11.09.12 Email to Nawaf
I hope you had a good weekend. I'm in the library again today but will
come and try to find you this afternoon or tomorrow morning. In the
meantime here's an update of where I've got to so far, as requested:
PEOPLE I'VE SPOKEN TO/OBSERVED
General ITU nursing staff
Cardiac ITU nursing staff
Pulse power analysis (LiDCO)
Pulmonary artery catheter
Pulse contour CO (PiCCO)
Bioelectrical impedence cardiography
POTENTIAL PARAMETERS FOR OPTIMISATION
End-diastolic volume (Transesophageal ultrasonography)
Visual assesment of RV stretch
Serum lactate / pH
Tissue oxygen delivery (DO2I) /Oxygen delivery index
Oxygen consumption (VO2I)
Mixed or central venous sats
Systolic flow time (FTc)
KEY PAPERS ADDRESSING POST-SURGERY OPTIMISATION
McKendry et al, BMJ 329: "Randomised controlled trial assessing the
impact of a nurse delivered, flow monitored protocol for optimisation
of circulatory status after cardiac surgery."
Optimised stroke volume index using blood/colloid fluid challenges and
adrenaline/GTN. Monitoring via oesophageal Doppler probe. Length of
hospital stay reduced in study group.
Pölönen et al, Anesthesia and analgesia 90: 1052- "A prospective,
randomized study of goal-oriented hemodynamic therapy in cardiac
Optimised mixed venous oxygen saturation and arterial lactate
concentration using volume expansion and dobutamine. (Both the study
and control groups were optimised for PCWP, cardiac index, MAP and
Hb). Morbidity and length of stay reduced in study group.
Pearse et al, Critical care 9: R687- "Early goal-directed therapy
after major surgery reduces complications and duration of hospital
stay. A randomised, controlled trial"
Optimised oxygen delivery index using colloid fluid challenges and
dopexamine. Monitoring via LiDCO. Complications and length of stay
reduced in study group.
Pearse et al, Critical care 9: "Changes in central venous saturation
after major surgery, and association with outcome."
Observational study assessing the association of post-operative
complications with ScvO2, DO2I, CI, P-POSSUM score and use of GDT.
ScvO2 is independently associated with incidence of complications.
I'm currently working on a protocol to bring to the meeting tomorrow,
based on the above papers along with what is done in general ITU. I'll
send that to you once I'm finished.