Craig Morris

Pro-Con Debate: We should not Measure Cardiac output in Critical Care

The measurement of cardiac output in critical care appears to be increasingly common. However, both the monitoring technologies and the therapeutic approaches they inform have often proved highly controversial. As the range of alternative technologies available continues to increase, it seems worthwhile to question whether this monitoring modality should be used at all. The aim of this pro-con debate is to review the key evidence and to explain the often quite widely differing interpretations placed upon it. The term cardiac output monitoring refers to technology, whose primary purpose is to monitor global blood flow. The principles of the various technologies have been reviewed elsewhere.1

The Use of High-Flux Albumin Haemofiltration (HFAF) with Evaclio EC-2C™ in the Management of Liver Failure as a Bridge to Transplantation

A 44-year-old male who developed liver failure four years after orthotopic liver transplant was managed using high-flux albumin haemofiltration as a bridge to transplant. The technique, which involves using conventional haemofiltration with a plasma component separator using a filter with a sieving coefficient of 20% for albumin, is described.

Mobilising Oedema in the Oedematous Critically Ill Patient with ARDS: Do We Seek Natriuresis Not Diuresis?

In the treatment of the acute respiratory distress syndrome in the intensive care unit, one of the aims is to achieve a negative fluid balance. Traditional use of sole-agent loop diuretics such as furosemide often results in the loss of free water, dehydration, hypernatraemia and metabolic alkalosis, with therapeutic failure once water is replaced. A more rational approach is to induce natriuresis with loss of sodium in the urine to reduce extracellular and interstitial fluid volume, not total body water. Polypharmacy with a loop diuretic combined with other weak diuretics to prevent tubules modifying glomerular filtrate, promotes natriuresis with large volume urinary losses and minimal electrolyte disturbance, and the excretion of urine with a composition comparable to plasma.

Cervical Spine - A Reply

Drs Morris and Lavery do not recommend widespread use of sophisticated imaging such as MRI or dynamic fluoroscopy as screening tools because of the lack of good evidence that these imaging techniques provide added value. However, they do suggest that ‘units with experience and availability of MRI or dynamic fluoroscopy may consider their routine use but outcomes should be incorporated into comparative audit’. They do not specify the detail of the audit or the precise comparisons.