Top

Critical Care

Published in:

Open Access 01-04-2011 | Research

Transpulmonary thermodilution for hemodynamic measurements in severely burned children

Authors: Ludwik K Branski, David N Herndon, Jaron F Byrd, Michael P Kinsky, Jong O Lee, Shawn P Fagan, Marc G Jeschke

Published in: Critical Care | Issue 2/2011

Abstract

Introduction

Monitoring of hemodynamic and volumetric parameters after severe burns is of critical importance. Pulmonary artery catheters, however, have been associated with many risks. Our aim was to show the feasibility of continuous monitoring with minimally invasive transpulmonary thermodilution (TPTD) in severely burned pediatric patients.

Methods

This prospective cohort study was conducted in patients with severe burns over 40% of the total body surface area (TBSA) who were admitted to the hospital within 96 hours after sustaining the injury. TPTD measurements were performed using the PiCCO system (Pulsion Medical Systems, Munich, Germany). Cardiac Index (CI), Intrathoracic Blood Volume Index (ITBVI) (Stewart-Hamilton equation), Extravascular Lung Water Index (EVLWI) and Systemic Vascular Resistance Index (SVRI) measurements were recorded twice daily. Statistical analysis was performed using one-way repeated measures analysis of variance with the post hoc Bonferroni test for intra- and intergroup comparisons.

Results

Seventy-nine patients with a mean age (±SD) of 9 ± 5 years and a mean TBSA burn (±SD) of 64% ± 20% were studied. CI significantly increased compared to level at admission and was highest 3 weeks postburn. ITBVI increased significantly starting at 8 days postburn. SVRI continuously decreased early in the perioperative burn period. EVLWI increased significantly starting at 9 days postburn. Young children (0 to 5 years old) had a significantly increased EVLWI and decreased ITBVI compared to older children (12 to 18 years old). EVLWI was significantly higher in patients who did not survive burn injury.

Conclusions

Continuous PiCCO measurements were performed for the first time in a large cohort of severely burned pediatric patients. The results suggest that hyperdynamic circulation begins within the first week after burn injury and continues throughout the entire intensive care unit stay.

Available only for authorised users

Herndon DN, Parks DH: Comparison of serial debridement and autografting and early massive excision with cadaver skin overlay in the treatment of large burns in children. J Trauma 1986, 26: 149-152. 10.1097/00005373-198602000-00009CrossRefPubMed

Janzekovic Z: A new concept in the early excision and immediate grafting of burns. J Trauma 1970, 10: 1103-1108. 10.1097/00005373-197012000-00001CrossRefPubMed

Thompson P, Herndon DN, Abston S, Rutan T: Effect of early excision on patients with major thermal injury. J Trauma 1987, 27: 205-207. 10.1097/00005373-198702000-00019CrossRefPubMed

Baxter CR, Marvin JA, Curreri PW: Early management of thermal burns. Postgrad Med 1974, 55: 131-139.PubMed

Demling RH: Fluid replacement in burned patients. Surg Clin North Am 1987, 67: 15-30.PubMed

Demling RH, Will JA, Belzer FO: Effect of major thermal injury on the pulmonary microcirculation. Surgery 1978, 83: 746-751.PubMed

Hilton JG, Marullo DS: Effects of thermal trauma on cardiac force of contraction. Burns Incl Therm Inj 1986, 12: 167-171. 10.1016/0305-4179(86)90154-3CrossRefPubMed

Kramer GC, Lund T, Beckum O: Pathophysiology of burn shock and burn edema. In Total Burn Care. 3rd edition. Edited by: Herndon DN. Philadelphia: Saunders Elsevier; 2007:93-104.CrossRef

Wiener RS, Welch HG: Trends in the use of the pulmonary artery catheter in the United States, 1993-2004. JAMA 2007, 298: 423-429. 10.1001/jama.298.4.423CrossRefPubMed

10.

Rupérez M, López-Herce J, García C, Sánchez C, García E, Vigil D: Comparison between cardiac output measured by the pulmonary arterial thermodilution technique and that measured by the femoral arterial thermodilution technique in a pediatric animal model. Pediatr Cardiol 2004, 25: 119-123. 10.1007/s00246-003-0450-2CrossRefPubMed

11.

Holm C, Mayr M, Tegeler J, Hörbrand F, Henckel von Donnersmarck G, Mühlbauer W, Pfeiffer UJ: A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns 2004, 30: 798-807. 10.1016/j.burns.2004.06.016CrossRefPubMed

12.

Sakka SG, Kozieras J, Thuemer O, van Hout N: Measurement of cardiac output: a comparison between transpulmonary thermodilution and uncalibrated pulse contour analysis. Br J Anaesth 2007, 99: 337-342. 10.1093/bja/aem177CrossRefPubMed

13.

Schmidt S, Westhoff TH, Hofmann C, Schaefer JH, Zidek W, Compton F, van der Giet M: Effect of the venous catheter site on transpulmonary thermodilution measurement variables. Crit Care Med 2007, 35: 783-786. 10.1097/01.CCM.0000256720.11360.FBCrossRefPubMed

14.

Della Rocca G, Costas MG: Intrathoracic blood volume: clinical applications. In Yearbook of Intensive Care and Emergency Medicine. Edited by: Vincent JL. Berlin: Springer; 2006:142-151.CrossRef

15.

Warden GD: Fluid resuscitation and early management. In Total Burn Care. 3rd edition. Edited by: Herndon DN. Philadelphia: Saunders Elsevier; 2007:107-118.CrossRef

16.

Bortolani A, Governa M, Barisoni D: Fluid replacement in burned patients. Acta Chir Plast 1996, 38: 132-136.PubMed

17.

Fabri PJ: Monitoring of the burn patient. Clin Plast Surg 1986, 13: 21-27.PubMed

18.

Baxter CR, Shires T: Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci 1968, 150: 874-894. 10.1111/j.1749-6632.1968.tb14738.xCrossRefPubMed

19.

Klein MB, Hayden D, Elson C, Nathens AB, Gamelli RL, Gibran NS, Herndon DN, Arnoldo B, Silver G, Schoenfeld D, Tompkins RG: The association between fluid administration and outcome following major burn: a multicenter study. Ann Surg 2007, 245: 622-628. 10.1097/01.sla.0000252572.50684.49PubMedCentralCrossRefPubMed

20.

Pulmonary Artery Catheter Consensus Conference: consensus statement: New Horiz. 1997, 5: 175-194.

21.

Bishop MH, Shoemaker WC, Appel PL, Meade P, Ordog GJ, Wasserberger J, Wo CJ, Rimle DA, Kram HB, Umali R, et al.: Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma. J Trauma 1995, 38: 780-787. 10.1097/00005373-199505000-00018CrossRefPubMed

22.

Bishop MH, Shoemaker WC, Appel PL, Wo CJ, Zwick C, Kram HB, Meade P, Kennedy F, Fleming AW: Relationship between supranormal circulatory values, time delays, and outcome in severely traumatized patients. Crit Care Med 1993, 21: 56-63. 10.1097/00003246-199301000-00013CrossRefPubMed

23.

Schiller WR, Bay RC: Hemodynamic and oxygen transport monitoring in management of burns. New Horiz 1996, 4: 475-482.PubMed

24.

Pfeiffer UJ, Birk M, Aschenbrenner G, Blumel G: The system for quantitating thermal-dye extravascular lung water. In Computers in Critical Care and Pulmonary Medicine. Volume 2. Edited by: Prakash O. London: Plenum; 1982:123-125.CrossRef

25.

Pulsion: PiCCO Technology. Munich: Pulsion Medical Systems AG; 2006.

26.

Jeschke MG, Mlcak RP, Finnerty CC, Norbury WB, Gauglitz GG, Kulp GA, Herndon DN: Burn size determines the inflammatory and hypermetabolic response. Crit Care 2007, 11: R90. 10.1186/cc6102PubMedCentralCrossRefPubMed

27.

Schiffmann H, Erdlenbruch B, Singer D, Singer S, Herting E, Hoeft A, Buhre W: Assessment of cardiac output, intravascular volume status, and extravascular lung water by transpulmonary indicator dilution in critically ill neonates and infants. J Cardiothorac Vasc Anesth 2002, 16: 592-597. 10.1053/jcan.2002.126954CrossRefPubMed

28.

Weyland A, Buhre W, Wietasch G, Hoeft A, Cuhls H, Ruschewski W, Sonntag H: Clinical value of aortic thermodilution monitoring of cardiac output in a small child after surgical correction of tetralogy of Fallot. J Cardiothorac Vasc Anesth 1995, 9: 435-437. 10.1016/S1053-0770(05)80101-6CrossRefPubMed

29.

Eisenberg PR, Hansbrough JR, Anderson D, Schuster DP: A prospective study of lung water measurements during patient management in an intensive care unit. Am Rev Respir Dis 1987, 136: 662-668.CrossRefPubMed

30.

Mitchell JP, Schuller D, Calandrino FS, Schuster DP: Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis 1992, 145: 990-998.CrossRefPubMed

31.

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL: Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006, 354: 2564-2575.CrossRef

32.

Leteurtre S, Duhamel A, Grandbastien B, Lacroix J, Leclerc F: Paediatric logistic organ dysfunction (PELOD) score. Lancet 2006, 367: 897. author reply 900-902CrossRefPubMed

33.

Leteurtre S, Martinot A, Duhamel A, Proulx F, Grandbastien B, Cotting J, Gottesman R, Joffe A, Pfenninger J, Hubert P, Lacroix J, Leclerc F: Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet 2003, 362: 192-197. 10.1016/S0140-6736(03)13908-6CrossRefPubMed

34.

Adams HR, Baxter CR, Izenberg SD: Decreased contractility and compliance of the left ventricle as complications of thermal trauma. Am Heart J 1984, 108: 1477-1487. 10.1016/0002-8703(84)90695-1CrossRefPubMed

35.

Horton JW: Left ventricular contractile dysfunction as a complication of thermal injury. Shock 2004, 22: 495-507. 10.1097/01.shk.0000145205.51682.c3CrossRefPubMed

36.

Horton JW: A model of myocardial inflammation and dysfunction in burn complicated by sepsis. Shock 2007, 28: 326-333. 10.1097/01.shk.0000238064.54332.c8CrossRefPubMed

37.

Szabo K: Cardiac support in burned patients with heart disease. Acta Chir Plast 1989, 31: 22-34.PubMed

38.

White DJ, Carlson D, Ordway GA, Horton JW: Protective role of heat stress in burn trauma. Crit Care Med 2004, 32: 1338-1345. 10.1097/01.CCM.0000128571.39037.09CrossRefPubMed

39.

Sakka SG, Bredle DL, Reinhart K, Meier-Hellmann A: Comparison between intrathoracic blood volume and cardiac filling pressures in the early phase of hemodynamic instability of patients with sepsis or septic shock. J Crit Care 1999, 14: 78-83. 10.1016/S0883-9441(99)90018-7CrossRefPubMed

40.

Sakka SG, Meier-Hellmann A: Cardiac output measurements. J Cardiothorac Vasc Anesth 1999, 13: 515-517.CrossRefPubMed

41.

Sakka SG, Meier-Hellmann A: Extremely high values of intrathoracic blood volume in critically ill patients. Intensive Care Med 2001, 27: 1677-1678. 10.1007/s001340101071CrossRefPubMed

42.

Sakka SG, Reinhart K, Meier-Hellmann A: Comparison of pulmonary artery and arterial thermodilution cardiac output in critically ill patients. Intensive Care Med 1999, 25: 843-846. 10.1007/s001340050962CrossRefPubMed

Title: Transpulmonary thermodilution for hemodynamic measurements in severely burned children
Authors: Ludwik K Branski
David N Herndon
Jaron F Byrd
Michael P Kinsky
Jong O Lee
Shawn P Fagan
Marc G Jeschke
Publication date: 01-04-2011
Publisher: BioMed Central
Published in: Critical Care / Issue 2/2011
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc10147

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Transpulmonary thermodilution for hemodynamic measurements in severely burned children

Abstract

Introduction

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2011

Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial

Activated protein C in septic shock: a propensity-matched analysis

New treatment options against gram-negative organisms

Inspiratory muscle training in difficult to wean patients: work it harder, make it better, do it faster, makes us stronger

Clinical review: Adiponectin biology and its role in inflammation and critical illness

A pseudo-Rumsfeldian approach to pleural effusions in mechanically ventilated patients