Peripheral venous pressure predicts central venous pressure poorly in pediatric patients

Purpose: Using peripheral venous pressure (PVP) instead of central venous pressure (CVP) as a volume monitor decreases patient risks and costs, and is convenient. This study was undertaken to determine if PVP predicts CVP in pediatric patients. METHODS: With ethical approval and informed consent, 30 pediatric patients aged neonate to 12 yr requiring a central venous line were studied prospectively in a tertiary care teaching hospital. In the supine position, PVP and CVP were simultaneously transduced. Ninety-six paired recordings of CVP and PVP were made. Correlation and Bland-Altman analysis of agreement of end-expiratory measurements were performed. RESULTS: The mean (SD; range) CVP was 10.0 mmHg (6.0; -1.0 to 27.0); the mean PVP was 13.7 mmHg (6.3; 0.0 to 33.0); offset (bias) of PVP > CVP was 3.7 mmHg with SD 2.6. The 95% confidence intervals (CI) for the bias were 3.2 to 4.1 mmHg. In the Bland-Altman analysis, lower and upper limits of agreement (LOA; CI in parentheses) were -1.5 (-2.3 to -0.7) and 8.8 (8.1 to 9.6) mmHg. Eight of 96 points were outside the limits of agreement. The correlation of PVP on CVP was r = 0.92, P < 0.0001. For a subset of ten patients (20 simultaneous recordings) with iv catheters proximal to the hand, limits of agreement were better - offset: 3.8 mmHg (+/- 1.4); lower LOA: 1.2 mmHg (0.25 to 2.1); upper LOA: 6.6 mmHg (5.7 to 7.5). CONCLUSION: Peripheral venous pressure measured from an iv catheter in the hand predicts CVP poorly in pediatric patients.     

Peripheral venous pressure is an alternative to central venous pressure in paediatric surgery patients

BACKGROUND: Peripheral venous pressure (PVP) is easily and safely measured. In adults, PVP correlates closely with central venous pressure (CVP) during major non-cardiac surgery. The objective of this study was to evaluate the agreement between CVP and PVP in children during major surgery and during recovery. METHODS: Fifty patients aged 3-9 years, scheduled for major elective surgery, each underwent simultaneous measurements of CVP and PVP at random points during controlled ventilation intraoperatively (six readings) and during spontaneous ventilation in the post-anaesthesia care unit (three readings). In a subset of four patients, measurements were taken during periods of hypotension and subsequent fluid resuscitation (15 readings from each patient). RESULTS: Peripheral venous pressure was closely correlated to CVP intraoperatively, during controlled ventilation (r=0.93), with a bias of 1.92 (0.47) mmHg (95% confidence interval = 2.16-1.68). In the post-anaesthesia care unit, during spontaneous ventilation, PVP correlated strongly with CVP (r = 0.89), with a bias of 2.45 (0.57) mmHg (95% confidence interval = 2.73-2.17). During periods of intraoperative hypotension and fluid resuscitation, within-patient changes in PVP mirrored changes in CVP (r = 0.92). CONCLUSION: In children undergoing major surgery, PVP showed good agreement with CVP in the perioperative period. As changes in PVP parallel, in direction, changes in CVP, PVP monitoring may offer an alternative to direct CVP measurement for perioperative estimation of volume status and guiding fluid therapy.     

Usefulness of a central venous catheter during hepatic surgery

Aim: Central venous catheter (CVC) is often inserted during liver resection because a low central venous pressure (CVP) reduces blood loss and the procedure may be associated with circulatory impairment. The aim of the study was to evaluate the usefulness of a CVC besides the measurements of CVP, and whether peripheral venous pressure (PVP) measurement could be used reliably in place of CVP.
Methods: We conducted an observational study during a 16-month period. Number of CVC inserted, expected surgical difficulties, and intraoperative complications which could lead to treatment involving a CVC were prospectively recorded and analysed. Measurements of CVP and PVP were simultaneously obtained at different times during surgery. Bias and limits of agreement with their 95% confidence interval (95% CI) were calculated.
Results: Of the 101 patients included, 28 had expected surgical difficulties. Of the 75 CVCs inserted, only six (8%) were used for another purpose that CVP measurement in patients with expected surgical difficulties. A total of 124 measurements in 23 patients were recorded. Mean CVP was 4.8 ± 2.9 mmHg and mean PVP was 6.9 ± 3.1 mmHg ( P <0.0001). The bias was −2.1 ± 1.1 mmHg (95% CI: −2.3 to −1.9). When adjusted by the average bias of −2 mmHg, PVP predicted a CVP≤5 mmHg with a sensitivity and a specificity of 93% and 87%, respectively.
Conclusion: Routine insertion of a CVC should be discussed in patients without expected surgical difficulties. Thus, PVP monitoring may suffice to estimate CVP in uncomplicated cases.     

Correlation of peripheral venous pressure and central venous pressure in surgical patients

OBJECTIVE: To determine the degree of agreement between central venous pressure (CVP) and peripheral venous pressure (PVP) in surgical patients. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Patients without cardiac dysfunction undergoing major elective noncardiac surgery (n = 150). MEASUREMENTS AND MAIN RESULTS: Simultaneous CVP and PVP measurements were obtained at random points in mechanically ventilated patients during surgery (n = 100) and in spontaneously ventilating patients in the postanesthesia care unit (n = 50). In a subset of 10 intraoperative patients, measurements were made before and after a 2-L fluid challenge. During surgery, PVP correlated highly to CVP (r = 0.86), and the bias (mean difference between CVP and PVP) was -1.6 +/- 1.7 mmHg (mean +/- SD). In the postanesthesia care unit, PVP also correlated highly to CVP (r = 0.88), and the bias was -2.2 +/- 1.9 (mean +/- SD). When adjusted by the average bias of -2, PVP predicted the observed CVP to within +/-3 mmHg in both populations of patients with 95% probability. In patients receiving a fluid challenge, PVP and CVP increased similarly from 6 +/- 2 to 11 +/- 2 mmHg and 4 +/- 2 to 9 +/- 2 mmHg. CONCLUSION: Under the conditions of this study, PVP showed a consistent and high degree of agreement with CVP in the perioperative period in patients without significant cardiac dysfunction. PVP -2 was useful in predicting CVP over common clinical ranges of CVP. PVP is a rapid noninvasive tool to estimate volume status in surgical patients.     

Peripheral venous pressure as a measure of venous compliance during pheochromocytoma resection

Venous pressures measured from peripheral venous catheters (PVP) closely estimate the central venous pressure (CVP) in surgical and critically ill patients. CVP is often used to estimate intravascular volume; however, fluctuations of CVP may also be induced by changes in venous tone caused by alpha-adrenergic catecholamine stimulation. We simultaneously monitored PVP, CVP, and mean arterial blood pressure during resection of pheochromocytoma in a 63-yr-old woman and found excellent correlation between the three pressure variables, suggesting that fluctuations of PVP reflect overall changes in vascular tone.     

Peripheral venous pressure as a predictor of central venous pressure during orthotopic liver transplantation

STUDY OBJECTIVE: To assess the reliability of peripheral venous pressure (PVP) as a predictor of central venous pressure (CVP) in the setting of rapidly fluctuating hemodynamics during orthotopic liver transplant surgery. DESIGN: Prospective clinical trial. SETTING: UCLA Medical Center, main operating room-liver transplant surgery. PATIENTS: Nine adult patients with liver failure undergoing orthotopic liver transplant surgery. INTERVENTIONS: A pulmonary artery catheter and a 20-g antecubital peripheral intravenous catheter dedicated to measuring PVP were placed in all patients after standard general endotracheal anesthesia induction and institution of mechanical ventilation. MEASUREMENTS: Peripheral venous pressure and CVP were recorded every 5 minutes and/or during predetermined, well-defined surgical events (skin incision, venovenous bypass initiation, portal vein anastamosis, 5 minute post graft reperfusion, abdominal closure). Pulmonary artery pressure and cardiac output (via thermodilution) were recorded every 15 and 30 minutes, respectively. MAIN RESULTS: Peripheral venous pressure (mean +/- SD) was 11.0 +/- 4.5 mmHg vs a CVP of 9.5 +/- 5.0; the two measurements differed by an average of 1.5 +/- 1.6 mmHg. Peripheral venous pressure correlated highly with CVP in every patient, and the overall correlation among all nine patients calculated using a random-effects regression model was r = 0.95 (P < 0.0001). A Bland-Altman analysis used to determine the accuracy of PVP in comparison to CVP yielded a bias of -1.5 mmHg and a precision of +/-3.1 mm Hg. CONCLUSION: Our study confirms that PVP correlates with CVP even under adverse hemodynamic conditions in patients undergoing liver transplantation.     

Effect of catheter site on the agreement of peripheral and central venous pressure measurements in neurosurgical patients

STUDY OBJECTIVE: Previous studies suggest a correlation of central venous pressure (CVP) with peripheral venous pressure (PVP) in different clinical setups. The aim of this study was to investigate the effect of measurement site on PVP and its agreement with CVP in patients undergoing general anesthesia. DESIGN: Prospective randomized study. SETTINGS: University hospital. PATIENTS: Thirty patients of American Society of Anesthesiologists physical status I and II undergoing elective craniotomy. INTERVENTIONS: Patients were randomly assigned into Group A (antecubital; n=15) and Group D (dorsum hand; n=15) for antecubital and hand dorsum catheterization sites, respectively. Central venous pressure and PVP were monitored throughout the study. A total of 1925 simultaneous measurements were recorded at 5-minute intervals. Bland-Altman assessment for agreement was used for CVP and PVP in 2 groups. MEASUREMENTS: Peripheral venous pressure measurements were within the range of +/-2 mm Hg of CVP values, in 93.9% of the measurements in Group A, and in 91.2% of the measurements in Group D. Considering all measurements, mean bias was -0.072 mm Hg (95% CI, -0.134 to -0.010). Group A measurements showed a bias (CVP-PVP) of 0.173+/-3.557 mm Hg, whereas the bias was -0.122+/-4.322 mm Hg (mean+/-SDcorrected for repeated measurements) in Group D. All of the measurements were within mean+/-2SD of bias, which means that PVP and CVP are interchangeable in our clinical setting. CONCLUSION: Peripheral venous pressure measurement may be a noninvasive alternative for estimating CVP in patients undergoing elective neurosurgical operations. Measuring PVP from hand dorsum does not interfere with the agreement of CVP and PVP.     

The relationship between central venous pressure and pulmonary capillary wedge pressure during aortic surgery

Twenty-three ASA physical status II-III patients scheduled for elective abdominal aortic surgery were studied preoperatively with multiple unit gated acquisition angiography (MUGA) scan to determine the resting left ventricular and right ventricular ejection fractions (LVEF and RVEF respectively). Intraoperatively pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) were measured in each patient at five different time periods in the horizontal, 24 degrees head up, and 24 degrees head down table tilt positions. The correlation between absolute values and changes in PCWP and CVP, and the degree to which preoperative knowledge of LVEF and RVEF predicted these correlations were examined. Resting LVEF ranged from 0.1 to 0.84. Thirteen of the 23 patients failed to show significant correlation (p less than 0.05) between the absolute values of PCWP and CVP either before and/or after aortic crossclamp. When the correlation coefficients from this analysis were ranked against LVEF, there was a weak but significant correlation before aortic crossclamp (r = 0.41), but not after. The correlation between a change in PCWP and a change in CVP was significant for the 23 patients at all time intervals, before and after aortic crossclamp. However, the prediction of a change of PCWP value from a known change of CVP value ranged in accuracy from +/- 3 mmHg to +/- 12.5 mmHg. The study suggests that if the filling pressures of both ventricles need to be assessed during aortic surgery, then the PCWP and CVP must be independently measured.(ABSTRACT TRUNCATED AT 250 WORDS)     

Can peripheral venous pressure be an alternative to central venous pressure during right hepatectomy in living donors?

The safety of living donors is a matter of cardinal importance in addition to obtaining optimal liver grafts to be transplanted. Central venous pressure (CVP) is known to have significant correlation with the amount of bleeding during parenchymal transection and many centers have adopted CVP monitoring for right hepatectomy. However, central line cannulation can induce some serious complications. Peripheral venous pressure (PVP) has been suggested as a comparable alternative to CVP. The aim of this study was to determine whether a clinically acceptable agreement or a reliable correlation between CVP and PVP exist and if CVP can be replaced by PVP in living liver donors. A central venous catheter was placed through the right internal jugular vein and a peripheral venous catheter was inserted at antecubital fossa in the right arm. CVP and PVP were recorded in 15-minute intervals in 50 adult living donors. The paired data were divided into 3 stages: preparenchymal transection, parenchymal transection, and postparenchymal transection. A total of 1,430 simultaneous measurements of CVP and PVP were recorded. Overall, the PVP, CVP, and bias were 7.0+/-2.46, 5.9+/-2.32, and 1.16+/-1.12 mmHg, respectively. A total of 88.9% of all measurements were clinically within acceptable limits of bias (+/-2 mmHg). Regression analysis showed a high correlation coefficient between PVP and CVP (r=0.893; P<0.001) and the limits of agreement were -1.03 to 3.34 overall. In conclusion, frequencies of differences, bias, correlation coefficient, and limits of agreement between PVP and CVP remained relatively constant throughout the operation. Therefore, PVP measurement in the arm can be an alternative to predict CVP and further, obviate central venous catheter-related complications in living liver donors.     

Effect of body temperature on peripheral venous pressure measurements and its agreement with central venous pressure in neurosurgical patients

Previous studies suggest a correlation of central venous pressure (CVP) with peripheral venous pressure (PVP) in different clinical settings. The effect of body temperature on PVP and its agreement with CVP in patients under general anesthesia are investigated in this study. Fifteen American Society of Anesthesiologists I-II patients undergoing elective craniotomy were included in the study. CVP, PVP, and core (Tc) and peripheral (Tp) temperatures were monitored throughout the study. A total of 950 simultaneous measurements of CVP, PVP, Tc, and Tp from 15 subjects were recorded at 5-minute intervals. The measurements were divided into low- and high-Tc and -Tp groups by medians as cutoff points. Bland-Altman assessment for agreement was used for CVP and PVP in all groups. PVP measurements were within range of +/-2 mm Hg of CVP values in 94% of the measurements. Considering all measurements, mean bias was 0.064 mm Hg (95% confidence interval -0.018-0.146). Corrected bias for repeated measurements was 0.173 +/- 3.567 mm Hg (mean +/- SD(corrected)). All of the measurements were within mean +/- 2 SD of bias, which means that PVP and CVP are interchangeable in our setting. As all the measurements were within 1 SD of bias when Tc was > or = 35.8 degrees C, even a better agreement of PVP and CVP was evident. The effect of peripheral hypothermia was not as prominent as core hypothermia. PVP measurement may be a noninvasive alternative for estimating CVP. Body temperature affects the agreement of CVP and PVP, which deteriorates at lower temperatures.     

Peripheral venous pressure as a hemodynamic variable in neurosurgical patients

Neurosurgical patients undergoing either craniotomy or complex spine surgery are subject to wide variations in blood volume and vascular tone. The ratio of these variables yields a pressure that is traditionally measured at the superior vena cava and referred to as "central venous pressure" (CVP). We have investigated an alternative to CVP by measuring peripheral venous pressure (PVP), which, in parallel animal studies, correlates highly with changes in absolute blood volume (r = 0.997). We tested the hypothesis that PVP trends parallel CVP trends and that their relationship is independent of patient position. We also tested and confirmed the hypothesis, during planned circulatory arrest, that PVP approximates mean systemic pressure (circulatory arrest pressure), which reflects volume status independent of cardiac function. PVP was compared with CVP across 1026 paired measurements in 15 patients undergoing either craniotomy (supine, n = 8) or complex spine surgery (prone, n = 7). Repeated-measures analysis of variance indicated a highly significant relationship between PVP and CVP (P < 0.001), with a Pearson correlation coefficient of 0.82. The correlation was best in cases with significant blood loss (estimated blood loss >1000 mL; r = 0.885) or hemodynamic instability (standard deviation of CVP > 2; r = 0.923). Implications: In patients undergoing either elective craniotomy or complex spine surgery, peripheral venous pressure (PVP) trends correlated with central venous pressure (CVP) trends with a mean offset of 3 mm Hg (PVP > CVP). PVP trends provided equivalent physiological information to CVP trends in this subset of patients, especially during periods of hemodynamic instability. In addition, measurements made during a planned circulatory arrest support the hypothesis that PVP approximates mean systemic pressure (systemic arrest pressure), which is a direct index of patient volume status independent of cardiac or respiratory activity.     

The relationship of abdominal perfusion pressure with mortality in critically ill pediatric patients

PurposeTo the best of our knowledge, in the literature, there is no data regarding clinical utility of the abdominal perfusion pressure (APP) in critically ill children. Thus, in the present study, we aimed to investigate the clinical utility of APP in predicting of survival in critically ill children with IAH.DesignA prospective cohort study of patients between 1 month to 18 years who had risk for intra-abdominal hypertension from June 2013 to January 2014.SettingPediatric intensive care unit (PICU) at a tertiary university hospital.PatientsThirty-five (16 female) PICU patients who had risk for the development of IAH were included. Serial intraabdominal pressure (IAP) and mean arterial pressure (MAP) measurements were performed. Abdominal perfusion pressure was calculated using the formula (MAP-IAP).Measurements and Main ResultsOverall mortality rate was 49% (n = 17). The mortality rate in patients with IAP mean ≥ 10 mmHg (n = 27, 77%) was 55% (n = 15), while 53% (n = 16) in patients with IAP max ≥ 10 mmHg (n = 30, 86%) and 47% (n = 7) in patients with IAP min ≥ 10 mmHg (n = 15, 43%). Overall mean APP was 58 ± 20 mmHg. Logistic regression analysis revealed that decrease in minAPP was associated with increased risk for mortality (Odds ratio for each 1 mmHg decrease in APP was 1.052 [CI 95%, 1.006–1.100], p < 0.05). ROC curve analysis revealed that, in predicting mortality, area under curve for minAPP was 0.765. The optimal cut-off point for APP was obtained as 53 mmHg with the 77.8% sensitivity and 70.6% specificity using the IU method.ConclusionsOur findings showed that APP seems to be a useful tool in predicting mortality. Interventions to improve APP may be associated with better outcomes in critically ill PICU patients.Level of evidenceLevel II.Type of studyDiagnostic.     

A comparison between systolic pressure variations under mechanical ventilation and classic pressure parameters in predicting fluid responsiveness in patients after coronary surgery

Evaluation of the value of the systolic pressure variations (SPV) under mechanical ventilation and of its components (delta down and delta up) in predicting fluid responsiveness in patients after coronary surgery by comparison with classic parameters. A prospective,randomized study, on 50 patients who underwent CABG surgery, in the early postoperative period (the first two hours). We assessed the following parameters: CO, CI, CVP, PCWP, SAP, DAP, MAP, SVP, delta down and delta up. The including criteria were: sinus rhythm, CI < or = 2,5 l/min/m2, PCP < 18 mmHg. All the patients underwent a fluid challenge (500 ml of colloids in 10 min). Three patients were excluded: 3 for a PCWP > 18 mm Hg, 1 for loosing the sinus rhythm and 1 for an early return in the OR for bleeding. After a new assessment of the same parameters the patients were divided in two groups: group A (28 pts) with a raise of CI > 15%, and group B (22 pts) with a CI variation < 15%. In each group was statistically analyzed the variation of each parameter. Results Both parameters provided by SPV analysis are able to predict the fluid responsiveness with a great accuracy: the positive predictive value of a SPV > 12 mmHg is above 92,85% and of a delta down > 5 mm Hg is above 96,42%; the negative predictive value of a SPV < or = 12 mmHg is above 90,90% and of a delta down = 5 mm Hg is above 95,45%. None of the "classic" pressure parameters (MAP, CVP, PCWP) used in hemodynamic assessment have revealed a statistical significant variation. The SVP method's parameters are superior to classic pressure parameters (MAP, CVP, PCWP) in predicting fluid responsiveness in patients after coronary surgery.     

The effect of predictive display on the control of step changes in effect site sevoflurane levels*

Graphical displays of past and future levels of drugs may be a useful adjunct to manual dosing. We have previously found that a display of predicted future values speeds step changes in end‐tidal sevoflurane. In this study anaesthetists made step changes of 0.3% in effect site sevoflurane, with and without the display and as increases and decreases. We analysed 91 changes. When the predictive display was present, users made larger vaporiser dial changes of 3.9% vs 3.1% (95% CI for the difference ?1.3% to ?0.01%, p = 0.046) reflected in larger end‐tidal changes (95% CI for the difference ?0.009 vol% to ?0.34 vol%, p = 0.06). There was no difference in the speed of change (220 vs 227 s (95% CI for the difference ?51 to 32 s)), or in the accuracy of the change. In this study the predictive display influenced the magnitude of the step changes made by anaesthetists but did not affect the speed or overall accuracy of the change.     

Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence

OBJECTIVE: To determine the comparative efficacy of selective decontamination of the digestive tract in critically ill surgical and medical patients, and in selected subgroups of surgical patients with pancreatitis, major burn injury, and those undergoing major elective surgery and transplantation. DATA SOURCES: The MEDLINE database was searched from January 1966 to December 1996 using the terms "decontamination or prophylaxis," "intensive care units," and "antibiotics." The search was limited to English-language studies evaluating the efficacy of selective decontamination of the digestive tract in human subjects. STUDY SELECTION: The primary review was restricted to prospective randomized trials. DATA EXTRACTION: End points of interest included rates of nosocomial pneumonia, bacteremia, urinary tract infection, wound infection, mortality, and length of intensive care unit stay. Methodologic quality of individual studies was assessed using a previously described model. DATA SYNTHESIS: Odds ratios (ORs) together with their (95% confidence interval [Cls]) were reported and determined using the Mantel-Haenszel method. Mortality was significantly reduced with the use of selective decontamination of the digestive tract in critically ill surgical patients (OR, 0.7, 95% CI, 0.52-0.93), while no such effect was demonstrated in critically ill medical patients (OR, 0.91; 95% CI, 0.71-1.18). The greatest effect was demonstrated in studies where both the topical and systemic components of the regimen were used. Rates of pneumonia were reduced in both subsets of patients, while those of bacteremia were significantly reduced only in surgical patients. CONCLUSIONS: Selective decontamination of the digestive tract notably reduces mortality in critically ill surgical patients, while critically ill medical patients derive no such benefit. These data suggest that the use of selective decontamination of the digestive tract should be limited to those populations in whom rates of nosocomial infection are high and in whom infection contributes notably to adverse outcome.     

原位肝移植术无肝期体肺循环的变化及维持

目的 分析晚期肝病患者非静脉转流原位肝移手术不同阶段体、肺循环的变化并探讨维持无肝期血流动力学的措施. 方法收集68例肝移植患者手术前(麻醉诱导后)、无肝期前、无肝期5 min、无肝期30 min、新肝期5 min、新肝期30 min、新肝期60 min、术毕、术后12h及24h各时间点中心静脉压(CVP)、心率(HR)、平均动脉压(MABP)、平均肺动脉压(MPAP)、肺动脉楔压(PAWP)、心脏指数(CI)、体循环阻力(SVR)、肺循环阻力(PVR)等数据,并根据无肝期CVP将患者分为3组:A组(CVP<4 mm Hg),B组(4 mm Hg≤CVP≤6 mm Hg),C组(CVP>6 mm Hg),分析比较3组患者手术各时期及术后血流动力学指标变化,以及血管活性药多巴胺、去甲肾上腺素、肾上腺素用量及尿量. 结果肝移植手术不同阶段,患者体、肺循环发生不同变化,与无肝期前相比,无肝期HR增快,CVP、MABP、PVP、CI、PAWP降低,SVR、PVR增高,P<0.05,具有显著性差异,表现为循环血容量降低,体循环及肺血管阻力增高;新肝期早期(新肝期5、30 min)HR减慢,CVP、PAWP、MPAP、PVR、SVR增高(P<0.05),新肝期开始,MABP降低、升高波动大,5 min后升高并趋于稳定.3组间比较,B组患者各时期血体、肺循环指标波动最小,术中血管活性药用量最少,与A、C组比较,差异有统计学意义(P＜0.05). 结论原位肝移植术中患者体、肺循环剧烈变化主要发生在无肝期及新肝早期,无肝期血流动力学的恰当维持尤为重要,适量补充血容量并复合应用多巴胺、去甲肾上腺素、肾上腺素等血管活性药,维持CVP4～6 mm Hg、MABP≥60 mm Hg、PAWP、SVR、PVR正常范围,有利于患者新肝期及术后血流动力学的稳定.     

Recipient Hemodynamics During Non-Heart-Beating Donor Kidney Transplantation Are Major Predictors of Primary Nonfunction

Non-heart-beating donor (NHBD) kidneys may substantially expand the donor pool, but many transplant centers are reluctant to use these kidneys because of the relatively high incidence of primary nonfunction (PNF). In heart-beating donor kidneys, intravascular fluid depletion during transplant surgery is associated with delayed graft function (DGF). Therefore, we studied the effect of the recipients' hemodynamic status on the outcome of 177 NHBD kidney transplantations. Independent statistically significant predictors of PNF were average central venous pressure (CVP) below 6 cmH(2)O (adjusted odds ratio (AOR) 3.1 (95% CI: 1.4-7.1), p=0.007), average systolic blood pressure below 110 mmHg (AOR 2.6 (95% CI: 1.1-5.9), p=0.03) and pre-operative diastolic blood pressure below 80 mmHg (AOR 2.4 (95% CI: 1.0-5.9), p=0.05). Donor characteristics were not independently associated with PNF (p>0.10). In a subgroup analysis of 56 paired kidneys, 29% of the recipients with the lower CVP of the pair experienced PNF compared with 11% of their counterparts with higher CVP (p=0.09). Our study indicates that recipient hemodynamics during transplant surgery are major predictors of PNF. Therefore, improving recipient hemodynamics by expansion of the intravascular volume is expected to enhance the results of NHBD kidney transplantations and may enlarge the donor pool by increasing the acceptance of NHBD kidneys.     

Right ventricular end-diastolic volume monitoring after cardiac surgery.

INTRODUCTION: In the postoperative management of cardiac surgery patients, pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) are the most commonly used parameters of preload. However, these pressure parameters are easily affected by ventricular compliance, positive end-expiratory pressure and other factors. The aim of this study was to evaluate whether right ventricular end-diastolic volume index (RVEDVI) reflects cardiac output or ventricular preload in patients after cardiac surgery during postoperative management. METHODS: We performed measurements in 31 patients postoperatively in the intensive care unit every 1 or 2 hours using a modified thermodilution catheter. RESULTS: There were 999 measured hemodynamic data sets and the measurement duration was 47 +/- 21 hours (mean +/- SD). RVEDVI was 119 +/- 32 ml/m(2), cardiac index (CI) was 2.7 +/- 0.7 L/min/m(2), and PCWP was 11 +/- 4 mmHg. A significant correlation was found between RVEDVI, CVP and CI in 15 of 31 patients, and between PCWP and CI in 4 of 22 patients. In 33% of cases, CVP showed a negative correlation with CI, whereas 7% showed a negative correlation between RVEDVI and CI. CONCLUSION: RVEDVI was a significant index during the postoperative management after cardiac surgery.     

Prevalence and clinical correlates of white coat hypertension in chronic kidney disease.

BACKGROUND: The role of white coat hypertension (WCH) in the poor control of blood pressure (BP) in chronic kidney disease (CKD) is ill defined. METHODS: We measured systolic clinical (CBP) and ambulatory blood pressure (ABP) in 290 consecutive patients with non-dialysis CKD [glomerular filtration rate (GFR) <60 ml/min/1.73 m(2)]. We defined normotension (NOR) if CBP and daytime ABP <130 mmHg, sustained hypertension (SH) when both BP >or=130 mmHg, WCH if only daytime ABP <130 mmHg, and masked hypertension (MH) when only CBP <130 mmHg. RESULTS: NOR patients were 15.5%, WCH 31.7%, SH 46.9% and MH 5.9%. Due to the high prevalence of WCH, achievement of BP target (<130 mmHg) was more than doubled by daytime ABP than CBP (47.2 vs 21.4%). WCH was characterized by prevalence of diabetes (31.5%), left ventricular hypertrophy (LVH; 50.0%) and CBP values (146 +/- 12 mmHg) lower than in SH (41.9%, 71.3% and 158 +/- 18 mmHg) but greater than in NOR (17.8%, 37.8% and 118 +/- 7 mmHg). Among patients with CBP >or=130 mmHg, the independent risk of having SH rather than WCH increased in the presence of higher CBP [Odds ration (OR) 1.61, 95% confidence intervals (CI) 1.29-2.02], LVH (OR 1.94, 95% CI 1.03-3.63) and proteinuria (OR 3.12, 95% CI 1.31-7.43). In the WCH group, 24 h, daytime and nighttime ABP were 118 +/- 7/68 +/- 8, 120 +/- 7/71 +/- 8 and 112 +/- 12/63 +/- 9 mmHg, respectively. CONCLUSIONS: In CKD, WCH is highly prevalent and can be predicted in the absence of higher CBP, LVH and proteinuria. In these patients, pursuing a low BP target may not be safe because of the risk of cardio-renal hypoperfusion especially at nighttime.     

The effect of aspirin in transfusion-related acute lung injury in critically ill patients

Aspirin has been found to improve outcomes in an animal model of transfusion-related acute lung injury. We examined the association of aspirin use before admission to the intensive care unit and the development of transfusion-related acute lung injury in critically ill patients. We performed a post-hoc analysis of a nested case-control study that had been undertaken in a tertiary referral hospital. Transfusion-related acute lung injury cases were matched with controls (transfused patients not developing lung injury). Of these 218 patients, 66 used aspirin (30%). Use of aspirin did not alter the risk of transfusion-related acute lung injury after transfusion of platelets (OR 1.06, CI 0.59-1.91, p = 0.85), plasma (OR 1.06, 95% CI 0.59-1.92, p = 0.84), or red blood cells (OR 1.09, 95% CI 0.61-1.94, p = 0.77). Adjustment for confounding variables using propensity scoring also did not affect the risk of acquiring transfusion-related acute lung injury (p = 0.66). In conclusion, aspirin did not protect against transfusion-related lung injury in this cohort of critically ill patients.