Chest
Clinical Investigations in Critical CareFluid Balance during Pulmonary Edema: Is Fluid Gain a Marker or a Cause of Poor Outcome?
Section snippets
MATERIALS AND METHODS
The data for this study were collected prospectively from June 14, 1987 to June 22, 1989 in the medical ICU of Barnes Hospital, St. Louis. During this time, 302 balloon-flotation pulmonary artery catheters were placed, usually for evaluation of shock or pulmonary edema. Although 201 patients were excluded from entering the study, a post hoc analysis failed to reveal any systematic sources of bias or difference in outcome for these patients vs the patients who actually participated in the study
Analysis by Survival
The baseline characteristics of survivors and non-survivors are shown in Table 1. Not surprisingly, the baseline scores for severity of illness were significantly lower for survivors. A larger fraction of patients in the surviving group also had a clinical diagnosis of CHF. Seven patients did not meet criteria for sepsis syndrome, ARDS, or CHF (ie, four had interstitial pulmonary disease, two had massive gastrointestinal bleeding, and one had cirrhosis). The only significant difference in the
DISCUSSION
The issue of fluid management in pulmonary edema is not new. In both cardiogenic and noncardiogenic pulmonary edema, the intent to limit edema accumulation by reducing the pulmonary microvascular hydrostatic pressure follows directly from the model of capillary fluid dynamics embodied by the familiar Starling equation.15, 16, 17 Experimentally, reducing microvascular pressures consistently limits EVLW accumulation.5,18, 19, 20, 21 In CHF, there is little controversy about management, since the
Reasons for and Outcome of Patients Excluded from Study
Of the 302 patients who underwent PAC over the approximately two-year period of recruiting patients, 201 were excluded for the following reasons (number of patients in parentheses): (1) patient-related technical problems (69), including contraindicated arterial catheter, and PAC performed for preoperative assessment only; (2) patient-unrelated technical problems (42), including investigative staff unavailable or equipment malfunction or supply shortage; (3) technique unreliable (38), including
ACKNOWLEDGMENTS:
We thank Ms. Debra Babcock and Mr. Michael Provence of the Biostatistics Department for their help with statistical considerations; Charles Owen, R.N., and Denise Canfield, R.N., for help with data collection; the pulmonary fellows, medical house staff, and nurses of the Barnes Hospital Medical and Respiratory Intensive Care Units for their help in performing the EVLW measurements; and Ms. Lisa Schomaker for her secretarial assistance.
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Supported in part by National Institutes of Health grant HL41476.