can improve patients outcome., (© Georg Thieme Verlag Stuttgart · New York.)

Predicting the effects of volume expansion on cardiac output and oxygen delivery is of major importance in different clinical scenarios. Functional hemodynamic parameters based on pulse waveform analysis, which are relying on the effects of mechanical ventilation on stroke volume and its surrogates, have been shown to be reliable predictors of fluid responsiveness during anesthesia and intensive care unit treatment, as demonstrated by several clinical studies and meta-analyses. However, different limitations of these parameters have to be considered when they are used in clinical practice. Today, they can be continuously and automatically monitored by a variety of commercially available devices. These parameters have been introduced into the concept of perioperative fluid management and hemodynamic optimization - an approach that may positively impact postoperative patients' outcomes. In this article, technical aspects of the assessment of the functional hemodynamic parameters derived from pulse waveform analysis are summarized, emphasizing their advantages, limitations and potential applications, primarily in a perioperative setting in order to improve patient outcome.

Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. With increased concerns about the use of invasive techniques, notably the pulmonary artery catheter, to measure cardiac output, recent years have seen an influx of new, less-invasive means of measuring hemodynamic variables, leaving the clinician somewhat bewildered as to which technique, if any, is best and which he/she should use. In this consensus paper, we try to provide some clarification, offering an objective review of the available monitoring systems, including their specific advantages and limitations, and highlighting some key principles underlying hemodynamic monitoring in critically ill patients.

The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. A correct understanding of the complex coagulation pathophysiology in the perioperative setting is essential for an effective treatment. In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.

Functional hemodynamic parameters, such as stroke volume variation (SVV) and pulse pressure variation (PPV), are useful hemodynamic monitoring tools for the assessment of fluid responsiveness. These parameters are based on heart-lung interaction during positive mechanical pressure ventilation: Cyclic changes of intrathoracic pressure result in a reduced venous return and a decreased cardiac stroke volume after inspiration followed by a restoration of preload and stroke volume after expiration. Hemodynamic monitoring systems based on pulse wave analysis allow an automatic assessment of SVV and--at least for some of the devices--of PPV. Moreover, PPV is being integrated in the standard monitoring in the operating room and the intensive care unit, and the noninvasive plethysmographic assessment of fluid responsiveness has been recently introduced. These developments will result in a broader application of functional hemodynamic parameters in the near future. In contrast to traditional preload parameters (i.e. central venous pressure), SVV and PPV allow the prediction of fluid responsiveness and thus the determination of the actual position on an individual Frank-Starling curve or--in other words--the assessment of an individual preload reserve. Different studies in the last decade were able to prove the validity of this concept. However, to use these functional hemodynamic parameters in daily clinical practice, some limitations have to be considered. Arrhythmia and right heart failure, but also spontaneous breathing of a patient, or small tidal volumes may preclude reliable assessment. Based on these aspects, an ideal area of application of these parameters may be the use during perioperative hemodynamic optimization to improve patient outcome. However, only few studies on goal-directed therapy guided by these parameters have been published so far., (Copyright © 2011. Published by Elsevier B.V.)

Cardiac output monitoring in the cardiac surgery patient is standard practice that is traditionally performed using the pulmonary artery catheter. However, over the past 20 years, the value of pulmonary artery catheters has been challenged, with some authors suggesting that its use might be not only unnecessary but also harmful. New minimally invasive devices that measure cardiac output have become available. In this paper, we review their operative principles, limitations, and utility in an integrated approach that could potentially change patients' outcome. However, it is now clear that it is how the monitor is used (ie, the protocol or therapy associated with its use, or its lack thereof), and not the monitor per se, that should be questioned when a patient's outcome is being evaluated.

Platelets play a central role in primary hemostasis. Analysis of platelet function is therefore a cornerstone in the global assessment of the coagulation status in the perioperative setting, primarily in patients receiving antiplatelet medication, such as cyclooxygenase-1 inhibitors, adenosine diphosphate antagonists and glycoprotein IIb/IIIa inhibitors. In these patients, knowledge of residual platelet function is highly warranted in order to maintain an optimal and individual balance perioperatively between platelet function and inhibition - that is, bleeding and thrombosis. Traditional laboratory-based assays, such as light-transmission aggregometry and flow cytometry, are the clinical standards of platelet function testing today. Light-transmission aggregometry is one of the most widely used tests to identify and diagnose defects in platelet function. The majority of the conventional laboratory-based techniques are labor intensive, costly and time consuming, and require a high degree of experience and expertise to perform and interpret. Therefore, new automated technologies have been developed to measure platelet function more rapidly and easily, and several techniques can be used at the bedside, including whole blood aggregometry, high shear-induced platelet function assessment or viscoelastic measurement techniques. All methods assessing platelet function are summarized and their limitations are discussed in this article, emphasizing their perioperative use.

Objectives: Arterial pressure waveform analysis is a less invasive alternative to the pulmonary artery catheter for continuous cardiac output (CO) measurement. Uncalibrated and calibrated systems are actually available (ie, the FloTrac/Vigileo system [Edwards Lifesciences, Irvine, CA] and the PiCCOplus system [Pulsion Medical Systems, Munich, Germany]). According to the FloTrac/Vigileo manufacturer, reliable measurements can be performed using any existing arterial catheter. The aim of this study was to evaluate CO determined by the FloTrac/Vigileo system using a radial (FCO(radial)) and femoral arterial catheter (FCO(femoral)) as well as the PiCCOplus system (PCO). Intermittent pulmonary artery thermodilution (ICO) was used as primary reference technique., Design: A prospective clinical study., Setting: A teaching hospital, single center., Participants: Twenty-six cardiac surgery patients., Interventions: Perioperative CO measurements., Measurements and Main Results: CO was assessed at predefined measurement points. FCO(radial), FCO(femoral), and PCO were recorded after the induction of anesthesia, after sternotomy, at skin closure, after intensive care unit transfer, and during intensive care unit stay 12 and 24 hours after study initiation. ICO was determined as the mean of 3 bolus injections. Bland-Altman analysis revealed comparable mean bias and limits of agreement for FCO(radial), FCO(femoral), and PCO when compared with ICO. There was a decreased agreement for all devices in the postoperative period. However, a consistently close agreement was observed for the direct comparison between FCO(radial) and FCO(femoral)., Conclusions: Performance of the FloTrac/Vigileo system via radial as well as femoral access and the PiCCOplus monitoring for cardiac output measurement were comparable when tested against intermittent thermodilution in cardiac surgery patients., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Coagulopathy in surgical patients is an important factor in triggering major perioperative complications, i.e., intra- or postoperative bleeding and thrombo-embolic events associated with an increased mortality and morbidity. Different methods exist to assess the coagulation status of patients before, during and after surgery. Routine coagulation tests have long been considered to be the clinical standard. However, these tests have considerable limitations. Information regarding the kinetics of clot formation, clot strength, interaction of the coagulation components, platelet function and fibrinolysis is not available. Moreover, there is an important delay in obtaining test results. In contrast, thrombelastography and thrombelastometry, which both measure the visco-elastic properties of whole blood, allow the dynamic assessment of a developing clot, from fibrin formation to clot strengthening and clot lysis. Both techniques are increasingly being used in daily clinical practice in order to detect perioperative coagulopathy and to guide predominantly pro-coagulant therapy in different settings. This article provides an overview of both techniques, thrombelastography (TEG) and thrombelastometry (ROTEM), and their field of perioperative application considering of recently published data.

Introduction: The FloTrac/Vigileo (Edwards Lifesciences, Irvine, CA, USA) allows pulse pressure-derived cardiac output measurement without external calibration. Software modifications were performed in order to eliminate initially observed deficits. The aim of this study was to assess changes in cardiac output determined by the FloTrac/Vigileo system (FCO) with an initially released (FCOA) and a modified (FCOB) software version, as well as changes in cardiac output from the PiCCOplus system (PCO; Pulsion Medical Systems, Munich, Germany). Both devices were compared with cardiac output measured by intermittent thermodilution (ICO)., Methods: Cardiac output measurements were performed in patients after elective cardiac surgery. Two sets of data (A and B) were obtained using FCOA and FCOB in 50 patients. After calibration of the PiCCOplus system, triplicate FCO and PCO values were recorded and ICO was determined in the supine position and cardiac output changes due to body positioning were recorded 15 minutes later (30 degrees head-up, 30 degrees head-down, supine). Student's t test, analysis of variance and Bland-Altman analysis were calculated., Results: Significant changes of FCO, PCO and ICO induced by body positioning were observed in both data sets. For set A, DeltaFCOA was significantly larger than DeltaICO induced by positioning the head down. For set B, there were no significant differences between DeltaFCOB and DeltaICO. For set A, increased limits of agreement were found for FCOA-ICO when compared with PCO-ICO. For set B, mean bias and limits of agreement were comparable for FCOB-ICO and PCO-ICO., Conclusions: The modification of the FloTrac/Vigileo system resulted in an improved performance in order to reliably assess cardiac output and track the related changes in patients after cardiac surgery.

A 37-yr-old patient scheduled for elective bursectomy developed fulminant malignant hyperthermia (MH) under sevoflurane anesthesia. The first sign was a dramatic increase in end-tidal CO(2). Symptomatic and specific therapy was rapidly instituted. Postoperative rhabdomyolysis was treated with veno-venous hemofiltration. The patient rejected open muscle biopsy for in vitro contracture testing. Therefore, molecular testing was performed. An infrequent MH causative mutation was identified on the ryanodine receptor gene. This case report confirms the causative nature of this mutation. It also shows that molecular genetic investigation may be as appropriate as in vitro contracture testing to confirm the diagnosis after a clinical episode of MH.

Objectives: Recombinant activated factor VII (rFVIIa) is increasingly being given to treat massive bleeding. However, there is no clear guidance on which patients are suitable for treatment and how the effects of treatment should be monitored. The aim of this in vitro study was to assess the coagulation status of severely hemodiluted blood samples before and after treatment with therapeutic doses of rFVIIa and/or fibrinogen with 2 viscoelastic point-of-care coagulation analyzers: ROTEM (Pentapharm GmbH, Munich, Germany) and Sonoclot (Sienco Inc, Arvada, CO)., Design: Laboratory study., Setting: Research coagulation laboratory., Participants: Ten healthy male volunteers without hereditary or acquired coagulation disorders., Interventions: Blood samples were obtained. After severe hemodilution with albumin 5%, therapeutic doses of rFVIIa and/or fibrinogen were added, and the coagulation status was assessed with new 1:1,000 diluted tissue factor-activated tests from ROTEM and Sonoclot., Measurements and Main Results: The administration of therapeutic doses of rFVIIa to hemodiluted samples shortened the initiation phase of coagulation only. Isolated fibrinogen administration to physiologic levels improved both the initiation of coagulation as well as clot formation and strength. Combined fibrinogen and rFVIIa administration further improved both effects., Conclusions: ROTEM and Sonoclot were able to monitor the effects of rFVIIa and fibrinogen administration with 1:1,000 diluted tissue factor-activated tests. The efficacy of rFVIIa was largely dependent on the presence of high levels of fibrinogen in reversing this severe dilutional coagulopathy.

Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.

Objectives: The aim of this study was to compare the following approaches to assess left ventricular preload by transesophageal echocardiography (TEE): left ventricular end-diastolic volume index (LVEDVI) determined by using the method of disc summation (LVEDVI(Md)) and left ventricular end-diastolic area index (LVEDAI) were compared with LVEDVI assessed by the modified Simpson formula (LVEDVI(Si)). Global end-diastolic volume index (GEDVI) and stroke volume index (SVI) measured by the PiCCO(plus) system (Pulsion Medical Systems, Munich, Germany) were used as TEE-independent reference variables., Design: Prospective observational study., Setting: Community hospital., Participants: Twenty-two patients undergoing elective cardiac surgery., Interventions: After the induction of anesthesia, hemodynamic assessment by TEE and the PiCCO(plus) system was made 20 (T(1)) and 10 minutes (T(2)) before and 10 (T(3)) and 20 minutes (T(4)) after a fluid trial. At each time point, LVEDVI(Md), LVEDAI, LVEDVI(Si), GEDVI, and SVI were determined., Measurements and Main Results: The fluid trial resulted in a significant increase of all preload variables measured at T(3). At T(4), all preload variables but LVEDVI(Md) showed a significant decrease. The mean bias +/- 2 SD for percent changes (Delta) of LVEDVI(Md) - DeltaLVEDVI(Si) was 1.5% +/- 59.0% and for DeltaLVEDAI - Delta LVEDVI(Si) 0.9% +/- 23.6%. The correlation between LVEDVI(Md) and LVEDVI(Si) was significantly weaker than between LVEDAI and LVEDVI(Si) (p < 0.001). Comparing TEE measurements with GEDVI and SVI, strong correlations were observed for LVEDAI and LVEDVI(Si) only., Conclusion: The method of disc summation cannot be recommended for preload assessment during a fluid challenge in cardiac surgery patients. By contrast, single-plane area measurements provided reliable information when compared with the application of the modified Simpson formula.

Introduction: Stroke volume variation (SVV) has repeatedly been shown to be a reliable predictor of fluid responsiveness. Various devices allow automated clinical assessment of SVV. The aim of the present study was to compare prediction of fluid responsiveness using SVV, as determined by the FloTrac/Vigileo system and the PiCCOplus system., Methods: In patients who had undergone elective cardiac surgery, SVVFloTrac was determined via radial FloTrac sensor, and SVVPiCCO and pulse pressure variation were assessed via a femoral PiCCO catheter. Stroke volume was assessed by transpulmonary thermodilution. All variables were recorded before and after a volume shift induced by a change in body positioning (from 30 degrees head-up position to 30 degrees head-down position). Pearson correlation, t-test, and Bland-Altman analysis were performed. Area under the curve was determined by plotting receiver operating characteristic curves for changes in stroke volume in excess of 25%. P < 0.05 was considered statistically significant., Results: Body positioning resulted in a significant increase in stroke volume; SVVFloTrac and SVVPiCCO decreased significantly. Correlations of SVVFloTrac and SVVPiCCO with change in stroke volume were similar. There was no significant difference between the areas under the curve for SVVFloTrac and SVVPiCCO; the optimal threshold values given by the receiver operating characteristic curves were 9.6% for SVVFloTrac (sensitivity 91% and specificity 83%) and 12.1% for SVVPiCCO (sensitivity 87% and specificity 76%). There was a clinically acceptable agreement and strong correlation between SVVFloTrac and SVVPiCCO., Conclusion: SVVs assessed using the FloTrac/Vigileo and the PiCCOplus systems exhibited similar performances in terms of predicting fluid responsiveness. In comparison with SVVPiCCO, SVVFloTrac has a lower threshold value.