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Chun EH, Chung MH, Kim JE, Lee HS, Jo Y, Jun JH. Use of stepwise lung recruitment maneuver to predict fluid responsiveness under lung protective ventilation in the operating room. Sci Rep 2024; 14:11649. [PMID: 38773192 PMCID: PMC11109109 DOI: 10.1038/s41598-024-62355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/16/2024] [Indexed: 05/23/2024] Open
Abstract
Recent research has revealed that hemodynamic changes caused by lung recruitment maneuvers (LRM) with continuous positive airway pressure can be used to identify fluid responders. We investigated the usefulness of stepwise LRM with increasing positive end-expiratory pressure and constant driving pressure for predicting fluid responsiveness in patients under lung protective ventilation (LPV). Forty-one patients under LPV were enrolled when PPV values were in a priori considered gray zone (4% to 17%). The FloTrac-Vigileo device measured stroke volume variation (SVV) and stroke volume (SV), while the patient monitor measured pulse pressure variation (PPV) before and at the end of stepwise LRM and before and 5 min after fluid challenge (6 ml/kg). Fluid responsiveness was defined as a ≥ 15% increase in the SV or SV index. Seventeen were fluid responders. The areas under the curve for the augmented values of PPV and SVV, as well as the decrease in SV by stepwise LRM to identify fluid responders, were 0.76 (95% confidence interval, 0.61-0.88), 0.78 (0.62-0.89), and 0.69 (0.53-0.82), respectively. The optimal cut-offs for the augmented values of PPV and SVV were > 18% and > 13%, respectively. Stepwise LRM -generated augmented PPV and SVV predicted fluid responsiveness under LPV.
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Affiliation(s)
- Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Mi Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngbum Jo
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
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Messina A, Chew MS, Poole D, Calabrò L, De Backer D, Donadello K, Hernandez G, Hamzaoui O, Jozwiak M, Lai C, Malbrain MLNG, Mallat J, Myatra SN, Muller L, Ospina-Tascon G, Pinsky MR, Preau S, Saugel B, Teboul JL, Cecconi M, Monnet X. Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine. Intensive Care Med 2024; 50:548-560. [PMID: 38483559 DOI: 10.1007/s00134-024-07344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy.
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Lorenzo Calabrò
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Via Dell'artigliere 8, 37129, Verona, Italy
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olfa Hamzaoui
- Service de Médecine Intensive Réanimation Polyvalente, Robert Debré Hospital, University Hospitals of Reims, Unité HERVI « Hémostase et Remodelage Vasculaire Post-Ischémie » - EA 3801, University of Reims, Reims, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire L'Archet 1, Service de Médecine Intensive Réanimation, Nice, France
- Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Christopher Lai
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Sheyla Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine, Nîmes University Hospital, Place du Professeur Debré, 30029, Nîmes, France
- Hôpital universitaire Carémeau, University of Montpellier (MUSE), Nîmes, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sebastian Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000, Lille, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean-Louis Teboul
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy
| | - Xavier Monnet
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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Attou R, Du T, Velissaris D, Redant S, Talpoș MT, Pierrakos C. Evaluating the efficacy of a standardized 4 mL/kg fluid bolus technique in critically ill patients with elevated P vaCO 2: secondary analysis of two prospective studies. Front Med (Lausanne) 2024; 11:1348747. [PMID: 38585150 PMCID: PMC10996368 DOI: 10.3389/fmed.2024.1348747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Limiting the fluid bolus (FB) volume may attenuate side effects, including hemodilution and increased filling pressures, but it may also reduce hemodynamic responsiveness. The minimum volume to create hemodynamic effects is considered to be 4 mL/kg. In critically ill patients, the hemodynamic effects of FB with this volume have not been adequately investigated and compared to higher quantities. We hypothesized that a standardized FB approach using 4 mL/kg has comparable hemodynamic and metabolic effects to the common practice of physician-determined FB in critically ill patients. Methods We conducted post hoc analysis of two trials in non-selected critically ill patients with central venous-to-arterial CO2 tension (PvaCO2) >6 mmHg and no acute bleeding. All patients received crystalloids either at a physician-determined volume and rate or at 4 mL/kg pump-administered at 1.2 L/h. Cardiac index (CI) was calculated with transthoracic echocardiogram, and arterial and venous blood gas samples were assessed before and after FB. Endpoints were changes in CI and oxygen delivery (DO2) >15%. Results A total of 47 patients were eligible for the study, 15 of whom received physician-determined FB and 32 of whom received standardized FB. Patients in the physician-determined FB group received 16 (12-19) mL/kg at a fluid rate of 1.5 (1.5-1.9) L/h, compared to 4.1 (3.7-4.4) mL/kg at a fluid rate of 1.2 (1.2-1.2) L/h (p < 0.01) in the standardized FB group. The difference in CI elevations between the two groups was not statistically significant (8.8% [-0.1-19.9%] vs. 8.4% [0.3-23.2%], p = 0.76). Compared to physician-determined FB, the standardized FB technique had similar probabilities of increasing CI or DO2 by >15% (odds ratios: 1.3 [95% CI: 0.37-5.18], p = 0.66 and 1.83 [95% CI: 0.49-7.85], p = 0.38). Conclusion A standardized FB protocol (4 mL/kg at 1.2 L/h) effectively reduced the volume of fluid administered to critically ill patients without compromising hemodynamic or metabolic effects.
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Affiliation(s)
- Rachid Attou
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Du
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mircea T. Talpoș
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Charalampos Pierrakos
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Messina A, Uryga A, Giardina A, Ciliberti P, Battaglini D, Patroniti N, Czosnyka M, Monnet X, Cecconi M, Robba C. The effect of passive leg raising test on intracranial pressure and cerebral autoregulation in brain injured patients: a physiological observational study. Crit Care 2024; 28:23. [PMID: 38229147 PMCID: PMC10790469 DOI: 10.1186/s13054-023-04785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The use of the passive leg raising (PLR) is limited in acute brain injury (ABI) patients with increased intracranial pressure (ICP) since the postural change of the head may impact on ICP and cerebral autoregulation. However, the PLR use may prevent a positive daily fluid balance, which had been recently associated to worse neurological outcomes. We therefore studied early and delayed effects of PLR on the cerebral autoregulation of patients recovering from ABI. MATERIALS AND METHODS This is a Prospective, observational, single-center study conducted in critically ill patients admitted with stable ABI and receiving invasive ICP monitoring, multimodal neuromonitoring and continuous hemodynamic monitoring. The fluid challenge consisted of 500 mL of crystalloid over 10 min; fluid responsiveness was defined as cardiac index increase ≥ 10%. Comparisons between different variables at baseline and after PLR were made by paired Wilcoxon signed-rank test. The correlation coefficients between hemodynamic and neuromonitoring variables were assessed using Spearman's rank test. RESULTS We studied 23 patients [12 patients (52.2%) were fluid responders]. The PLR significantly increased ICP [from 13.7 (8.3-16.4) to 15.4 (12.0-19.2) mmHg; p < 0.001], cerebral perfusion pressure (CPP) [from 51.1 (47.4-55.6) to 56.4 (49.6-61.5) mmHg; p < 0.001] and the pressure reactivity index (PRx) [from 0.12 (0.01-0.24) to 0.43 (0.34-0.46) mmHg; p < 0.001]. Regarding Near Infrared Spectroscopy (NIRS)-derived parameters, PLR significantly increased the arterial component of regional cerebral oxygen saturation (O2Hbi) [from 1.8 (0.8-3.7) to 4.3 (2.5-5.6) μM cm; p < 0.001], the deoxygenated hemoglobin (HHbi) [from 1.6 (0.2-2.9) to 2.7 (1.4-4.0) μM cm; p = 0.007] and total hemoglobin (cHbi) [from 3.6 (1.9-5.3) to 7.8 (5.2-10.3): p < 0.001]. In all the patients who had altered autoregulation after PLR, these changes persisted ten minutes afterwards. After the PLR, we observed a significant correlation between MAP and CPP and PRx. CONCLUSIONS In ABI patient with stable ICP, PLR test increased ICP, but mostly within safety values and thresholds. Despite this, cerebral autoregulation was importantly impaired, and this persisted up to 10 min after the end of the maneuvre. Our results discourage the use of PLR test in ABI even when ICP is stable.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy.
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Pietro Ciliberti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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Messina A, Caporale M, Calabrò L, Lionetti G, Bono D, Matronola GM, Brunati A, Frassanito L, Morenghi E, Antonelli M, Chew MS, Cecconi M. Reliability of pulse pressure and stroke volume variation in assessing fluid responsiveness in the operating room: a metanalysis and a metaregression. Crit Care 2023; 27:431. [PMID: 37940953 PMCID: PMC10631038 DOI: 10.1186/s13054-023-04706-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pulse pressure and stroke volume variation (PPV and SVV) have been widely used in surgical patients as predictors of fluid challenge (FC) response. Several factors may affect the reliability of these indices in predicting fluid responsiveness, such as the position of the patient, the use of laparoscopy and the opening of the abdomen or the chest, combined FC characteristics, the tidal volume (Vt) and the type of anesthesia. METHODS Systematic review and metanalysis of PPV and SVV use in surgical adult patients. The QUADAS-2 scale was used to assess the risk of bias of included studies. We adopted a metanalysis pooling of aggregate data from 5 subgroups of studies with random effects models using the common-effect inverse variance model. The area under the curve (AUC) of pooled receiving operating characteristics (ROC) curves was reported. A metaregression was performed using FC type, volume, and rate as independent variables. RESULTS We selected 59 studies enrolling 2,947 patients, with a median of fluid responders of 55% (46-63). The pooled AUC for the PPV was 0.77 (0.73-0.80), with a mean threshold of 10.8 (10.6-11.0). The pooled AUC for the SVV was 0.76 (0.72-0.80), with a mean threshold of 12.1 (11.6-12.7); 19 studies (32.2%) reported the grey zone of PPV or SVV, with a median of 56% (40-62) and 57% (46-83) of patients included, respectively. In the different subgroups, the AUC and the best thresholds ranged from 0.69 and 0.81 and from 6.9 to 11.5% for the PPV, and from 0.73 to 0.79 and 9.9 to 10.8% for the SVV. A high Vt and the choice of colloids positively impacted on PPV performance, especially among patients with closed chest and abdomen, or in prone position. CONCLUSION The overall performance of PPV and SVV in operating room in predicting fluid responsiveness is moderate, ranging close to an AUC of 0.80 only some subgroups of surgical patients. The grey zone of these dynamic indices is wide and should be carefully considered during the assessment of fluid responsiveness. A high Vt and the choice of colloids for the FC are factors potentially influencing PPV reliability. TRIAL REGISTRATION PROSPERO (CRD42022379120), December 2022. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=379120.
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Affiliation(s)
- Antonio Messina
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
| | - Mariagiovanna Caporale
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lorenzo Calabrò
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Giulia Lionetti
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Daniele Bono
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Guia Margherita Matronola
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Andrea Brunati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Luciano Frassanito
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Emanuela Morenghi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Messina A, Sotgiu G, Saderi L, Puci M, Negri K, Robba C, Sanfilippo F, Romagnoli S, Cecconi M. Phenotypes of hemodynamic response to fluid challenge during anesthesia: a cluster analysis. Minerva Anestesiol 2023; 89:653-662. [PMID: 36943710 DOI: 10.23736/s0375-9393.23.16992-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The fluid challenge (FC) response is usually evaluated as binary, which may be inadequate to describe the complex interactions between heart function and vascular tone response after fluid administration. We applied a clustering approach to assess the different phenotypes of cardiovascular responses to FC administration, considering the associations of all the baseline variables potentially influencing pressure and flow response to a FC. Secondarily, we evaluated the reliability of baseline hemodynamic variables in discriminating fluid responsiveness, which is considered the standard approach at the bedside. METHODS Five merged datasets from elective surgical patients receiving a FC dose ≥4 mL/kg, infused over 10 minutes. In a principal component approach, hierarchical clustering was used to define hemodynamic phenotypes of response to FC administration. Hierarchical cluster analysis with Ward linkage was carried out to define similar patient groups using the Gower distance for the mixed combination of continuous and categorical variables. No a priori criteria of fluid responsiveness were applied. The area (AUC) under the pre-FC variables' receiver operating characteristic curves (ROC) was also built to predict fluid responsiveness, defined as SVI ≥10% after FC. RESULTS We analyzed 223 patients. The cluster analysis identified three hemodynamic clusters of patients: cluster 1 (98 patients, 44.0%) showed an average increase of mean arterial pressure (MAP) and Stroke Volume Index (SVI) of 17.3% (11.9-23.1) and 13.1% (0.5-23.4) at the end of FC, respectively. These patients showed baseline flow and pressure variables slightly below physiological ranges, with high pulse pressure variation (PPV). Cluster 2 (68 patients, 30.5%) showed no increase of MAP and SVI at the end of FC. These patients showed baseline flow and pressure variables within physiological ranges, with low hear rate (HR) and PPV. Cluster 3 (57 patients, 25.5%) showed no MAP increase and an SVI increase of 13.1 (2.1-19.6). These patients showed baseline pressure variables within physiological ranges, low flow variables associated to high HR and PPV. The pulse pressure variation (PPV) showed an AUC of 0.82 (0.03), with a grey zone ranging from 6% to 12%, including 86 (38.5%) patients. CONCLUSIONS Clustering analysis identified three hemodynamic clusters with different response phenotypes to FC. This promising approach may enhance the ability to detect fluid responsiveness at the bedside, by considering the specific association of parameters and not the presence of a single one, such as the PPV. In fact, in our cohort the reliability of the PPV was limited, showing high sensibility and specificity only above 12% and below 6%, respectively, and a grey zone including 38.5% of patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy -
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy -
| | - Giovanni Sotgiu
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Mariangela Puci
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Katerina Negri
- Department of Anesthesia and Intensive Care, University of Milan, Milan, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Šribar A, Jurinjak IS, Almahariq H, Bandić I, Matošević J, Pejić J, Peršec J. Hypotension prediction index guided versus conventional goal directed therapy to reduce intraoperative hypotension during thoracic surgery: a randomized trial. BMC Anesthesiol 2023; 23:101. [PMID: 36997847 PMCID: PMC10061960 DOI: 10.1186/s12871-023-02069-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/25/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE Intraoperative hypotension is linked to increased incidence of perioperative adverse events such as myocardial and cerebrovascular infarction and acute kidney injury. Hypotension prediction index (HPI) is a novel machine learning guided algorithm which can predict hypotensive events using high fidelity analysis of pulse-wave contour. Goal of this trial is to determine whether use of HPI can reduce the number and duration of hypotensive events in patients undergoing major thoracic procedures. METHODS Thirty four patients undergoing esophageal or lung resection were randomized into 2 groups -"machine learning algorithm" (AcumenIQ) and "conventional pulse contour analysis" (Flotrac). Analyzed variables were occurrence, severity and duration of hypotensive events (defined as a period of at least one minute of MAP below 65 mmHg), hemodynamic parameters at 9 different timepoints interesting from a hemodynamics viewpoint and laboratory (serum lactate levels, arterial blood gas) and clinical outcomes (duration of mechanical ventilation, ICU and hospital stay, occurrence of adverse events and in-hospital and 28-day mortality). RESULTS Patients in the AcumenIQ group had significantly lower area below the hypotensive threshold (AUT, 2 vs 16.7 mmHg x minutes) and time-weighted AUT (TWA, 0.01 vs 0.08 mmHg). Also, there were less patients with hypotensive events and cumulative duration of hypotension in the AcumenIQ group. No significant difference between groups was found in terms of laboratory and clinical outcomes. CONCLUSIONS Hemodynamic optimization guided by machine learning algorithm leads to a significant decrease in number and duration of hypotensive events compared to traditional goal directed therapy using pulse-contour analysis hemodynamic monitoring in patients undergoing major thoracic procedures. Further, larger studies are needed to determine true clinical utility of HPI guided hemodynamic monitoring. TRIAL REGISTRATION Date of first registration: 14/11/2022 Registration number: 04729481-3a96-4763-a9d5-23fc45fb722d.
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Affiliation(s)
- Andrej Šribar
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia
- Zagreb University School of Dental Medicine, Gundulićeva 5, Zagreb, Croatia
| | - Irena Sokolović Jurinjak
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia
| | - Hani Almahariq
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia
| | - Ivan Bandić
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia
| | - Jelena Matošević
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia
| | - Josip Pejić
- Department of Thoracic Surgery, University Hospital Dubrava, Av. Gojka Šuška 6, Zagreb, Croatia
| | - Jasminka Peršec
- Clinical Department of Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia.
- Zagreb University School of Dental Medicine, Gundulićeva 5, Zagreb, Croatia.
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8
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Messina A, Calabrò L, Pugliese L, Lulja A, Sopuch A, Rosalba D, Morenghi E, Hernandez G, Monnet X, Cecconi M. Fluid challenge in critically ill patients receiving haemodynamic monitoring: a systematic review and comparison of two decades. Crit Care 2022; 26:186. [PMID: 35729632 PMCID: PMC9210670 DOI: 10.1186/s13054-022-04056-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000–2010 and 2011–2021.
Methods
We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold.
Results
We included 124 studies, 32 (25.8%) published in 2000–2010 and 92 (74.2%) in 2011–2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011–2021 compared to the 2000–2010 period.
Conclusions
In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000–2010 decade, in 2011–2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.
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9
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Messina A, Bakker J, Chew M, De Backer D, Hamzaoui O, Hernandez G, Myatra SN, Monnet X, Ostermann M, Pinsky M, Teboul JL, Cecconi M. Pathophysiology of fluid administration in critically ill patients. Intensive Care Med Exp 2022; 10:46. [PMID: 36329266 PMCID: PMC9633880 DOI: 10.1186/s40635-022-00473-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Fluid administration is a cornerstone of treatment of critically ill patients. The aim of this review is to reappraise the pathophysiology of fluid therapy, considering the mechanisms related to the interplay of flow and pressure variables, the systemic response to the shock syndrome, the effects of different types of fluids administered and the concept of preload dependency responsiveness. In this context, the relationship between preload, stroke volume (SV) and fluid administration is that the volume infused has to be large enough to increase the driving pressure for venous return, and that the resulting increase in end-diastolic volume produces an increase in SV only if both ventricles are operating on the steep part of the curve. As a consequence, fluids should be given as drugs and, accordingly, the dose and the rate of administration impact on the final outcome. Titrating fluid therapy in terms of overall volume infused but also considering the type of fluid used is a key component of fluid resuscitation. A single, reliable, and feasible physiological or biochemical parameter to define the balance between the changes in SV and oxygen delivery (i.e., coupling “macro” and “micro” circulation) is still not available, making the diagnosis of acute circulatory dysfunction primarily clinical. Fluids are drugs used in patients with shock to increase the cardiac output with the aim to improve oxygen delivery to the cells. The response to fluid administration is determined by the physiological interaction of cardiac function and venous return. In septic shock, the beneficial clinical response of fluid administration is rapidly reduced after few hours and fluid titration is crucial to avoid detrimental fluid overload. The fluid challenge is a fluid bolus given at a defined quantity and rate to assess fluid responsiveness. The ideal fluid for critically ill patients does not exist; however, crystalloids should be used as first choice. Balanced crystalloid solutions may be associated with better outcomes but the evidence is still low. Albumin infusion may have a role in already fluid resuscitated patients at risk of fluid overload. Fluid administration is integrated into the complex management of pressure and flow “macro” hemodynamic variables, coupled to the “micro” local tissue flow distribution and regional metabolism. Macro-variables are managed by measuring systemic blood pressure and evaluating the global cardiac function. The critical threshold of oxygen delivery to the cells is difficult to estimate, however, several indexes and clinical signs may be considered as surrogate of that, and integrated in a decision-making process at the bedside.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
| | - Jan Bakker
- NYU Langone Health and Columbia University Irving Medical Center, New York, USA.,Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Olfa Hamzaoui
- Service de Reanimation PolyvalenteHopital Antoine Béclère, Hopitaux Universitaires Paris-Saclay, Clamart, France
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, Paris, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Messina A, Colombo D, Lionetti G, Calabrò L, Negri K, Robba C, Cammarota G, Costantini E, Cecconi M. Pressure response to fluid challenge administration in hypotensive surgical patients: a post-hoc pharmacodynamic analysis of five datasets. J Clin Monit Comput 2022; 37:449-459. [PMID: 36197548 DOI: 10.1007/s10877-022-00918-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/17/2022] [Indexed: 10/10/2022]
Abstract
In this study we evaluated the effect of fluid challenge (FC) administration in elective surgical patients with low or normal blood pressure. Secondarily, we appraised the pharmacodynamic effect of FC in normotensive and hypotensive patients. We assessed five merged datasets of patients with a baseline mean arterial pressure (MAP) above or below 65 mmHg and assessed the changes of systolic, diastolic, mean and dicrotic arterial pressures, dynamic indexes of fluid responsiveness and arterial elastance over a 10-min infusion. The hemodynamic effect was assessed by considering the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), the time when the maximal value was observed (tmax) and change from baseline at 5-min (d5) after FC end. A stroke volume index increase > 10% with respect to the baseline value after FC administration indicated fluid response. Two hundred-seventeen patients were analysed [102 (47.0%) fluid responders]. On average, FC restored a MAP [Formula: see text] 65 mmHg after 5 min. The AUCs and the dmax of pressure variables and arterial elastance of hypotensive patients were all significantly greater than normotensive patients. Pressure variables and arterial elastance changes in the hypotensive group were all significantly higher at d5 as compared to the normotensive group. In hypotensive patients, FC restores a MAP [Formula: see text] 65 mmHg after 5 min from infusion start. The hemodynamic profile of FC in hypotensive and normotensive patients is different; both the magnitude of pressure augmentation and duration is greater in the hypotensive group.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy.
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Italy
| | | | | | - Katerina Negri
- Department of Anesthesia and Intensive Care, Università degli studi di Milano, Milan, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | | | | | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
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De Backer D, Aissaoui N, Cecconi M, Chew MS, Denault A, Hajjar L, Hernandez G, Messina A, Myatra SN, Ostermann M, Pinsky MR, Teboul JL, Vignon P, Vincent JL, Monnet X. How can assessing hemodynamics help to assess volume status? Intensive Care Med 2022; 48:1482-1494. [PMID: 35945344 PMCID: PMC9363272 DOI: 10.1007/s00134-022-06808-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023]
Abstract
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Nadia Aissaoui
- Assistance publique des hôpitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, médecine interne reanimation, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, 25 rue Leblanc, 75015, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Ludhmila Hajjar
- Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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Desebbe O, Mondor W, Gergele L, Raphael D, Vallier S. Variations of pulse pressure and central venous pressure may predict fluid responsiveness in mechanically ventilated patients during lung recruitment manoeuvre: an ancillary study. BMC Anesthesiol 2022; 22:269. [PMID: 35999508 PMCID: PMC9396758 DOI: 10.1186/s12871-022-01815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Maintaining a constant driving pressure during a prolonged sigh breath lung recruitment manoeuvre (LRM) from 20 to 45 cmH20 peak inspiratory pressure in mechanically ventilated patients has been shown to be a functional test to predict fluid responsiveness (FR) when using a linear regression model of hemodynamic parameters, such as central venous pressure (CVP) and pulse pressure (PP). However, two important limitations have been raised, the use of high ventilation pressures and a regression slope calculation that is difficult to apply at bedside. This ancillary study aimed to reanalyse absolute variations of CVP (ΔCVP) and PP (ΔPP) values at lower stages of the LRM, (40, 35, and 30 cm H20 of peak inspiratory pressure) for their ability to predict fluid responsiveness. Methods Retrospective analysis of a prospective study data set in 18 mechanically ventilated patients, in an intensive care unit. CVP, systemic arterial pressure parameters and stroke volume (SV) were recorded during prolonged LRM followed by a 500 mL crystalloid volume expansion. Patients were considered as fluid responders if SV increased more than 10%. Receiver-operating curves (ROC) analysis with the corresponding grey zone approach were performed. Results Areas under the ROC to predict fluid responsiveness for ΔCVP and ΔPP were not different between the successive stepwise increase of inspiratory pressures [0.88 and 0.89 for ΔCVP at 45 and 30 cm H20 (P = 0.89), respectively, and 0.92 and 0.95 for ΔPP at 45 and 30 cm H20, respectively (P = 0.51)]. Using a maximum of 30 cmH2O inspiratory pressure during the LRM, ΔCVP and ΔPP had a threshold value to predict fluid responsiveness of 2 mmHg and 4 mmHg, with sensitivities of 89% and 89% and specificities of 67% and 89%, respectively. Combining ΔPP and ΔCVP decreased the proportion of the patients in the grey zone from 28 to 11% and showed a sensitivity of 88% and a specificity of 83%. Conclusions A stepwise PEEP elevation recruitment manoeuvre of up to 30 cm H20 may predict fluid responsiveness as well as 45 cm H20. The combination of ΔPP and ΔCVP optimizes the categorization of responder and non-responder patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01815-1.
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and Intensive Care, Ramsay Sante Sauvegarde Clinic, Lyon, France.
| | - Whitney Mondor
- Department of Biosciences, Claude Bernard University, Lyon, France
| | - Laurent Gergele
- Department of Anesthesiology and Intensive Care, Ramsay Sante HPL Clinic, Saint-Etienne, France
| | - Darren Raphael
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, USA
| | - Sylvain Vallier
- Department of Anesthesiology and Intensive Care, Elsan Alpes-Belledonne Clinic, Grenoble, France
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Messina A, Cecconi M. Letter to editor. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2021; 1:22. [PMID: 37386666 DOI: 10.1186/s44158-021-00024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 07/01/2023]
Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy.
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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14
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Messina A, Sotgiu G, Saderi L, Cammarota G, Capuano L, Colombo D, Bennett V, Payen D, DE Backer D, Navalesi P, Cecconi M. Does the definition of fluid responsiveness affect passive leg raising reliability? A methodological ancillary analysis from a multicentric study. Minerva Anestesiol 2021; 88:272-281. [PMID: 34709017 DOI: 10.23736/s0375-9393.21.15944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluid challenge (FC) is often adopted as gold standard used to assess the reliability of passive leg raising (PLR) in predicting fluid responsiveness in the intensive care unit (ICU). This study aimed to address the impact of the different definitions and timings used to assess FC response on PLR reliability. METHODS Ancillary study from a data set of a multicentric study in 85 ICU patient with acute circulatory failure who received a FC (500 mL of crystalloids in 10 minutes) within the first 48h of ICU admission, preceded by PLR in 30 patients. FC response was assessed considering the changes in cardiac index (CI) and stroke volume index (SVI) using different thresholds and at different timepoints. RESULTS The definitions of fluid responsiveness by using CI or SVI with a 15% increase after 10 minutes were associated to the best performances of the PLR [AUC (95% CI) 0.94 (0.83-1.01); vs. AUC (95% CI) 0.95 (0.87-1.02)]. The sensitivity of the PLR by adopting the CI or the SVI as reference variable ranged from 54.1% to 67.6% and from 81.5% to 100.0%; the specificity from 65.9% to 78.0% and from 79.5% to 100.0%, respectively. Considering all the subgroups, the number of responders 10 minutes after FC administration was higher as compared to 15 and 30 minutes (140 vs. 120 and 125, respectively, p < 0.05). CONCLUSIONS The reliability of the PLR test to predict fluid responsiveness depends on the definition of FC adopted. The timing of FC outcome assessment affected the overall fluid responsiveness.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy -
| | - Giovanni Sotgiu
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | | | - Lorenzo Capuano
- Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Novara, Italy
| | - Victoria Bennett
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, London, UK
| | | | - Daniel DE Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Paolo Navalesi
- Section of Anesthesiology and Intensive Care, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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