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) (2.8 2.8)% 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% www.chestjournal.org.cn CHEST 2007 9 4 9 569
(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, 2300- (PPV) (NPV) 2399 Erwin Rd, Durham, NC 27710; e-mail: j.matthew.brennan. 94% 96% [11] 98@alum.dartmouth.org PP RAP PCWP 570
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 40 000 [31] RAP [32] 30 min HCU 10 HCU ( Vpeak) 30 s Vpeak PP ( 1) 15º 2 5min 1 A B C www.chestjournal.org.cn CHEST 2007 9 4 9 571
1 (1) Vpeak-BA PP 17 (CVP) / 60 15 / cm 170 10 /kg 83 26 /kg m -2 29 8 15 (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) (2.8 2.8)% Vpeak-BA [25] Vpeak-BA (%) 100 ( - )/ ( )/2 2 30 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 -1 101 18 /mmhg 78 15 / min -1 21 6 583 106 /ml kg -1 9 2 PEEP / mm Hg 7 2 CVP / mm Hg 10 6 PP / % 11 7 Vpeak-BA / % 13 8 572
Vpeak / % r =0.84 30 15 0 15 30 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) 30 20 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 0.84 2) 13% PP PP ( 3) Vpeak-BA 16% ( 0.947) 91% 95% ( 3) Bland-Altman Vpeak-BA PP (-2.1 4.1)% 4 Vpeak-BA PP ( κ 0.82) 30 17 (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% 15 0.1 www.chestjournal.org.cn CHEST 2007 9 4 9 573
Vpeak / % 30 15 3 PP / % r =0.84 0 15 30 13% 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 0 6.06 HCU Vpeak-BA PP -12-14 Vpeak-BA 16% PP 13% 13% PP Bland-Altman 4 Bland-Altman ( PP- Vpeak) - 6 ( PP + Vpeak) / 2 +1.96* 0 20 40 574
(PPV 94% NPV 96%) ( PP Vpeak-Ao Vpeak-BA) ( ) VT 8 ml/kg 1 Calvin JE, et al. Surgery 1981;90:61 76 2 Schneider AJ, et al. Am Heart J 1988;116:103 112 PEEP 5 10 mm Hg 3 Reuse C, et al. Chest 1990;98: 1450 1454 [38] 4 Magder S, et al. J Crit Care 1992;7:76 85 VT 6mL/kg 5 Diebel LN, et al. Arch Surg 1992;127:817 822 6 Diebel L, et al. J Trauma 1994;37:950 955 7 Wagner JG, et al. Chest 1998;113:1048 1054 VT 8 Tavernier B, et al. Anesthesiology 1998;89:1313 1321 9 Magder S, et al. J Crit Care 1999;14:164 171 10 Tousignant CP, et al. Anesth Analg 2000;90:351 355 11 Michard F, et al. Am J Respir Crit Care Med 2000;162:134 138 12 Feissel M, et al. Chest 2001;119:867 873 13 The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. N Engl J Med 2006;354:2213 2224 14 Badgett RG, et al. JAMA 1997;277:1712 1719 BA 15 Gadsboll N, et al. Eur Heart J 1989;10:1017 1028 16 Butman SM, et al. J Am Coll Cardiol 1993;22:968 974 17 Chakko S, et al. Am J Med 1991;90:353 359 18 Stein JH, et al. Am J Cardiol 1997;80:1615 1618 19 Cook DJ. Am J Med Sci 1990;299:175 178 Vpeak-BA PP 20 Demeria DD, et al. Chest 2004;126:747S CVP 21 Shah, M. JAMA 2005;294:1664 1670 22 Vpeak-BA 16% Connors AF Jr, et al. JAMA 1996;276:889 897 23 Ivanov RI, et al. New Horiz 1997;5:268 276 PP 13% PP 13% 24 Ivanov R, et al. Crit Care Med 2000;28:615 619 25 Feissel M, et al. Chest 2001;119:867 873 HCU Philadelphia, PA: WB Saunders, 2005;232 245 Vpeak-BA PP 27 Scheer BV, et al. Crit Care 2002;6:199 204 PP Vpeak-BA 29 Vignon P, et al. Intensive Care Med 2004; 30:718 723 30 Kobal SL, et al. Chest 2004;126:693 701 31 Brennan JM, et al. Circulation 2005;112:U652 U653 32 Jue J, et al. J Am Soc Echocardiogr 1992;5:613 619 33 Bland JM, et al. Lancet 1986;i:307 310 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;20:455 461 www.chestjournal.org.cn CHEST 2007 9 4 9 575
34 Squara P, et al. Chest 1997;111:351 358 35 Kumar A, et al. Crit Care Med 2004;32:691 699 36 Monnet X, et al. Intensive Care Med 2005;31:1195 1201 37 Soubrier S, et al. Crit Care 2005;9(Sppl 1):55 38 Charron C, et al. Anesth Analg 2006;102:1511 1517 CHEST 2007;131:1301-1307 CHEST - 614 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;29:1171-1177 Jernigan J,et al.ann Intern Med 1993;119:304-311 576