Use of pulse pressure variation and stroke volume variation in spontaneously breathing patients to assess dynamic arterial elastance and to predict arterial pressure response to fluid administration

Abstract

Introduction We aimed to audit the prescribing practice on a busy 14-bedd general ICU, and develop standardised practices and tools to improve safety. Prescribing errors occur as commonly as in 10% of UK hospital admissions, costing 8.5 extra bed days per admission, and costing the National Health Service an estimated £1 billion per annum [1]. The majority of these mistakes are avoidable [2]. Methods We audited the daily infusion charts of all patients in three separate spot checks, over 1 week. We assessed all aspects of prescriptions that make them legal and valid, in accordance with national guidance [3]. New procedures were introduced, which included a standardised prescription sticker, with common, preprinted, infusion prescriptions on (noradrenaline, propofol, and so forth), and education on using the new prescription stickers. A month later the audit process was repeated. Results We assessed 129 prescriptions in the fi rst round, and 111 after intervention, demonstrating a 70% improvement in safe prescribing. Only 24% of prescriptions initially fulfi lled best practice criteria, improving to 94% afterwards. We also reduced the number of infusions running without prescription, 7 (6%) versus 24 (19%). See Figures 1 and 2. Conclusion Our audit supports the need for standardised prescribing practices within critical care, especially when dealing with potentially harmful vasoactive/sedative drugs. With a small, cost-eff ective intervention (£20 for 6,200 stickers), we improved prescribing accuracy, and thus patient safety in intensive care. Introduction The theft and tampering of controlled drugs (CDs) remains a prevalent patient safety issue. Sadly there are numerous reports of critical care staff stealing CDs for personal use or fi nancial gain and notably there have been some cases where CDs have been substituted for other medications in order to delay detection of the theft. This creates both the hazard of medication errors and potentially exposes patients to opioid intoxicated healthcare workers. As most critical care staff have access to CDs, when drugs are found to be missing it can be diffi cult to identify the perpetrators. Therefore the implementation of a deterrent which also improves the methods of detection is warranted. ReferencesMethods The Limpet, a device which incorporates a proximity sensor and a camera unit, was installed within the CD cupboard of the critical care unit. Whenever the cupboard was accessed the date and time were recorded and a photograph was taken to identify the staff member. Mock thefts were subsequently undertaken by a designated staff member at random times. This allowed testing of the product to determine the number of times the 'thief' was correctly identifi ed. Publication of this supplement has been supported by ISICEM. M E E T I N G A B S T R AC T SFigure 1 (abstract P1). Accuracy of prescriptions before intervention. Figure 2 (abstract P1). Accuracy of prescriptions after intervention.Critical Care 2014, Volume 18 Suppl 1 http://ccforum.com/supplements/18/S1 © 2014...

Empagliflozin does not change cardiac index nor systemic vascular resistance but rapidly improves left ventricular filling pressure in patients with type 2 diabetes: a randomized controlled study

“…First, hemodynamic parameters were assessed by non-invasive pulse contour analysis (ClearSight System ® ). However, this technique has extensively been validated against invasive hemodynamic measurements and is an established method in clinical practice [14,26,27]. Second, we did not measure other hemodynamic parameters such as pulse pressure, central arterial blood pressure, markers of arterial stiffness that have been shown to be affected by empagliflozin treatment for 6 weeks [28].…”

Detection of volume loss using the Nexfin device in blood donors

“…In this study, we used the non-invasive Nexfin monitor for haemodynamic measurements. It measures continuous arterial blood pressure and subsequently calculates CO [5,13,[16][17][18][19][20][21][22] and PPV [5,11,13,23,24] from the arterial pressure waveform. It is restricted to patients with normal peripheral perfusion, and several studies have reported on its limited value in critically ill patients or during septic shock [25,26].…”

“…In a recent study by Cecconi and colleagues, it was shown that PPV and SVV with the Nexfin can be used to predict fluid responsiveness in spontaneously breathing patients who are not subjected to forced inspiration or controlled breathing manoeuvres [13]. They assumed that spontaneous breathing artefacts affect the PPV and SVV equally, and this would therefore have no effect on the PPV/SVV ratio reflecting dynamic arterial elastance [13].…”

“…They assumed that spontaneous breathing artefacts affect the PPV and SVV equally, and this would therefore have no effect on the PPV/SVV ratio reflecting dynamic arterial elastance [13]. We did not use dynamic arterial elastance in our study, as this parameter is mainly validated to predict whether arterial blood pressure improves after a fluid challenge [27].…”

“…In particular, from the study by Hong et al it was concluded that the predictive value of PPV during forced inspiration for fluid responsiveness was greater than that seen during spontaneous breathing [12]. In contrast, the Nexfin dynamic elastance based on the PPV/SVV ratio adequately predicted the arterial pressure response to a fluid bolus in spontaneously breathing patients without forced breathing manoeuvres [13]. To avoid the influence of breathing artefacts on haemodynamic indices, others investigated the ability to detect a volume shift in conscious volunteers using PPV [14], cardiac output [15] or stroke volume [16].…”