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Fri Jul 11 02:46:03 BST 2008

Rangraj, this brings me to the considerations re: cardiac output measurement as part of regular monitoring.
As you highlighted, right now we give inordinate weight to the BP as we unfortunately have little else to go by. 
Our management will be quite different with cardiac output, mixed venous or other continuous variable as far as diagnosis at the moment - shock/no shock as well as interventions we do - more fluid/more pressors/more inotropes.
Which ones are the techniwues that will make it into the mainstream - anyone wants to take a bet ? After pulse oximetry and ETCO2 it has been a long while since we had any noew minimally invasive monitors...
Do you believe these will improve outcomes as opposed to the PA catheter ?

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One of these is the Endotracheal CO Monitor - ECOM - continuous stroke volume measurement based on electrical impedance on changes of a voltage field generted by elcetrodes on the cuff of the ET tube. It is $ 125/ ET tube. 

It correlates with thermodilution:
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=C9B896C23F1FB9A001EE5AE7DC72444B?year=2001&index=7&absnum=745 

It correlates with an aortic root flowmeter:
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=278D4F36969BD0EE9BDDD16D96D77539?year=2002&index=7&absnum=1140

Overall Google search on ECOM:
http://www.google.com/search?hl=en&rls=com.microsoft%3A*%3AIE-SearchBox&rlz=1I7SKPB&q=ECOM+cardiac+output
  Ivan Hronek MD                                                                              
Los Angeles, CA 
no conflict of interests
http://health.groups.yahoo.com/group/Anesthideas/    
                                          Do not fear to be eccentric in opinion, for every opinion now
accepted was once eccentric. - Bertrand Russell-
________________________________

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----- Original Message ----
From: Rangraj Setlur <rangraj at gmail.com>
To: Discussion Care Medicine of Critical <ccm-l at ccm-l.org>; anesthideas <Anesthideas at yahoogroups.com>
Sent: Thursday, July 10, 2008 8:59:15 AM
Subject: [ai] lesson of the day

fifty something female taken up for excision of a thyroid met to the brain, infiltrating the skull and skin. preop embolisation done.towards the end of excision, starts dumping blood on the floor.blood pressure crashes. ten units of blood and around five litres of colloids and crystalloids, boluses and infusion of vasopressin, maxed out infusion of norepinephrine. 
brain stops pulsating, blood pressure around 40/? for around fourty minutes.sinuses packed away, dural patch losely applied, and  skin sutured. blood pressure starts coming up( everyone goes ahh... Cushings).shifted to ICU, i switched the radial art line to a femoral art line. BP 100/40. pupils fixed and widely dilated. we agreed that the widely dilated pupils were a result of sympathetic stimulation. after around half an hour, dicrotic notch dissapears, blood pressure 100/10 mm Hg (MAP 40 mmHg) . ? heart working in the face of complete vasoplegia. The neurosurgeons tell the relatives not to expect anything, and we in the intensive care keep plugging away with norepinephrine vasopressin, warming and blood products. 
to cut a long story short, its now six hours after surgery, shes completely awake though hemiplegic, and trying to pull her tube out. we're sedating her and continuing to correct her metabolic acidosis. we'll take her on a road trip tomorrow and scan her brain, and think about extubation if she continues to look good.
I guess the lesson is that in a supine patient, pressure doesn't equal flow. And, of course, in hemorrhagic shock, you never can tell.
rangraj

-- 
Lt Col Rangraj Setlur
Associate Professor
Department of Anaesthesiology and Critical Care
Armed Forces Medical College
Pune
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[ai] lesson of the day