CHEST ( PP) PP 30 HCU. Vpeak-BA. DPP 13% (r -0.21) DPP (r -0.16) HCU.

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1 CHEST J. Matthew Brennan, MD; John E. A. Blair, MD; Chetan Hampole, MD; Sascha Goonewardena, MD; Samip Vasaiwala, MD; Dipak Shah, MD; Kirk T. Spencer, MD; and Gregory A. Schmidt, MD, FCC ( PP) (HCU) ( Vpeak-BA) PP 30 HCU 30 Vpeak-BA DPP (r 0.84) ( )% κ 0.82 Vpeak-BA 16% DPP 13% ( 91% 95%) CVP Vpeak-BA (r -0.21) DPP (r -0.16) HCU Vpeak-BA PP Vpeak-BA 16% CHEST

2 (hand-carried ultrasound) pressure variation) (mechanical ventilation) (pulse CVP = central venous pressure HCU = hand-carried ultrasound NPV = negative predictive value PCWP = pulmonary capillary wedge pressure PEEP = positive end-expiratory pressure PPmax = pulse pressure maximum PPmin = pulse pressure minimum PPV = positive predictive value PP = radial artery pulse pressure variation RAP = right atrial pressure RHC = right-heart catheterization VE = volume expansion Vpeak = peak blood flow velocity Vpeak-Ao = aortic blood flow peak velocity variation Vpeak-BA = brachial artery blood flow velocity variation VT = tidal volume (VE) [19,20] [1 12] 28% 60% (RAP) (PCWP) ARDS [13] (RHC) [13,21 24] ICU 5y [4,8,9,11,25] [14 18] Frank-Starling From the Department of Cardiology (Drs. Brennan, Blair, [26] Hampole,Goonewardena, Vasaiwala, Shah, and Spencer), The University of Chicago Hospitals, Chicago, IL; and the Carver College of Medicine (Dr. Schmidt), University of Iowa, Iowa ( PP) City, IA. Correspondence to: J. Matthew Brennan, MD, Division of Cardiovascular Diseases, Duke University Medical Center, (PPV) (NPV) 2399 Erwin Rd, Durham, NC 27710; j.matthew.brennan. 94% 96% [11] 98@alum.dartmouth.org PP RAP PCWP 570

3 RAP PCWP PP [27] PP 30 ( Vpeak- Ao) VE PPV 91% NPV 100% [25] (VT) 8 ml/kg (PEEP) 5 10 mm Hg ICU (HCU) ICU [28 30] SonoSite Titan HCU (SonoSite HCU Bothell WA) 5MHz 7.7l b [31] RAP [32] 30 min HCU 10 HCU ( Vpeak) 30 s Vpeak PP ( 1) 15º 2 5min 1 A B C CHEST

4 1 (1) Vpeak-BA PP 17 (CVP) / / cm /kg /kg m (50) 15 (50) 16 (53) 14 (47) 23 (77) 8 (27) 4 (13) 5 (17) (1) x _ s (%) 30 s 30 s 13%) 2 Vpeak-BA 15 s PPV NPV Bland-Altman [33] PP Vpeak-BA 30 (Vpeak- κ PP BA) ( )% Vpeak-BA [25] Vpeak-BA (%) 100 ( - )/ ( )/ VT (9 2) ml / kg PEEP (7 2) cm H 2 O CVP Pearson PP Vpeak-BA CVP 13% PP ( PP 13%) ( PP 5% (0% 5% 5% 10% 10% 15% 15% 20% 20% 25% 25%) Vpeak-Ao Vpeak-BA 30 s VT - VT / (PPmax) (PPmin) 30 s PP [11] PP (%) = 100 (PPmax - PPmin) / ( PPmax + PPmin) / 2 x _ s / min /mmhg / min /ml kg PEEP / mm Hg 7 2 CVP / mm Hg 10 6 PP / % 11 7 Vpeak-BA / %

5 Vpeak / % r = PP / % VE [3,7,11,34,35] [4,8,11,12] ( PP Vpeak-Ao) HCU Vpeak-BA 2 RHC [11,13,21~24] 30 CVP (60 15) (29 8) kg / m 2 ( 1) CVP PP (r -0.16) 1 ( ( PP Vpeak) 15 min BP 10% ) (78 15) mm Hg (101 18) /min( 2) Vpeak-BA PP (13 8) % (11 7) % Vpeak-BA PP PP [27] (r ) 13% PP PP ( 3) Vpeak-BA 16% ( 0.947) 91% 95% ( 3) Bland-Altman Vpeak-BA PP ( )% 4 Vpeak-BA PP ( κ 0.82) (57%) CVP (10 6) mm Hg CVP Vpeak-BA (r -0.21) PP (r -0.16) [11,12] PP Vpeak-Ao 3 Vpeak-BA 16% PP 13% 91% 95% PPV 91% NPV 95% 37% CHEST

6 Vpeak / % PP / % r = % PP ( PP 13% Vpeak-BA 16% ) ICU RHC [36] Vpeak-BA RHC RHC PP HCU Vpeak-BA PP Vpeak-BA PP Soubrier [37] PP ICU ( 0.81) (n 32) 12% PP ( 13%) Vpeak-BA PP 13% Vpeak-Ao ( 15%) PP Vpeak-BA 12 6 HCU HCU Vpeak-BA PP Vpeak-BA 16% PP 13% 13% PP Bland-Altman 4 Bland-Altman ( PP- Vpeak) - 6 ( PP + Vpeak) / *

7 (PPV 94% NPV 96%) ( PP Vpeak-Ao Vpeak-BA) ( ) VT 8 ml/kg 1 Calvin JE, et al. Surgery 1981;90: Schneider AJ, et al. Am Heart J 1988;116: PEEP 5 10 mm Hg 3 Reuse C, et al. Chest 1990;98: [38] 4 Magder S, et al. J Crit Care 1992;7:76 85 VT 6mL/kg 5 Diebel LN, et al. Arch Surg 1992;127: Diebel L, et al. J Trauma 1994;37: Wagner JG, et al. Chest 1998;113: VT 8 Tavernier B, et al. Anesthesiology 1998;89: Magder S, et al. J Crit Care 1999;14: Tousignant CP, et al. Anesth Analg 2000;90: Michard F, et al. Am J Respir Crit Care Med 2000;162: Feissel M, et al. Chest 2001;119: The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. N Engl J Med 2006;354: Badgett RG, et al. JAMA 1997;277: BA 15 Gadsboll N, et al. Eur Heart J 1989;10: Butman SM, et al. J Am Coll Cardiol 1993;22: Chakko S, et al. Am J Med 1991;90: Stein JH, et al. Am J Cardiol 1997;80: Cook DJ. Am J Med Sci 1990;299: Vpeak-BA PP 20 Demeria DD, et al. Chest 2004;126:747S CVP 21 Shah, M. JAMA 2005;294: Vpeak-BA 16% Connors AF Jr, et al. JAMA 1996;276: Ivanov RI, et al. New Horiz 1997;5: PP 13% PP 13% 24 Ivanov R, et al. Crit Care Med 2000;28: Feissel M, et al. Chest 2001;119: HCU Philadelphia, PA: WB Saunders, 2005; Vpeak-BA PP 27 Scheer BV, et al. Crit Care 2002;6: PP Vpeak-BA 29 Vignon P, et al. Intensive Care Med 2004; 30: Kobal SL, et al. Chest 2004;126: Brennan JM, et al. Circulation 2005;112:U652 U Jue J, et al. J Am Soc Echocardiogr 1992;5: Bland JM, et al. Lancet 1986;i: Vpeak- 26 Guyton AC, et al. Cardiac output, venous return, and their regulation. Textbook of medical physiology. 11th ed. 28 Spevack DM, et al. Echocardiography 2003;20: CHEST

8 34 Squara P, et al. Chest 1997;111: Kumar A, et al. Crit Care Med 2004;32: Monnet X, et al. Intensive Care Med 2005;31: Soubrier S, et al. Crit Care 2005;9(Sppl 1):55 38 Charron C, et al. Anesth Analg 2006;102: CHEST 2007;131: CHEST CHEST - C. Stop vancomycin and metronidazole and start nafcillin. Once the fact that the isolated Staphylococcus aureus is sensitive to methicillin is recognized, the best treatment is to switch to a methicillin like drug, such as nafcillin. While vancomycin is an effective agent against methicillinresistant S aureus, it is not nearly as effective against a methicillin sensitive to organism as a β-lactam antibiotic such as nafcillin.in a recent study, the use of vancomycin against a methicillin-sensitive S aureus resulted in a much worse outcome, with an increased likelihood of death (odds ratio 14). Thus answer C is correct: use full-dose nafcillin. Because of the above discussion, options A and B are not appropriate. Although ceftriaxone has some activity against methicillin sensitive S aureus, it is clearly inferior to nafcillin (option D). Addding nafcillin to vancomycin is probably not going to lower the effectiveness of therapy with nafcillin, but continuation of vancomycin exposes the patient (and his surroundings) for the development of vancomycin-resistant organisms. Gonzalez C,et al.clin Infect Dis 1999;29: Jernigan J,et al.ann Intern Med 1993;119:

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