The online version of this article (doi:10.1186/cc10421) contains supplementary material, which is available to authorized users.
Profs. Jean-Louis Teboul and Xavier Monnet are members of the Medical Advisory Board of Pulsion Medical Systems. As consultants for this company, they received honoraria. The company did not finance the manuscript. The company was not involved in any part of the conception or performance of the study. The other authors declare that they have no conflict of interest.
XM conceived the study, performed analysis and interpretation of the data, and drafted the manuscript. RP performed the collection of data, contributed to analysis and interpretation of the data and helped draft the manuscript. MK performed the collection of data, contributed to analysis and interpretation of the data, and helped draft the manuscript. MJ contributed to the collection of data, CR participated in the design of the study, contributed to analysis and interpretation of the data and helped draft the manuscript. J-LT conceived the study, participated in its design, contributed to analysis and interpretation of the data and helped draft the manuscript. All authors read and approved the final manuscript.
We wanted to determine the number of cold bolus injections that are necessary for achieving an acceptable level of precision for measuring cardiac index (CI), indexed global end-diastolic volume (GEDVi) and indexed extravascular lung water (EVLWi) by transpulmonary thermodilution.
We included 91 hemodynamically stable patients (age 59 (25% to 75% interquartile range: 39 to 79) years, simplified acute physiologic score (SAPS)II 59 (53 to 65), 56% under norepinephrine) who were monitored by a PiCCO2 device. We performed five successive cold saline (15 mL, 6°C) injections and recorded the measurements of CI, GEDVi and EVLWi.
Considering five boluses, the coefficient of variation (CV, calculated as standard deviation divided by the mean of the five measurements) was 7 (5 to 11)%, 7 (5 to 12)% and 7 (6 to 12)% for CI, GEDVi and EVLWi, respectively. If the results of two bolus injections were averaged, the precision (2 × CV/√ number of boluses) was 10 (7 to 15)%, 10 (7 to 17)% and 8 (7 to 14)% for CI, GEDVi and EVLWi, respectively. If the results of three bolus injections were averaged, the precision dropped below 10%, that is, the cut-off that is generally considered as acceptable (8 (6 to 12)%, 8 (6 to 14)% and 8 (7 to 14)% for CI, GEDVi and EVLWi, respectively). If two injections were performed, the least significant change, that is, the minimal change in value that could be trusted to be significant, was 14 (10 to 21)%, 14 (10 to 24)% and 14 (11 to 23)% for CI, GEDVi and EVLWi, respectively. If three injections were performed, the least significant change was 12 (8 to 17)%, 12 (8 to 19)% and 12 (9 to 19)% for CI, GEDVi and EVLWi, respectively, that is, below the 15% cut-off that is usually considered as clinically relevant.
These results support the injection of at least three cold boluses for obtaining an acceptable precision when transpulmonary thermodilution is used for measuring CI, GEDVi and EVLWi.
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Training documents for advanced hemodynamic monitoring. [ http://www.pulsion.com]
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- Precision of the transpulmonary thermodilution measurements
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