REGISTRATIONS ARE NOW CLOSED! The EACTAIC Education Committee has organised the seminar episode in collaboration with the Leuven University – Leuven – Belgium. The Leuven University – Leuven – Belgium supported this seminar episode.
What’s in it for me?
After participating in this webinar, you will better understand the following:
The place of the perioperative use of the pulmonary artery catheter in the modern cardiac anesthesia era.
The advantages and limitations of using transpulmonary thermodilution for advanced monitoring in hemodynamically unstable patients.
The limitations of invasive arterial blood pressure monitoring derived from the radial artery in patients undergoing cardiac surgery.
The risk factors for the development of an attenuated radial blood pressure post-CPB and how to detect a central-to-peripheral pressure gradient non-invasively.
Moderation:
Dieter Van Beersel University Hospitals Leuven, Belgium Steffen Rex University Hospitals Leuven, Belgium
Programme:
Time
Topic
Speaker
18.00 – 18.05
Introduction by the programme director
Dieter Van Beersel University Hospitals Leuven, Belgium
18.05 – 18.07
Poll (1)
—
18.07 – 18.27
Is there any place for the PAC in modern cardiac anesthesia?
Steffen Rex, University Hospitals Leuven, Belgium Albert Van Zyl, University of Stellenbosch, Tygerberg Hospital, South Africa
18.27 – 18.29
Poll (2)
—
18.29 – 18.44
Transpulmonary thermodilution: advantages and limitations.
Xavier Monnet Paris-Saclay University Hospitals, France
18.44 – 18.46
Poll (3)
—
18.46 – 19.11
Can we trust radial artery pressure monitoring during cardiac surgery?
André Denault, Montreal Heart Institute, Canada Mathias Jacquet-Lagrèze, Hospices Civils de Lyon, France
19.11 – 19.30
Open Discussion and QA
—
19.30 – 19.32
Take Home Messages
Dieter Van Beersel Steffen Rex
University Hospitals Leuven, Belgium
19.32 – 19.34
Closing and Future EACTAIC Events
EACTAIC Education Chair
Take Home Message
In complex patients with hemodynamic instability during and after cardiac surgery, we should measure cardiac output to guide treatment. Blood pressure monitoring is not enough.
Only invasive hemodynamic monitoring devices provide reliable information in complex shock patients.
The PAC is more useful for assessment of the RV: afterload, PVR and RV-PA coupling.
TPTD uses calibrated pulse-contour analysis and provides more information to guide fluid administration. Regular calibration is needed.
Radial artery pressure monitoring is unreliable in up to 1/3 of patients undergoing cardiac surgery with the use of CPB, while femoral artery catheterization is much more reliable.
Several non-invasive methods can be used at the bedside to detect the presence of a radial-to-femoral pressure gradient.
Registrations:
REGISTRATIONS ARE NOW CLOSED!
IMPORTANT: If you do not receive your link 48 hours after the registration, please contact eactaic@iameetings.sg Registrations will be accepted until 17.25 of the 6th of February. All the registrations sent after that time, will not be accepted.
All these statements have merit. Indeed it has been shown that lack of use of the PAC have lead to poor interpretation of PAC data. This is why the information gathered from the PAC should be interpreted by clinicians with experience with PAC use. Also, to measure how much the CVS delivers (CO) it is useful to measure how the tissues are functioning (SvO2) with what is being delivered to them.
Having an therepeatic intervention plan coupled with the interpreted data, extensive training and increased use in specialised centers are all factors that improve misinterpretation issues.
Training is best done under guidance of clinicians with experience in PAC interpretation and management.
See Answer 1
See answer 2
See answer 3
The modern PAC determines cardiac output by a combination of thermal indicator dilution and a stochastic system, which overcomes the limitations of cold bolus injection variation and injecting at different parts of the respiratory cycle. Yelderman M. Continuous measurement of cardiac output with the use of stochastic system identification techniques. J Clin Monit. 1990;6(4):322–32.
The preference is individualised to the specific patient.
AT least every hour, and at evry time arterial tone is suspected to be changed (change in the dose of vasopressor, large change in diastolic arterial pressure)
It remains fully reliable. Indeed, the dilution of the cold indicator occurs over several cardiac cycles, and arrhythmia does not affect the measurement
The post-cardiac surgery setting is one where the technique is used regurlarly. It is fully reliable, and may help especially through the easy estimation of LV contractility
Low Vt creates some false positives in PPV and SVV. However, a short increase in Vt from 6 to 8 mL/kg for one min allows the estimation of preload responsiveness, through the increase in PPV (see PMID 35633423 for details)
No, the risk of inserting an arterial cath must be evaluated indicidually. In such patients, the brachial access may be a safe aletrnative, indeed
Yes, it is indeed an alternative to the femoral route, easiest in sedated/anesthesised patients as the elbow should remain in straight position
It creats some false positive
FloTrac is an uncalibrated pulse contour analysis device. Then, its reliability is impaired by the administration of vasopressors, which my be a problem in the setting of cardiac surgery
Kanazawa et al. studied different site of measurement along the radial humeral and the subclavian artery. They found a strong correlation between the distance from the aorta to the site of measurement and the pressure drop from the aorta to the site of measurement (Kanazawa M, Fukuyama H, Kinefuchi Y, Takiguchi M, Suzuki T. Relationship between aortic-to-radial arterial pressure gradient after cardiopulmonary bypass and changes in arterial elasticity. Anesthesiology 2003; 99: 48-53. Doi: ). In Lyon when we use the brachial acces, we insert the catheter between the brachial location and the axillary location and use a cathether with a 13 cm lenght which make the site of measurement quite close to the aortic pressure whichi is equal to the femoral pressure.
Two mechanisms have been proposed to explain the RFAPG: first an excess of vasodilation in peripheral vascular bed and secondly an excess of arterial vasoconstriction or physical obstruction of medium size arteries (Fuda G, Denault A, Deschamps A, et al. Risk Factors Involved in Central-to-Radial Arterial Pressure Gradient During Cardiac Surgery. Anesth Analg 2016; 122: 624-32. Doi: 10.1213/ANE.0000000000001096, Bouchard-Dechene V, Couture P, Su A, et al. Risk Factors for Radial-to-Femoral Artery Pressure Gradient in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2018; 32: 692-8. Doi: 10.1053/j.jvca.2017.09.020)
We completely aggre with you in the scope of "structural" aetiology of the gradient, But we have to bear in mind that this kind of aetiolgy is far much rarer than the dynamic gradient that occurs in up to 30 % of cardiopulmonary bypass.
In Montreal, the double monitoring is considered usual care. We think that it can bring a clear advantage by reducing the amount of norepinephrine, le lenght of exposure to norepinephrine and the rate of adverse events. Nevertheless those statement come from non interventional study and it is hard to convince colleague without a prospective randomized study. In Lyon we did not manage to convince to systematicaly used a double catheter but we do it routinely for Aortic dissection, cardiac translplantation, complex surgery. In patients with high doses of norepinphrine ( > 0.7 µg/kg/min) we insert a needle in the aorta to assess aortic pressure, if there is more than 10 mmHg of gradient we insert a femoral cathether during the end of the surgery.
See answer 16
Exess of vasodilation drugs and vasopressors seems key factors, so reducing the depth of anaesthesia and the amount of opioids and hypnotic drugs may reduce the risk of a significant gradient.
See answer 16
We use 4 and 8 cm radial cathether
A significant RAFPG had been described during septic shock (e.g. Kim WY, Jun JH, Huh JW, Hong SB, Lim CM, Koh Y. Radial to femoral arterial blood pressure differences in septic shock patients receiving high-dose norepinephrine therapy. Shock 2013; 40: 527-31. Doi: 10.1097/SHK.0000000000000064 ). In our ICU in lyon, any patients in septic shock that are not controled in the first hours ( 2/3) we use a PiCCO cathther that enable continuous CO monitoring and due to its femoral location confirm or rul out any RFAPG
We do not have any specific data, but it seems to us unlikely that the abdominal pressure is high enough to decrease the diameter of the aorta as much as creating a drop of pressure along the aorta and iliac arteries where the tip of a femoral cathether is.
Any scenario with a vasoplegic mechanism and high doses of vasopressors. In cinical practice we think of inserting a femoral access or barachial/axillary 13 cm long cathether in any patients with norepinephrine infusion rate greater than 0.5-1 µg/kg/min.
See answer 16
If you keep only one artery , you should prefer the femoral artery which have been proven to be closer to the aortic pressure except in case of lower limb artheriopathy.
We are not sure that there is clear evidence of a greater risk of artery line infection at the femoral site than the radial ( those data are not the same as for venous access). in the paper of G. Nutall There were 14 patients who developed the line-associated
infection due to their arterial line, resulting in an overall
infection rate of 2.4 per 10,000 patients (95% CI, 1.3 to
4.0 per 10,000 patients). Line-associated infections were
positive catheter tip cultures on surveillance cultures. For
the patients who developed infections, all of the arterial lines
were placed in the radial artery( G Nuttall, J Burckhardt, A Hadley (2016) Surgical and Patient Risk Factors for Severe Arterial Line Complications in Adults. Anesthesiology 590–597)
We do not have any specific data , bu we think that it cannot completely solve the problem as the pressure gardient is proportional to the distance from the aorta, see reponse 16
In the ICM there is no pediatric case. In lyon, our pediatric team has no preference but is aware of the risk of gradient and insert a femoral line whenever the rate of norepinephrine infusion is high.
