Two Methods of Hemodynamic and Volume Status Assessment in Critically Ill Patients: A Study of Disagreement.

INTRODUCTION: The invasive nature and potential complications associated with pulmonary artery (PA) catheters (PACs) have prompted the pursuit of less invasive monitoring options. Before implementing new hemodynamic monitoring technologies, it is important to determine the interchangeability of these modalities. This study examines monitoring concordance between the PAC and the arterial waveform analysis (AWA) hemodynamic monitoring system. METHODS: Critically ill patients undergoing hemodynamic monitoring with PAC were simultaneously equipped with the FloTrac AWA system (both from Edwards Lifesciences, Irvine, California). Data were concomitantly obtained for hemodynamic variables. Bland-Altman methodology was used to assess CO measurement bias and κ coefficent to show discrepancies in intravascular volume. RESULTS: Significant measurement bias was observed in both CO and intravascular volume status between the 2 techniques (mean bias, -1.055 ± 0.263 liter/min, r = 0.481). There was near-complete lack of agreement regarding the need for intravenous volume administration (κ = 0.019) or the need for vasoactive agent administration (κ = 0.015). CONCLUSIONS: The lack of concordance between PAC and AWA in critically ill surgical patients undergoing active resuscitation raises doubts regarding the interchangeability and relative accuracy of these modalities in clinical use. Lack of awareness of these limitations can lead to errors in clinical decision making when managing critically ill patients.

Nasoenteric tube complications.

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.

The glucogram: A new quantitative tool for glycemic analysis in the surgical intensive care unit.

BACKGROUND: Glycemic control is an important aspect of patient care in the surgical intensive care unit (SICU). This is a pilot study of a novel glycemic analysis tool - the glucogram. We hypothesize that the glucogram may be helpful in quantifying the clinical significance of acute hyperglycemic states (AHS) and in describing glycemic variability (GV) in critically ill patients. MATERIALS AND METHODS: Serial glucose measurements were analyzed in SICU patients with lengths of stay (LOS) >30 days. Glucose data were formatted into 12-hour epochs and graphically analyzed using stochastic and momentum indicators. Recorded clinical events were classified as major or minor (control). Examples of major events include cardiogenic shock, acute respiratory failure, major hemorrhage, infection/sepsis, etc. Examples of minor (control) events include non-emergent bedside procedures, blood transfusion given to a hemodynamically stable patient, etc. Positive/negative indicator status was then correlated with AHS and associated clinical events. The conjunction of positive indicator/major clinical event or negative indicator/minor clinical event was defined as clinical "match". GV was determined by averaging glucose fluctuations (maximal - minimal value within each 12-hour epoch) over time. In addition, event-specific glucose excursion (ESGE) associated with each positive indicator/AHS match (final minus initial value for each occurrence) was calculated. Descriptive statistics, sensitivity/specificity determination, and student's t-test were used in data analysis. RESULTS: Glycemic and clinical data were reviewed for 11 patients (mean SICU LOS 74.5 days; 7 men/4 women; mean age 54.9 years; APACHE II of 17.7 ± 6.44; mortality 36%). A total of 4354 glucose data points (1254 epochs) were analyzed. There were 354 major clinical events and 93 minor (control) events. The glucogram identified AHS/indicator/clinical event "matches" with overall sensitivity of 84% and specificity of 65%. We noted that while the mean GV was greater for non-survivors than for survivors (19.3 mg/dL vs. 10.3 mg/dL, P = 0.02), there was no difference in mean ESGE between survivors (154.7) and non-survivors (160.8, P = 0.67). CONCLUSIONS: The glucogram was able to quantify the correlation between AHS and major clinical events with a sensitivity of 84% and a specificity of 65%. In addition, mean GV was nearly two times higher for non-survivors. The glucogram may be useful both clinically (i.e., in the electronic ICU or other "early warning" systems) and as a research tool (i.e., in model development and standardization). Results of this study provide a foundation for further, larger-scale, multi-parametric, prospective evaluations of the glucogram.

Clinical uses of the medicinal leech: a practical review.

The medicinal leech, Hirudo medicinalis, is an excellent example of the use of invertebrates in the treatment of human disease. Utilized for various medical indications since the ancient times, the medicinal leech is currently being used in a narrow range of well-defined and scientifically-grounded clinical applications. Hirudotherapy is most commonly used in the setting of venous congestion associated with soft tissue replantations and free flap-based reconstructive surgery. This is a comprehensive review of current clinical applications of hirudotherapy, featuring a comprehensive search of all major medical search engines (i.e. PubMed, Google Scholar, ScientificCommons) and other cross-referenced sources. The authors focus on indications, contraindications, practical application/handling of the leech, and therapy-related complications.