J. M. Yee1, A. M. Strumwasser1, R. Hogen1, K. Dhanireddy2, S. Biswas1, P. J. Cobb1, D. H. Clark1 1University Of Southern California,Trauma, Acute Care Surgery, And Surgical Critical Care,Los Angeles, CA, USA 2University Of Southern California,Solid Organ Transplantation,Los Angeles, CA, USA
Introduction:
Hemodynamic monitoring in end-stage liver disease (ESLD) is controversial given difficulties in assessing volume responsiveness (VR) and cardiac function (CFx). Pulse waveform analysis (PWA) may supplant pulmonary artery catheterization (PAC) as a non-invasive modality. We hypothesize that PWA is equivalent to PAC for assessing VR and CFx post-orthotopic liver transplantation (OLT). Our specific aims were to determine if post-OLT PWA and PAC data are concordant for measures of VR and CFx, vary pre-and-post extubation, and impact cardiovascular management decisions.
Methods:
Between 2014-2015, (N=49) simultaneous PWA and PAC data (303 paired measurements) were obtained. Bland-Altman analysis determined variability and bias for CFx (cardiac index, CI), VR (stroke volume index, SVI), and vascular resistance (systemic vascular resistance index, SVRI). Reference ranges: CI 2.8-4.2 L/min/m2, SVI 33-47 ml/m2, SVRI 1200-2500 dynes/m2/cm5. Data were concordant if measurements agreed. For discordant data, cardiovascular management decisions (inotrope/pressor) were determined. Patients on post-OLT vasopressors, with vascular disease and/or ventilated < 8 ml/kg IBW.
Results:
Mean difference (ventilated) was 0.06 [-0.25,0.37] L/min/m2, 1.34 [-1.93,4.6] ml/m2, 736 [584,889] dynes/m2/cm5, and (extubated) was 0.17 [-0.2,0.54] L/min/m2, 2.67 [-2.19,7.52] ml/m2, 660 [416,904] dynes/m2/cm5 for CI, SVI, and SVRI respectively. 98.6%, 97.1%, 98% of ventilated patient data and 95.1%, 95.1%, 96.7% of extubated patient data for CI, SVI, and SVRI respectively, fell within 95% of these limits. For clinical interventions, PAC led to 5 unnecessary interventions whereas PWA led to 3.
Conclusion:
Comparing PAC and PWA, mean differences for CI and SVI fall within acceptable ranges of bias with high degree of concordance whereas SVRI data appears to have proportional variability outside of normal ranges. PWA may be used as an alternative to PAC post-OLT to assess VR and CFx.