Vilchez Monge A L, Tranche Alvarez-Cagigas I, Perez-Peña J, Olmedilla L, Jimeno C, Sanz J, Bellón Cano J M, Garutti I
Hospital General Universitario Gregorio Marañón, Madrid, Spain -
Minerva Anestesiol. 2014 Nov;80(11):1178-87. Epub 2014 Feb 25.
Liver transplantation (LT) implies hemodynamic instability, making invasive monitoring of cardiac output (CO) mandatory. Intermittent thermodilution with pulmonary artery catheter (PAC) remains the clinical gold standard to measure CO. The agreement between PAC and new monitoring methods in LT needs to be further investigated. Our aim is to clarify whether cardiac index (CI) measurements with transpulmonary intermittent thermodilution, and continuous pulmonary thermodilution methods agree sufficiently with those performed intermittently with PAC to be considered interchangeable during LT.
We studied prospectively hemodynamic parameters of 72 consecutive patients undergoing LT. Each CI was obtained simultaneously with three different techniques: intermittent (PACi) and continuous (CCI) pulmonary artery thermodilution with PAC, and intermittent transpulmonary thermodilution (TPTD) with PiCCO2 in 8 time points of the procedure, obtaining 1350 paired measurements. Exclusion criteria was retransplantation. The statistical Bland Altman method for repeated measures was used to assess agreement, and polar plot methodology to evaluate trending ability.
Analysis of agreement between PACi and TPTD measurements (N.=474 paired measurements) showed a bias of -0.42 L/min/m2, 95% limits of agreement (95%LoA) of ±1.5 L/min/m2 and percentage error of 45%. PACi-CCI comparisons (N.=431) showed bias of -0.02 L/min/m2, 95%LoA of ±1.96 L/min/m2, and percentage error of 64%. These results demonstrated questionable clinical agreement between PACi and TPTD, and no agreement between PACi and CCI. TPTD and CCI showed poor CO trending ability.
Continuous pulmonary thermodilution with PAC is not an alternative monitoring method of CO. Transpulmonary thermodilution CO monitoring with PiCCO2 shows too questionable agreement with the clinical gold standard (PACi) being in the limit of acceptance to be considered interchangeable during liver transplantation.
肝移植（LT）意味着血流动力学不稳定，因此对心输出量（CO）进行有创监测必不可少。使用肺动脉导管（PAC）进行间歇性热稀释仍然是测量CO的临床金标准。LT中PAC与新监测方法之间的一致性需要进一步研究。我们的目的是阐明经肺间歇性热稀释和连续肺热稀释法测量的心指数（CI）与使用PAC间歇性测量的心指数是否足够一致，以便在LT期间可视为可互换。
我们前瞻性地研究了72例连续接受LT患者的血流动力学参数。在手术的8个时间点，每种CI均通过三种不同技术同时获得：使用PAC进行间歇性（PACi）和连续性（CCI）肺动脉热稀释，以及使用PiCCO2进行间歇性经肺热稀释（TPTD），共获得1350对测量值。排除标准为再次移植。采用重复测量的统计Bland Altman方法评估一致性，并采用极坐标图方法评估趋势能力。
PACi与TPTD测量值之间的一致性分析（N = 474对测量值）显示偏差为-0.42 L/min/m²，一致性界限（95%LoA）为±1.5 L/min/m²，误差百分比为45%。PACi与CCI的比较（N = 431）显示偏差为-0.02 L/min/m²，95%LoA为±1.96 L/min/m²，误差百分比为64%。这些结果表明PACi与TPTD之间的临床一致性存疑，PACi与CCI之间无一致性。TPTD和CCI显示出较差的CO趋势能力。
使用PAC进行连续肺热稀释不是CO的替代监测方法。使用PiCCO2进行经肺热稀释CO监测与临床金标准（PACi）的一致性存疑，处于可接受的极限，在肝移植期间不能视为可互换。
