Improved Outcome Based on Fluid Management in Critically III Patients Requiring Pulmonary Artery Catheterization

Abstract

We performed a randomized, prospective trial to evaluate whether fluid management that emphasized diuresis and fluid restriction in patients with pulmonary edema could affect the development or resolution of extravascular lung water (EVLW), as well as time on mechanical ventilation and time in the intensive care unit (ICU), in critically ill patients requiring pulmonary artery catheterization (PAC). PAC was performed on 101 patients. A total of 52 patients were randomized to an EVLW management group using a protocol based on bedside indicator-dilution measurements of EVLW. The other 49 patients were randomized to a wedge pressure (WP) management group in whom fluid management decisions were guided by WP measurements. A total of 89 patients had pulmonary edema (defined as EVLW greater than 7 ml/kg ideal body weight). Except for a clinically unimportant difference in mean age, the two groups were entirely comparable at baseline. The study groups were managed differently, as evidenced by cumulative input-output of 2,239 +/- 3,695 ml (median = 1,600 ml) in the WP group versus 142 +/- 3,632 ml (median = 754 ml) in the EVLW group (p = 0.001). EVLW decreased significantly, and ventilator-days and ICU days were significantly shorter only in patients from the EVLW group. No clinically significant adverse effect occurred as a result of following the EVLW group algorithm. Thus, a lower positive fluid balance, especially in patients with pulmonary edema regardless of cause, is associated with reduced EVLW, ventilator-days, and ICU days.

Technological advancements in the care of the trauma patient

“…EVLW may detect pulmonary edema early, and may be an indicator of mortality in acute lung injury or severe sepsis [71][72][73]. EVLW has been used to guide fluid management in acute respiratory distress syndrome and subarachnoid hemorrhage [74][75][76][77]. An important drawback to both systems, however, is that data interpretation is unreliable in the setting of common tachyarrhythmias like atrial fibrillation.…”

Bestimmung des intrathorakalen Blutvolumens und des extrathorakalen Lungenwassers – Spielzeug oder Werkzeug?

“…Es muß jedoch betont werden, daß dieses Vorgehen bisher in keiner klinischen Studie überprüft wurde. Mitchel et al (18) haben jedoch zeigen können, daß eine ARDS-Therapie, die anhand der direkten Messung des EVLW geführt wird, im Vergleich zu einer Therapie, die sich in erster Linie am PCWP orientiert, zu einer verkürzten Beatmungsdauer und zu einem kürzeren Aufenthalt auf der Intensivstation führt.…”

Prevention and therapy of the adult respiratory distress syndrome

“…Clinical studies have demonstrated a reduced mortality rate in patients with ARDS in whom fluid removal and reduction of the capillary hydrostatic pressure were attainable; however, the praeter or propter of this observation is not clear at present [52,104,112,113,120]. In this regard, a therapeutic regimen guided by direct measurement of extravascular lung water may be superior to a management primarily addressing central venous and capillary wedge pressures [28,79]. A general recommendation for the concept of volume removal in the early exudative phase of ARDS [39,51,71] is, however, questionable for two reasons.…”