Keith Killu

Effect of lower limb compression devices on thermodilution cardiac output measurement.

Objective:The aim of this study was to determine whether lower limb (calf) sequential compression devices (SCDs) have a significant effect on thermodilution cardiac output measurements using a pulmonary artery catheter. Design:Prospective clinical investigation. Setting:Surgical and neurosurgical intensive care units in a university hospital. Patients:A total of 43 patients with pulmonary artery catheters and bilateral lower limb SCDs. Measurements and Main Results:Cardiac output was measured (average of three) when the SCDs were off (T1), during the first 2–4 secs of the inflation cycle (T2), during seconds 4–8 of the inflation cycle (T3), and when the SCDs were off again (T4). Cardiac output measurements were consistently lower when measured during the SCD inflation cycle. The decrease in cardiac output ranged from 7.58% to 49.5%, with a mean reduction of 24.51% in the first 2–4 seconds and 20.61% during seconds 4–8 (p < .001). Two patients displayed an increase in cardiac output during the inflation cycle; one patient had an increase of 2.78% and the other an increase of 13.5%. In 11 patients, measurements were also made using a pulse contour–analysis cardiac output device, but no changes in pulse contour–analysis cardiac output were observed during the same time period. Conclusions:Thermodilution cardiac output measurements via a pulmonary artery catheter should not be done during the inflation cycle of lower limb SCDs because they produce a falsely low cardiac output.

Racial differences in vasopressor requirements for septic shock.

ABSTRACT Objective: The objective of this study was to compare vasopressor requirements between African American (AA) patients and white patients in septic shock. Methods: This was a retrospective cohort review conducted over a 2-year period measuring total and mean dosage of various vasopressors used between two racial groups during the treatment of patients admitted with septic shock. The study included patients admitted to the intensive care unit with septic shock at an 805-bed tertiary, academic center. All septic shock patients were managed with vasopressors. Vasopressor selection, dosage, and duration were at the discretion of the treating physician. Total, mean, and duration of vasopressor dosing requirements were obtained for study participants. Comorbidities, prehospitalization antihypertensive medication requirements, intravenous fluids given during the septic shock phase, and source of infection were analyzed. Results: One hundred fifty-nine patients with septic shock were analyzed, of which 96 (60.4%) were AAs (P < 0.059). African Americans had higher rates of end-stage renal disease and hypertension compared with whites, 85.7% vs. 14.3% (P < 0.011; odds ratio [OR], 15.684) and 68.3% vs. 31.7% (P < 0.007; OR, 3.357), respectively. Norepinephrine (NE) was administered to 150 patients, 57.2% of which were AAs (P < 0.509). Thirteen patients received dopamine (5% AAs, P < 0.588), 40 patients received phenylephrine (15.7% AAs, P < 0.451), and five patients received epinephrine (1.9% AAs, P < 0.660). Comparing vasopressors between races, only NE showed statistical significance via logistic regression modeling for the AA race in terms of total dosage (AAs 736.8 [SD, 897.3] &mgr;g vs. whites 370 [SD, 554.2] &mgr;g, P < 0.003), duration of vasopressor used (AAs 38.38 [SD, 34.75] h vs. whites 29.09 [SD, 27.11] h, P < 0.037), and mean dosage (AAs 21.08 [SD, 22.23] &mgr;g/h vs. whites 12.37 [SD, 13.86] &mgr;g/h, P < 0.01). Mortality between groups was not significant. Logistic regression identified discrepancy of the mean dose NE in AAs compared with whites, with OR of 1.043 (P = 0.01). Conclusions: African American patients with septic shock were treated with higher doses of NE and required longer duration of NE administration compared with white patients.

The Fundamentals of Critical Care Support: local experience and a look into the future

Fundamentals of Critical Care Support (FCCS) is an educational course offered by the Society of Critical Care Medicine (USA) to provide and augment the basic knowledge for individuals managing critically ill patients. More than 10,000 clinicians every year throughout the world attend FCCS courses, preparing non‐intensivists to manage critically ill patients for the first 24 h until a consultation can be secured. The most important emphasis of the FCCS course is to learn the basic principles and the adaptation of multidisciplinary approaches to managing the critically ill. The curriculum consists of integrated lectures and skills stations helping to provide the knowledge and guidance in decision making. This article is an account of one institutions experience in offering this course for over 12 years.

Utility of Ultrasound Versus Landmark-Guided Axillary Artery Cannulation for Hemodynamic Monitoring in the Intensive Care Unit:

Objectives. To assess the utility of ultrasound-guided axillary artery catheterization compared with anatomical landmark technique catheterization in the intensive care unit. Design. Randomized controlled trial. Setting. University hospital surgical and neurosurgical intensive care unit. Patients. A total of 33 critically ill patients undergoing arterial line placement. Interventions. Axillary arterial line placement under ultrasound guidance or by using anatomical landmarks. Measurements and main results. Procedure duration, number of attempts (skin punctures), needle repositionings, and aborted procedures were compared. A total of 33 patients were randomly assigned to either the ultrasound group (n = 18) or the anatomical landmark group (n = 15). Aborted procedures were significantly greater in the landmark group (n = 4) than in the ultrasound group (n = 0); P = .019. Procedure duration (mean ± SD) in the ultrasound group was 7.01 ± 4.40 minutes compared with 9.29 ± 10.00 minutes in the landmark group; ...