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In the new century, our diagnostic armamentarium has been significantly reinforced by the 'three-dimensional' volumetric haemodynamic monitoring currently available at the bedside in many perioperative and intensive care settings. The volumetric approach has improved our insight into the haemodynamic scenarios of many critical illnesses and surgical interventions, including sepsis, circulatory shock, acute respiratory distress syndrome as well as cardiothoracic and transplantation surgery. However, the influence of volumetric haemodynamic monitoring on clinical outcome is still a subject for debates. This review presents physiological background, technical details, aspects of bedside use, limitations and further perspectives of the volumetric approach to the cardiopulmonary monitoring.

Background Pregnancy-related infections are the third most common cause of maternal death worldwide. The aim of this report is to present a case of pregnancy-related infection, which progressed into refractory septic shock accompanied by purpura fulminans and multiple organ failure. Case A 23-year-old woman in the postpartum period developed fulminant, refractory septic shock complicated by purpura fulminans and multiple organ failure syndrome (acute respiratory distress syndrome, acute kidney injury, and encephalopathy). Management included antibacterial therapy, fluid and transfusion therapy, nutritional support, protective mechanical ventilation, hydrocortisone, a large dose of ascorbic acid, and thiamine. There were no neurological consequences and all organ functions returned to normal, although the predicted hospital mortality based on the Sequential Organ Failure Assessment (SOFA) score was more than 90%. Conclusions Septic shock is a significant, yet not completely understood life-threatening condition, which can be associated with purpura fulminans, multiple organ dysfunction, disseminated intravascular coagulation, and massive tissue necrosis.

This study aimed to assess the predictive value of invasive and non-invasive dynamic parameters for evaluation of fluid responsiveness after off-pump coronary artery bypass grafting.Thirty-two adult patients after off-pump coronary surgery were enrolled into a single-center pilot prospective observational study. After arrival to the intensive care unit, all patients received standard fluid challenge test to assess fluid responsiveness. The patients with an increase in cardiac index ≥ 15% after the test were defined as fluid responders. We measured pulse pressure variation using 2 monitoring systems (PPVPiCCO and PPVNK), stroke volume variation, heart-lung interaction index, and plethysmogram variability index before and after standard fluid challenge test.After intensive care unit admission, the absolute values of stroke volume variation, PPVPiCCO, PPVNK, and heart-lung interaction index were significantly higher among fluid responders (P.05). Response to standard fluid challenge test was predicted by dynamic assessment of PPVPiCCO (area under the curve 0.84), PPVNK (area under the curve 0.71), stroke volume variation (area under the curve 0.77), and heart-lung interaction index (area under the curve 0.77) (P.05). The plethysmogram variability index value did not demonstrate any predictive ability regarding fluid responsiveness (area under the curve 0.5, P =.1).In patients after off-pump coronary surgery, both invasive parameters such as pulse pressure and stroke volume variations and non-invasive parameter such as heart-lung interaction index are able to predict fluid responsiveness. Thus, these dynamic parameters can be used to guide fluid therapy during the early postoperative period after off-pump coronary surgery.

Objective To test the hypothesis that a positive end-expiratory pressure test and the mini-fluid challenge predict fluid responsiveness in patients after off-pump coronary artery bypass grafting. Design Single-center pilot prospective observational study. Setting City Hospital #1 of Arkhangelsk, Russian Federation. Participants Thirty-two adult patients after off-pump coronary artery surgery. Interventions To assess fluid responsiveness, after arrival to the intensive care unit, all patients received a test with increase in positive end-expiratory pressure from 5 to 20 cmH2O for 2 minutes, a mini-fluid challenge test with administration of crystalloids at 1.5 mL/kg during 2 minutes, and standard fluid challenge test using 7 mL/kg during 10 minutes. Measurements and Main Results The patients with an increase in cardiac index by ≥15% after a standard fluid challenge test were defined as fluid responders. According to receiver operating characteristic analysis, a decrease in mean arterial pressure exceeding 5 mmHg in 120 seconds of the positive end-expiratory pressure test identified fluid responsiveness with an area under the curve of 0.73 (p = 0.03). The reduction in pulse pressure and stroke volume variations by more than 2% during mini-fluid challenge test predicted positive response to fluid load with an area under the curve of 0.77 and 0.75, respectively (p Conclusion Both the positive end-expiratory pressure test and the mini-fluid challenge test are feasible after off-pump coronary artery bypass grafting and can be used to predict fluid responsiveness in these patients.

Glycocalyx is a gel-like layer covering the surface of vascular endothelial cells. It consists of membrane-attached proteoglycans, glycosaminoglycan chains, glycoproteins, and plasma adhesive proteins. Glycocalyx plays a key role in maintaining vascular homeostasis, controls vascular permeability and the tone of the microvasculature, prevents microvascular thrombosis and regulates leukocyte adhesion. In sepsis and septic shock, damage and shedding of glycocalyx occurs. The degradation of glycocalyx is activated by reactive oxygen species and pro-inflammatory cytokines, such as tumor necrosis factor (TNF) and interleukin-1β (IL-1β). The inflammation-mediated degradation of glycocalyx leads to vascular hyperpermeability, unregulated vasodilation, microvascular thrombosis, and enhanced leukocyte adhesion. The inflammation-mediated degradation of glycocalyx leads to vascular hyperpermeability, unregulated vasodilation, microvascular thrombosis, and enhanced leukocyte adhesion. Clinical studies have demonstrated a correlation between the levels of glycocalyx components in the blood and organ dysfunction and mortality in sepsis and septic shock. Inflammation-induced damage to glycocalyx can cause a number of specific clinical effects of sepsis, including acute kidney damage, respiratory failure and liver dysfunction. Infusion therapy is an integral part of the treatment of sepsis, but super-aggressive infusion load methods (leading to hypervolemia) may increase the degradation of glycocalyx. Moreover, some markers of glycocalyx degradation, such as circulating levels of syndecan 1 or heparan sulfate, can be used as markers of endothelial dysfunction and sepsis severity.

Thirt y-t wo adult patients after of f-p ump coronary artery bypass grafting were enrolled into a prospective observational study. All patients received positive end expiratory pressure test ( PEE P -t est), min i-f luid challenge test (m FCT ) and standard fluid challenge test (s FCT ). Pulse pressure variation using two monitoring systems ( PPV P i CCO , PPV NK ), Stroke volume variation ( SVV ), hear t-l ung index ( HLI ) and plethysmogram variability index ( PVI ) were assessed before and after s FCT . The patients with an increase in cardiac index by ≥ 15% after fluid challenge were defined as fluid responders. According to receiver operating characteristic analysis, changes in mean arterial pressure induced by PEE P -t est identified fluid responsiveness with AUC 0.73 ( p = 0.03). The reduction in PPV P i CCO and SVV during m FCT predicted positive response to the fluid load with AUC 0.77 and 0.75, respectively ( p < 0.05). Response to s FLT can be predicted by the assessment of PPV P i CCO ( AUC 0.84), PPV NK ( AUC 0.71), SVV ( AUC 0.77) and HLI ( AUC 0.77) ( p < 0.05).

Along with the hemodynamic paradigm postulating that “only flow, not pressure matters,” in the new century, a number of “3D” volumetric parameters have evolved and become readily available at the bedside in many intensive care units. The volumetric approach to advanced hemodynamic monitoring has substantially improved the knowledge of the pathophysiology of critical illnesses, including circulatory shock and acute respiratory distress syndrome, yet many questions are to be addressed. The chapter presents the review of the physiological background, technical issues, bedside application, and further perspectives of volumetric hemodynamic monitoring.

Central venous pressure (CVP) reflects the pressure in the major veins, namely, vena cava superior and inferior. From the physiological point of view, the central venous pressure is a product of the complex interplay between potential heart performance and venous return; therefore, the response of CVP to the similar hemodynamic interventions can be opposite in different ICU patients. Historically, CVP was often used for the assessment of hemodynamics, volume status, and fluid responsiveness. However, over the last decades, multiple studies have demonstrated the absence of correlation of both absolute values and changes in CVP with end-diastolic left ventricle volume and cardiac output. Not surprisingly, CVP is unable to predict changes in cardiac output in response to fluid challenge. Nowadays, a certain “renaissance” of CVP seems to be possible since new studies show that increased baseline values and/or fast increment of this parameter are associated with progression to acute kidney injury, multiple organ failure, splanchnic congestion, and death. Thus, the therapy aiming to decrease CVP may improve organ function and clinical outcome. Obviously, there are many questions to be addressed concerning CVP in critically ill patients before the decision on when and how to use this hemodynamic parameter.

The prevention of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of paramount importance for improving outcomes both in the operating room and in the intensive care unit (ICU). Protective respiratory support includes a wide spectrum of interventions to decrease pulmonary stress–strain injuries. The motto ‘low tidal volume for all’ should become routine, both during major surgery and in the ICU, while application of a high positive end-expiratory pressure (PEEP) strategy and of alveolar recruitment maneuvers requires a personalized approach and warrants further investigation. Patient self-inflicted lung injury is an important type of VALI, which should be diagnosed and mitigated at the early stage, during restoration of spontaneous breathing. This narrative review highlights the strategies used for protective positive pressure ventilation. The emerging concepts of damaging energy and power, as well as pathways to personalization of the respiratory settings, are discussed in detail. In the future, individualized approaches to protective ventilation may involve multiple respiratory settings extending beyond low tidal volume and PEEP, implemented in parallel with quantifying the risk of VALI and PPC.

Objective Carotid endarterectomy (CEA) is effective for the prevention of stroke, yet can be associated with a postoperative cognitive dysfunction (POCD) that may be affected by the type of anesthesia. The aim of the study was to compare the effects of total intravenous anesthesia (TIVA) with propofol to volatile induction and maintenance of anesthesia (VIMA) with sevoflurane on cerebral tissue oxygen saturation (SctO2) and POCD. Design Single-center, pilot randomized prospective study. Settings Single-center, 1,000-bed clinical hospital. Participants The study included 40 adult male patients. Interventions None. Measurements and Main Results Patients were randomized to the TIVA (n = 20) or the VIMA (n = 20) groups. Cardiorespiratory parameters and SctO2 were monitored during CEA and through 20 hours postoperatively. Cognitive functions were assessed preoperatively and on days 1 and 5 after CEA using the Montreal Cognitive Assessment Score (MoCA). In both groups, the ipsilateral SctO2 decreased after clamping, whereas the contralateral SctO2 asymmetrically decreased in the TIVA group only compared both with baseline and with the VIMA group. The changes in MoCA by day 1 correlated with the relative change in the ipsilateral SctO2 after the clamping in the TIVA group (ρ = 0.54, p = 0.015). The improvement of MoCA from days 1 to 5 was related to the relative decline in MAP after the clamping. Better cognitive function was observed by day 5 after sevoflurane VIMA compared with TIVA. Conclusion In CEA, VIMA with sevoflurane might preserve oxygenation in the contralateral hemisphere, suppress an asymmetry of cerebral oxygenation, and improve the early postoperative cognition compared with propofol anesthesia.

Aim of the study. To assess the accuracy of USCOM in patients after off-pump coronary artery bypass grafting (OPCAB). Methods. We enrolled 14 patients who underwent elective OPCAB into an ongoing prospective observational study. The measurements of cardiac index (CI) based on USCOM (CIUSCOM) in comparison with thermodilution CI (CITD) were performed at seven stages during postoperative period. Statistical analysis included assessment of agreement in absolute values of CI using Bland–Altman analysis. Results. Totally, 98 pairs of data were collected. According to Bland–Altman analysis of all pairs of data, mean bias between CIUSCOM and CITD was –1.09 L/min/m2 with limits of agreement of ±1.18 L/min/m2 and percentage error of 63 %. In a subgroup of stages with requirement of mechanical ventilation the intermethod bias was –1.16 L/min/m2 with limits of agreement of ±1.15 L/min/m2 and percentage error of 67 %, in a subgroup of stages after tracheal extubation the mean bias was –1.00 L/min/m2 with limits of agreement of ±1.23 L/min/m2 and percentage error of 59 %. Conclusions. USCOM demonstrates poor accuracy with underestimation of CI compared to thermodilution technique both before and after tracheal extubation. This method can not be recommended as an acceptable alternative in cardiac surgery.

Extravascular lung water (index) (EVLW(I)) can be estimated using transpulmonary thermodilution (TPTD). Computed tomography (CT) with quantitative analysis of lung tissue density has been proposed to quantify pulmonary edema. We compared variables of pulmonary fluid status assessed using quantitative CT and TPTD in critically ill patients. In 21 intensive care unit patients, we performed TPTD measurements directly before and after chest CT. Based on the density data of segmented CT images we calculated the tissue volume (TV), tissue volume index (TVI), and the mean weighted index of voxel aqueous density (VMWaq). CT-derived TV, TVI, and VMWaq did not predict TPTD-derived EVLWI values ≥ 14 mL/kg. There was a significant moderate positive correlation between VMWaq and mean EVLWI (EVLWI before and after CT) (r = 0.45, p = 0.042) and EVLWI after CT (r = 0.49, p = 0.025) but not EVLWI before CT (r = 0.38, p = 0.086). There was no significant correlation between TV and EVLW before CT, EVLW after CT, or mean EVLW. There was no significant correlation between TVI and EVLWI before CT, EVLWI after CT, or mean EVLWI. CT-derived variables did not predict elevated TPTD-derived EVLWI values. In unselected critically ill patients, variables of pulmonary fluid status assessed using quantitative CT cannot be used to predict EVLWI.

Goal of the study: to evaluate the accuracy of invasive measurement of cardiac output (CO) by pulse wave transit time (PWTT) (esCCO, Japan) compared to transpulmonary thermodilution (TPTD) (PiCCO2 , Germany) after aortocoronary bypass (ACB) without cardiopulmonary bypass (ACB without CPB). Methods. 21 patients with ACB without CPB were enrolled into the study. During early post-operative period CO was simultaneously registered at eight stages basing on PWTT (COPWTT) and TPTD (COTPTD). Statistic analysis included evaluation of congruence of CO absolute values and capability to follow-up changes in CO. Results. In accordance with Bland-Altman analysis the average difference between two methods made 0.3 l/min. with consistency limits of ± 2.1 l/min. and percent error of 40%. Polar chart analysis showed the angular difference of 2.6°, radial consistency limits ± 53.3° and polar concordance of 69%. Conclusion: Lower repeatability of CO measurement by PWTT and insufficient capability to follow the changes in CO after ACB without CPB don not allow recommending this method in its invasive variant for routine practice as an alternative to thermodilution methods.

To assess the accuracy and applicability of a novel system, not requiring calibration, for continuous lactate monitoring with intravascular microdialysis in high-risk cardiac surgery.Single-center prospective observational study.City Hospital #1 of Arkhangelsk, Russian Federation.Twenty-one adult patients undergoing elective complex repair or replacement of two or more valves or combined valve and coronary artery cardiac surgery.After induction of anesthesia, in all patients a dedicated triple-lumen catheter functioning as a regular central venous catheter with integrated microdialysis function was inserted via the right jugular vein for continuous lactate monitoring using the intravascular microdialysis system.Lactate values displayed by the microdialysis system were compared with the reference arterial blood gas (ABG) values. In total, 432 paired microdialysis-ABG lactate samples were obtained. After surgery, the concentration of lactate increased significantly, peaking at 8 hours (p0.05). The lactate clearance within 8 hours after peak concentration was 50% (39%-63%). There was a significant correlation between LactateLactate concentration increased significantly after high-risk cardiac surgery. The intravascular microdialysis technique for lactate measurement provided acceptable accuracy and can be used for continuous blood lactate monitoring in cardiac surgery.

Pulmonary complications are common after cardiac surgery and are closely related to postoperative heart failure and adverse outcomes. Lung ultrasonography (LUS) is currently a widely accepted diagnostic approach with well-established methodology, nomenclature, accuracy, and prognostic value in numerous clinical conditions. The advantages of LUS are universally recognized and include bedside applicability, high diagnostic sensitivity and reproducibility, no radiation exposure, and low cost. However, routine perioperative ultrasonography during cardiac surgery generally is limited to echocardiography, diagnosis of pleural effusion, and as a diagnostic tool for postoperative complications in different organs, and few studies have explored the clinical outcomes in relation to LUS among cardiac patients. This narrative review presents the clinical evidence regarding LUS application in intensive care and during the perioperative period for cardiac surgery. Furthermore, this review describes the methodology and the diagnostic and prognostic accuracies of LUS. A summary of ongoing clinical trials evaluating the clinical outcomes related to LUS also is provided. Finally, this review discusses the rationale for upcoming clinical research regarding whether routine use of LUS can modify current intensive care practice and potentially affect the clinical outcomes after cardiac surgery.

Background The early warning scores may increase the safety of perioperative period. The objective of this study was to assess the diagnostic and predictive role of Integrated Pulmonary Index (IPI) after off-pump coronary artery bypass grafting (OPCAB). Materials and Methods Forty adult patients undergoing elective OPCAB were enrolled into a single-center prospective observational study. We assessed respiratory function using IPI that includes oxygen saturation, end-tidal CO2, respiratory rate, and pulse rate. In addition, we evaluated blood gas analyses and hemodynamics, including ECG, invasive arterial pressure, and cardiac index. The measurements were performed after transfer to the intensive care unit, after spontaneous breathing trial and at 2, 6, 12, and 18 h after extubation. Results and Discussion The value of IPI registered during respiratory support correlated weakly with cardiac index (rho = 0.4; p = 0.04) and ScvO2 (rho = 0.4, p = 0.02). After extubation, IPI values decreased significantly, achieving a minimum by 18 h. The IPI value ≤9 at 6 h after extubation was a predictor of complicated early postoperative period (AUC = 0.71; p = 0.04) observed in 13 patients. Conclusion In off-pump coronary surgery, the IPI decreases significantly after tracheal extubation and may predict postoperative complications.

Background The discontinuation of mechanical ventilation after coronary surgery may prolong and significantly increase the load on intensive care unit personnel. We hypothesized that automated mode using INTELLiVENT-ASV can decrease duration of postoperative mechanical ventilation, reduce workload on medical staff, and provide safe ventilation after off-pump coronary artery bypass grafting (OPCAB). The primary endpoint of our study was to assess the duration of postoperative mechanical ventilation during different modes of weaning from respiratory support (RS) after OPCAB. The secondary endpoint was to assess safety of the automated weaning mode and the number of manual interventions to the ventilator settings during the weaning process in comparison with the protocolized weaning mode. Materials and methods Forty adult patients undergoing elective OPCAB were enrolled into a prospective single-center study. Patients were randomized into two groups: automated weaning (n = 20) using INTELLiVENT-ASV mode with quick-wean option; and protocolized weaning (n = 20), using conventional synchronized intermittent mandatory ventilation (SIMV) + pressure support (PS) mode. We assessed the duration of postoperative ventilation, incidence and duration of unacceptable RS, and the load on medical staff. We also performed the retrospective analysis of 102 patients (standard weaning) who were weaned from ventilator with SIMV + PS mode based on physician’s experience without prearranged algorithm. Results and discussion Realization of the automated weaning protocol required change in respiratory settings in 2 patients vs. 7 (5–9) adjustments per patient in the protocolized weaning group. Both incidence and duration of unacceptable RS were reduced significantly by means of the automated weaning approach. The FiO2 during spontaneous breathing trials was significantly lower in the automated weaning group: 30 (30–35) vs. 40 (40–45) % in the protocolized weaning group (p

Cardiac output monitoring, as a part of a goal-directed haemodynamic management, has been shown to improve perioperative outcome in high-risk patients undergoing major surgical interventions. However, thorough validation of cardiac output monitoring devices in different clinical conditions is warranted. The aim of our study was to compare the reliability of a novel system for cardiac index (CI) monitoring based on uncalibrated pulse contour analysis (UPCA) with transpulmonary thermodilution (TPTD) during off-pump coronary artery bypass grafting (OPCAB).Twenty patients undergoing elective OPCAB were enrolled into the study. CI measured by means of UPCA (CIUPCA) was validated against CI determined with TPTD technique (CITPTD). Parallel measurements of CI were performed at nine stages during the surgery and after operation. We assessed the accuracy and the precision of individual values and the agreement of trends of changes in CI.Totally, 180 pairs of data were collected. There was a significant correlation between CIUPCA and CITPTD (ρ=0.836, P0.01). According to a Bland-Altman analysis, the mean bias between the methods was -0.14 litre min(-1) m(-2) with limits of agreement of ±0.82 litre min(-1) m(-2) and a percentage error of 31%. A polar plot trend analysis revealed acceptable angular bias (-0.54°), increased radial limits of agreement (±52.7°), and decreased polar concordance rate (74%).In OPCAB, UPCA provides accurate and precise CI measurements compared with TPTD. However, the ability of this method to follow trends in cardiac output is poor.NCT01773720 (ClinicalTrials.gov).

To evaluate the accuracy of estimated continuous cardiac output (esCCO) based on pulse wave transit time in comparison with cardiac output (CO) assessed by transpulmonary thermodilution (TPTD) in off-pump coronary artery bypass grafting (OPCAB). We calibrated the esCCO system with non-invasive (Part 1) and invasive (Part 2) blood pressure and compared with TPTD measurements. We performed parallel measurements of CO with both techniques and assessed the accuracy and precision of individual CO values and agreement of trends of changes perioperatively (Part 1) and postoperatively (Part 2). A Bland-Altman analysis revealed a bias between non-invasive esCCO and TPTD of 0.9 L/min and limits of agreement of ±2.8 L/min. Intraoperative bias was 1.2 L/min with limits of agreement of ±2.9 L/min and percentage error (PE) of 64 %. Postoperatively, bias was 0.4 L/min, limits of agreement of ±2.3 L/min and PE of 41 %. A Bland-Altman analysis of invasive esCCO and TPTD after OPCAB found bias of 0.3 L/min with limits of agreement of ±2.1 L/min and PE of 40 %. A 4-quadrant plot analysis of non-invasive esCCO versus TPTD revealed overall, intraoperative and postoperative concordance rate of 76, 65, and 89 %, respectively. The analysis of trending ability of invasive esCCO after OPCAB revealed concordance rate of 73 %. During OPCAB, esCCO demonstrated poor accuracy, precision and trending ability compared to TPTD. Postoperatively, non-invasive esCCO showed better agreement with TPTD. However, invasive calibration of esCCO did not improve the accuracy and precision and the trending ability of method.

Background: We recently reported that post-pneumonectomy pulmonary oedema (PPO) occurs after ventilating the remaining lung with excessive tidal volumes. Studies in small animals have indicated that nitric oxide (NO) release increases in hyper-inflated lungs, but confirmatory evidence from larger animals is still lacking. We hypothesized that PPO could be prevented by methylene blue (MB), an inhibitor of NO synthase. Methods: Sheep were subjected to a right-sided pneumonectomy (PE) and randomly assigned to a protectively ventilated group ((PROTV group, n=7) with tidal volumes of 6 ml/kg at 20 inflations/min and a positive end-expiratory pressure (PEEP) of 2 cmH2O, and two groups undergoing ‘injurious ventilation’ (INJV) with tidal volumes of 12 ml/kg and zero end-expiratory pressure (ZEEP), a control group (INJV group, n=7) and a treatment group subjected to MB 1 h after PE (INJV+MB group, n=7). Haemodynamic variables, lung mechanics, blood gases and plasma nitrites and nitrates (NOx) were determined. Results: PE reduced pulmonary blood volume, extravascular lung water (EVLWI) and quasistatic lung compliance in all groups, in parallel with a rise in peak airway pressure (P

To discuss the perioperative monitoring tools and targets for haemodynamic optimization and to assess the influence of goal-directed therapy (GDT) on organ function, complications and outcome in different categories of surgical patients.The choice of perioperative haemodynamic monitoring for GDT depends on the surgery-related and the patient-related risk. Conventional monitoring and minimally invasive approaches can be used for perioperative optimization of low-risk to moderate-risk patients. Thermodilution methods and continuous cardiac output/oxygen transport monitoring are the most reliable techniques for major surgery and high-risk/unstable patients. An important goal of perioperative haemodynamic therapy is to maintain cardiac function and organ perfusion, optimizing the balance between oxygen delivery and consumption. Several studies, using different monitoring tools and end-points, have shown that GDT provides optimal haemodynamic performance, improves organ function, reduces the number of complications and time to ICU and hospital discharge and decreases the mortality rate in high-risk surgical patients.GDT provides a number of benefits in major surgery. Based on adequate monitoring, the goal-directed algorithms facilitate early detection of pathophysiological changes and influence the perioperative haemodynamic therapy that can improve the clinical outcome. The perioperative GDT should be early, adequate and individualized for every patient.

Background: We hypothesized that in acute lung injury (ALI), the volume of pulmonary tissue with aqueous density, as determined by spiral computed tomography (CT), is associated with extravascular lung water content. Our aim was to compare tissue volume index, as assessed by CT, before and after oleic acid-induced ALI, with extravascular lung water indexes (EVLWI), determined with single transpulmonary thermodilution (EVLWISTD), thermal-dye dilution (EVLWITDD), and postmortem gravimetry (EVLWIG). Methods: Seven instrumented sheep received an intravenous infusion of oleic acid 0.08 ml/kg (OA group) and four animals had vehicle only (Control group). The day before, and immediately after the experiment, sheep were anesthetized to undergo quantitative CT examinations during a short breath hold. Hemodynamics, oxygenation, EVLWISTD ,a nd EVLW TDD were registered. Linear regression analysis was used to assess the relationships between EVLWISTD ,E VLW TDD ,E VLWI G, and lung tissue volume index (TVICT) determined with CT. Results: In the OA group, total lung volume increased compared with Controls. Poorly and non-aerated lung volumes increased a 3.6- and 4.9-fold, respectively, and TVICT almost doubled. EVLWISTD ,E VLWI TDD, and TVICT were associated significantly with EVLWIG (r 5 0.85, 0.90, and 0.88, respectively; Po0.001). TVICT deviated from the reference EVLWIG values to the greatest extent with am ean bias� 2SD of 4.0 � 6.0 ml/kg. Conclusions: In ovine oleic acid-induced ALI, lung tissue volume, as assessed by quantitative CT, is in close agreement with EVLWI, as determined by indicator dilution methods and postmortem gravimetry, but overestimates lung fluid content.

Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing.

Accumulation of extravascular lung water (EVLW) is a hallmark of pulmonary edema and acute respiratory distress syndrome (ARDS) of various etiologies [1]. Increased EVLW is associated with a high mortality rate [1–3]. Thus, in critically ill patients, the balance and maintenance of cardiac preload and vital organ perfusion should be thoroughly weighed against the deleterious effects of worsening pulmonary edema, and quantification of EVLW may offer a valuable therapeutic guide to providers of intensive care.

AIM: To determine the influence of intra-abdominal pressure (IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period. METHODS: Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study. IAP monitoring was performed via both a balloon-tipped nasogastric probe [intragastric pressure (IGP), CiMON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure (IBP), UnoMeterAbdo-Pressure Kit, UnoMedical, Denmark] on five consecutive stages: (1) after tracheal intubation (AI); (2) after ventral hernia repair; (3) at the end of surgery; (4) during spontaneous breathing trial through the endotracheal tube; and (5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages. RESULTS: The IAP (measured via both techniques) increased on average by 12% during surgery compared to AI (P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube (P < 0.01). In parallel, the gradient between РаСО2 and EtCO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/FiO2 decreased by 30% one hour after tracheal extubation (P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20% (P < 0.025). At all stages, we observed a significant correlation between IGP and IBP (r = 0.65-0.81, P < 0.01) with a mean bias varying from -0.19 mmHg (2SD 7.25 mmHg) to -1.06 mm Hg (2SD 8.04 mmHg) depending on the study stage. Taking all paired measurements together (n = 133), the median IGP was 8.0 (5.5-11.0) mmHg and the median IBP was 8.8 (5.8-13.1) mmHg. The overall r2 value (n = 30) was 0.76 (P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mmHg (2SD 4.2 mmHg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing ΔIBP and ΔIGP (n = 117). CONCLUSION: During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/FiO2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.