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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Month: February 2008 (Page 1 of 2)

Mini invasive hemodynamic monitoring: from arterial pressure to cardiac output

Abstract

To evaluate the Cardiac Output (CO) the standard invasive pulmonary artery catheter (PAC) is considered today the gold standard. The major criticism to the PAC is that its level of invasiveness is not supported by an improvement in patient’s outcome. The interest to lesser and lesser invasive techniques is high. Therefore, the alternative techniques have been recently developed.
Cardiac Output can be monitored continuously by different devices that analyze the arterial waveform to track changes in stroke volume (SV) and CO. The analysis of the arterial pressure wave to determine cardiac output is classified as Pulse Contour analysis or Pulse Pressure Analysis. Starting from a similar principle three main devices are now available on the market, with different algorithms and features:

• PiCCO System (Pulsion Medical System, Munich, Germany)
• LiDCOTM plus System (LidCO, Cambridge, UK)
• Flotrac technology and Vigileo Monitor (Edwards Lifesciences, Irvine, CA, USA).

The algorithm used by all these devices has been also implemented even with the analysis of the variation of stroke volume (SVV) and of the pulse pressure (PPV). SVV and PPV represent the variation of stroke volume and of the pulse pressure during the respiratory cycle. In sedated ventilated patients these indexes have proven to predict the response to a fluid challenge. A high variation (>10-12%) identifies with good sensitivity and specificity responders and not responders.

Key words: cardiac output, arterial pressure, stroke volume variation, pulse pressure variation

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Analgesia and sedation in hemodynamic unstable patient

Abstract

Pain, restlessness, tension and delirium are almost always encountered while treating hemodynamic unstable critical patients in the intensive care units. Usually in critical patients, the evaluation of the nature and pain intensity (VAS scale) are often impossible. During the last 10 years intense nociceptor somatic and visceral post operative pain is believed to be the most crucial factor in the development of endocrine and neurohumoral disorders, within the postoperative period. Chronic post operative pain is appearing often (30%-40%), with great influence on the quality of patients life. The modern principal in treating acute pain is the use of multimodal balanced analgesia approach, which is individually catered with drug and dose for each patient. Modern systemic analgesia is understood to be the continuous use of opiates or opioids, titrated towards pain intensity, with a minimum number of complications even in hemodynamic unstable patients. The combined use of opioids with NSAID and paracetamol reduces the overall dosage of opioids by 20% – 30% and therefore significantly contributes to hemodynamic and respiratory stability. Effective and safe epidural analgesia in hemodynamic unstable patients can be optimized by simultaneous use of various drugs with different mechanisms of action (local anaesthetic, opioid, adrenalin, ketamin). The accepted concept of analgosedation in critical patients is understood to be the use of short acting drugs (fentanyl, sufentanil, remifentanil, midazolam, propofol) in which drug dosage can be quickly adjusted in respect to the present clinical state of the patient.

Key words: acute postoperative pain, multimodal balanced analgesia, analgesia drugs

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Levosimendan in acute heart failure

Abstract

Numerous adverse effects and an increased mortality are the reasons why many clinicians are often unsuccessful with the inotropic agents presently in use. New therapeutic agents have been developed in the last few years to assist the clinician in the stabilization, support and treatment of cardiovascular disease.
One of the newest groups of inotropic agents is a group of agents, which increase the affinity of myofibrils for calcium and are called calcium sensitizers. Calcium sensitizers are the newest heterogeneous group of inotropic agents. The best known representatives of this group are levosimendan and pimobendan. Positive inotropic effects of levosimendan are achieved by its binding to troponin C and calcium, thereby stabilizing the tropomyosin molecule and prolonging the duration of actinmyosin overlap without a change in the net concentration of intracellular calcium. The vasodilatory effect of levosimendan is reached through activation of ATP-dependent potassium channels. This leads to a decrease in both afterload and preload, increased coronary blood flow and a resultant anti-ischemic effect. Levosimendan is therefore categorized as an antiischemic inotropic agent. Furthermore, experiments have confirmed that levosimendan as an opener of KATP – channels in the mitochondria and the sarcolemma of myocites may have an effect on the myocardium preconditioning

Key words: levosimendan, inotropic state, preconditioning, low cardiac output syndrome

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Extracorporeal membranous oxygenation (ECMO) in neonates and children experiences of a multidisciplinary paediatric intensive care unit

Abstract

Extracorporeal membranous oxygenation ECMO was applied in 18 patients. All children had deep hypoxia and 80% probability of dying. Average duration of ECMO in newborns was 131 hours, and in older patients 253 hours. Seven patients were discharged from the intensive care unit (late survivors), 5 of them are in perfect somatic and mental condition.

Key words: extracorporeal membra-nous oxygenation, neonate, child

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Thoracic electrical bioimpedance theory and clinical possibilities in perioperative medicine

Abstract

This article is a short review of thoracic electrical bioimpedance (TEB) theory and clinical capabilities. Cardiac output measurement is used primarily to guide therapy in complex, critically ill patients. Thoracic electrical bioimpedance is one of several noninvasive techniques that have been investigated to measure cardiac output and other hemodynamic parameters. Opinions in current literature continue to be conflicting as to the utility of thoracic electrical bioimpedance to that purpose. There is a limited number of good designed studies but they imply TEB is an accurate and reliable noninvasive method for determining cardiac output/cardiac index and it would be valuable for patients and circumstances in which intracardiac pressures and mixed venous blood samples are not necessary.

Key words: bioimpedance, non-invasive hemodynamic monitoring, cardiac output, pulmonary artery catheter, thermo dilution

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