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Kim HB, Soh S, Song JW, Kim MY, Kwak YL, Shim JK. Combination of Static Echocardiographic Indices for the Prediction of Fluid Responsiveness in Patients Undergoing Coronary Surgery: A Pilot Study. J Clin Med 2021; 10:jcm10091886. [PMID: 33925449 PMCID: PMC8123780 DOI: 10.3390/jcm10091886] [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: 01/26/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
We investigated the role of echocardiographic indices consisting of left ventricular end-diastolic area (LVEDA) in combination with Doppler-derived surrogates of diastolic compliance and filling (E/E′, E′/S′, E′/A′; early transmitral flow velocity (E), tissue Doppler-derived early (E′) diastolic, late (A′) diastolic, or peak systolic (S′) velocity of the mitral annulus) in predicting fluid responsiveness in off-pump coronary surgery. Hemodynamic and echocardiographic variables were prospectively assessed under general anesthesia before and after a fluid challenge of 6 mL/kg during apnea at atmospheric pressure in 64 patients with LV ejection fraction ≥40%. Forty patients (63%) were fluid responders (≥15% increase in stroke volume index). E/E′ and E′/S′ could predict fluid responsiveness with area under the receiver operating characteristic curve (AUROC) of 0.71 (95% confidence interval [CI], 0.56–0.85; p = 0.006) and 0.68 (95% CI, 0.54–0.82; p = 0.017), respectively. The combination of LVEDA and E/E′ showed incremental predictive ability for fluid responsiveness compared with LVEDA (AUROC, 0.60; p = 0.170) or pulse pressure variation (AUROC, 0.70; p = 0.002), yielding the highest AUROC of 0.78 (95% CI, 0.66–0.90; p < 0.001). The combined index of echocardiographic variables reflecting LV dimension (LVEDA) and diastolic compliance and filling (E/E′) is a potentially useful predictor of fluid responsiveness.
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Affiliation(s)
| | | | | | | | | | - Jae-Kwang Shim
- Correspondence: ; Tel.: +82-2-2228-8500; Fax: +82-2-364-2951
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Bilehjani E, Nader N, Farzin H, Haghighate Azari M, Fakhari S. The Evaluation of Factors Affecting Hemodynamic Variability in Mechanically-Ventilated Patients After Cardiac Surgery. Anesth Pain Med 2020; 10:e101832. [PMID: 33134143 PMCID: PMC7539053 DOI: 10.5812/aapm.101832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/21/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background Optimizing cardiac preload is usually the first step in patients with unstable hemodynamic. However, it should be remembered that an unnecessary volume expansion may exacerbate the hemodynamic. In mechanically ventilated patients, the ventilatory induced hemodynamic variations (VIHV) can be used to predict the fluid requirement. These variations (called dynamic indices of cardiac filling pressure), are superior to static indices (central venous and pulmonary artery occlusion pressure) in diagnosing any volume requirement. We theorized that some conditions other than hypovolemia might affect these hemodynamic variations. Objectives The current study aimed to discover these conditions in adult patients admitted to post-cardiac surgery ICU. Methods This antegrade cross-sectional study was conducted on 304 adult patients who were admitted to ICU after elective cardiac surgery in a teaching hospital (Tabriz-Iran). During the first 3 hours of the admission, the systolic (ΔSBP), diastolic (ΔDBP), mean (ΔMAP), and arterial blood pulse pressures (ΔPP) were invasively monitored and calculated in percent value. Because of the return of spontaneous breathing in most of the patients, the calculations were done only during the first 3-hour. All patients with spontaneous breathing, irregular cardiac rhythm, or re-admission to OR in this period were excluded from the study. We recorded demographic and surgical characteristics, perioperative hemodynamic and echocardiographic, and complications data and surveyed the correlation between VIHV and perioperative data. Results Two hundred and ninety two patients met the inclusion criteria. Coronary artery bypass grafting (CABG) was the most common surgery (64.4 %). Cardiopulmonary bypass (CPB) was used in 95.55% of the surgeries. In the first 24-hour, 51 patients required re-operation because of sternum closure, bleeding control, cardiac tamponade, and coronary artery revascularization. Mortality and morbidity occurred in 2 (0.68%) and 50 (17.12%) patients, respectively. Among VIHVs, the ΔPP had the most significant value. Thus, mean ΔPP was calculated and the correlation between its severity (≤ 20% vs. > 20%) and other values surveyed. It was high in patients with cardiac dysfunction and tamponade (P value < 0.001). No significant correlation was found between mean ΔPP severity and hemorrhage rate, fluid balance, need to vasoactive agents, blood products, or bleeding control, redo CABG or sternum closure surgery, time to tracheal extubation, ICU stay, and postoperative complications. Patients with closed sternum were the same as those with the unclosed sternum. Conclusions The ΔPP was the most sensitive VIHV parameter. Cardiac dysfunction and tamponade increased ΔPP. Unclosed sternum did not affect its value. ΔPP value did not affect postoperative complications rate, time to tracheal extubation, or ICU stay.
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Affiliation(s)
- Eissa Bilehjani
- Madani Heart Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader Nader
- Department of Anesthesiology, SUNY-Buffalo, Buffalo, United States
- Anesthesia and Perioperative Care, VA Western NY Healthcare System, Buffalo, United States
| | - Haleh Farzin
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Solmaz Fakhari
- Pain and Palliative Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Pain and Palliative Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Joosten A, Boudart C, Vincent JL, Vanden Eynden F, Barvais L, Van Obbergh L, Rinehart J, Desebbe O. Ability of a New Smartphone Pulse Pressure Variation and Cardiac Output Application to Predict Fluid Responsiveness in Patients Undergoing Cardiac Surgery. Anesth Analg 2019; 128:1145-1151. [PMID: 31094781 DOI: 10.1213/ane.0000000000003652] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32-36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60-0.84] vs 0.68 [0.54-0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54-0.92) and a specificity of 74% (95% CI, 0.55-0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42-0.88) and a specificity of 74% (95% CI, 0.48-0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP = 0.818 [P = .0001]; PPVPC = 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP = 0.645 [P = .19]; PPVPC = 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: -2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66-77). CONCLUSIONS In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness.
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Affiliation(s)
| | | | | | | | | | | | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, Irvine, California
| | - Olivier Desebbe
- Departments of Anesthesiology and Intensive Care, Clinique de la Sauvegarde, Lyon, France
- Université Lyon 1, EA4169, SFR Lyon-Est Santé - INSERM US 7- CNRS UMS 3453, Lyon, France
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Marques NR, De Riese J, Yelverton BC, McQuitty C, Jupiter D, Willmann K, Salter M, Kinsky M, Johnston WE. Diastolic Function and Peripheral Venous Pressure as Indices for Fluid Responsiveness in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2019; 33:2208-2215. [PMID: 30738752 DOI: 10.1053/j.jvca.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Identifying fluid responsiveness is critical to optimizing perfusion while preventing fluid overload. An experimental study of hypovolemic shock resuscitation showed the importance of ventricular compliance and peripheral venous pressure (PVP) on fluid responsiveness. The authors tested the hypothesis that reduced ventricular compliance measured using transesophageal echocardiography results in decreased fluid responsiveness after a fluid bolus. DESIGN Prospective observational study. SETTING Two-center, university hospital study. PARTICIPANTS The study comprised 29 patients undergoing elective coronary revascularization. INTERVENTION Albumin 5%, 7 mL/kg, was infused over 10 minutes to characterize fluid responders (>15% increase in stroke volume) from nonresponders. MEASUREMENTS AND MAIN RESULTS Invasive hemodynamics and the ratio of mitral inflow velocity (E-wave)/annular relaxation (e'), or E/e' ratio, were measured using transesophageal echocardiography to assess left ventricular (LV) compliance at baseline and after albumin infusion. Fifteen patients were classified as responders and 14 as nonresponders. The E/e' ratio in responders was 7.4 ± 1.9 at baseline and 7.1 ± 1.8 after bolus. In contrast, E/e' was significantly higher in nonresponders at baseline (10.7 ± 4.6; p = 0.04) and further increased after bolus (12.6 ± 5.5; p = 0.002). PVP was significantly greater in the nonresponders at baseline (14 ± 4 mmHg v 11 ± 3 mmHg; p = 0.02) and increased in both groups after albumin infusion. Fluid responsiveness was tested using the area under the receiver operating characteristic curve and was 0.74 for the E/e' ratio (95% confidence interval 0.55-0.93; p = 0.029) and 0.72 for the PVP (95% confidence interval 0.52-0.92; p = 0.058). CONCLUSION Fluid responders had normal LV compliance and lower PVP at baseline. In contrast, nonresponders had reduced LV compliance, which worsened after fluid bolus. E/e,' more than PVP, may be a useful clinical index to predict fluid responsiveness.
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Ding X, Liu DW, Cao YG, Zhang HM, Chen H, Zhao H, Wang XT. Ten Things to be Considered in Practicing Critical Care Echocardiography. Chin Med J (Engl) 2018; 131:1738-1743. [PMID: 29998895 PMCID: PMC6048937 DOI: 10.4103/0366-6999.235868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yan-Gong Cao
- Department of Critical Care Medicine, Hua Xin Hospital First Hospital of Tsinghua University, Beijing 100016, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Huan Chen
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hua Zhao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Balan C, Wong AVK. Sudden cardiac arrest in hypertrophic cardiomyopathy with dynamic cavity obstruction: The case for a decatecholaminisation strategy. J Intensive Care Soc 2017; 19:69-75. [PMID: 29456606 DOI: 10.1177/1751143717732729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Catecholamines are entrenched in the management of shock states. A paradigm shift has pervaded the critical care arena in recent years acknowledging their propensity to cause harm and fuel a 'death-spiral'. We present the case of a 21-year-old male following a witnessed out-of-hospital cardiac arrest who received high-quality cardiopulmonary resuscitation and standard advanced life support for refractory ventricular fibrillation until return of spontaneous circulation after 70 min. Early post-admission echocardiography revealed severe diffuse sub-basal left ventricular hypertrophy with dynamic mid-cavity obstruction and akinetic apical pouching. Within this context, a decatecholaminised strategy comprising a beta-blocker was used to augment the left ventricular end-diastolic volume and attain cardiovascular stability.
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Affiliation(s)
- Cosmin Balan
- Department of Critical Care Medicine, Oxford University Hospitals NHS Foundation Trust, UK
| | - Adrian View-Kim Wong
- Department of Critical Care Medicine, Oxford University Hospitals NHS Foundation Trust, UK
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017. [DOI: https://doi.org/10.1177/0885066617709434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia
- Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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Alvarado Sánchez JI, Amaya Zúñiga WF, Monge García MI. Predictors to Intravenous Fluid Responsiveness. J Intensive Care Med 2017; 33:227-240. [PMID: 28506136 DOI: 10.1177/0885066617709434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Management with intravenous fluids can improve cardiac output in some surgical patients. Management with static preload indicators, such as central venous pressure and pulmonary artery occlusion pressure, has not demonstrated a suitable relationship with changes in the cardiac output induced by intravenous fluid therapy. Dynamic indicators, such as the variability of arterial pulse pressure or stroke volume variation, have demonstrated a suitable relationship. Since improvement in cardiac output does not guarantee an adequate perfusion pressure, in patients with hypotension, it is also necessary to know whether arterial pressure will also increase with intravenous fluid therapy. In this regard, the functional assessment of arterial load by dynamic arterial elastance could help to determine which patients will improve not only their cardiac output but also their mean arterial pressure.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- 1 Department of Physiology, Universidad Nacional De Colombia, Bogota, Colombia.,2 Department of Anesthesiology, Centro Policlínico del Olaya, Bogota, Colombia
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Watson X, Cecconi M. Haemodynamic monitoring in the peri-operative period: the past, the present and the future. Anaesthesia 2017; 72 Suppl 1:7-15. [DOI: 10.1111/anae.13737] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 12/17/2022]
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Applicability of Pulse Pressure Variation during Unstable Hemodynamic Events in the Intensive Care Unit: A Five-Day Prospective Multicenter Study. Crit Care Res Pract 2016; 2016:7162190. [PMID: 27127648 PMCID: PMC4830752 DOI: 10.1155/2016/7162190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/07/2016] [Accepted: 02/16/2016] [Indexed: 12/29/2022] Open
Abstract
Pulse pressure variation can predict fluid responsiveness in strict applicability conditions. The purpose of this study was to describe the clinical applicability of pulse pressure variation during episodes of patient hemodynamic instability in the intensive care unit. We conducted a five-day, seven-center prospective study that included patients presenting with an unstable hemodynamic event. The six predefined inclusion criteria for pulse pressure variation applicability were as follows: mechanical ventilation, tidal volume >7 mL/kg, sinus rhythm, no spontaneous breath, heart rate/respiratory rate ratio >3.6, absence of right ventricular dysfunction, or severe valvulopathy. Seventy-three patients presented at least one unstable hemodynamic event, with a total of 163 unstable hemodynamic events. The six predefined criteria for the applicability of pulse pressure variation were completely present in only 7% of these. This data indicates that PPV should only be used alongside a strong understanding of the relevant physiology and applicability criteria. Although these exclusion criteria appear to be profound, they likely represent an absolute contraindication of use for only a minority of critical care patients.
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management. Pediatr Crit Care Med 2016; 17:S35-48. [PMID: 26945328 DOI: 10.1097/pcc.0000000000000633] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management. DATA SOURCES The expertise of the authors and a review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.
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Ho KM. Pitfalls in haemodynamic monitoring in the postoperative and critical care setting. Anaesth Intensive Care 2016; 44:14-9. [PMID: 26673584 DOI: 10.1177/0310057x1604400104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Haemodynamic monitoring is a vital part of daily practice in anaesthesia and intensive care. Although there is evidence to suggest that goal-directed therapy may improve outcomes in the perioperative period, which haemodynamic targets we should aim at to optimise patient outcomes remain elusive and controversial. This review highlights the pitfalls in commonly used haemodynamic targets, including arterial blood pressure, central venous pressure, cardiac output, central venous oxygen saturation and dynamic haemodynamic indices. Evidence suggests that autoregulation in regional organ circulation may change either due to chronic hypertension or different disease processes such as traumatic brain injury, cerebrovascular ischaemia or haemorrhage; this will influence the preferred blood pressure target. Central venous pressure can be influenced by multiple pathophysiological factors and, unless central venous pressure is very low, it is rarely useful as a predictor for fluid responsiveness. Central venous oxygen saturation can be easily increased by a high arterial oxygen tension, making it useless as a surrogate marker of good cardiac output or systemic oxygen delivery in the presence of hyperoxaemia. Many dynamic haemodynamic indices have been reported to predict fluid responsiveness, but they all have their own limitations. There is also insufficient evidence to support that giving fluid until the patient is no longer fluid responsive can improve patient-centred outcomes. With the exception in the context of preventing contrast-induced nephropathy, large randomised controlled studies suggest that excessive fluid treatment may prolong duration of mechanical ventilation without preventing acute kidney injury in the critically ill.
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Affiliation(s)
- K M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
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Hasanin A. Fluid responsiveness in acute circulatory failure. J Intensive Care 2015; 3:50. [PMID: 26594361 PMCID: PMC4653888 DOI: 10.1186/s40560-015-0117-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/16/2015] [Indexed: 01/21/2023] Open
Abstract
Although fluid resuscitation of patients having acute circulatory failure is essential, avoiding unnecessary administration of fluids in these patients is also important. Fluid responsiveness (FR) is defined as the ability of the left ventricle to increase its stroke volume (SV) in response to fluid administration. The objective of this review is to provide the recent advances in the detection of FR and simplify the physiological basis, advantages, disadvantages, and cut-off values for each method. This review also highlights the present gaps in literature and provides future thoughts in the field of FR. Static methods are generally not recommended for the assessment of FR. Dynamic methods for the assessment of FR depend on heart-lung interactions. Pulse pressure variation (PPV) and stroke volume variation (SVV) are the most famous dynamic measures. Less-invasive dynamic parameters include plethysmographic-derived parameters, variation in blood flow in large arteries, and variation in the diameters of central veins. Dynamic methods for the assessment of FR have many limitations; the most important limitation is spontaneous breathing activity. Fluid challenge techniques were able to overcome most of the limitations of the dynamic methods. Passive leg raising is the most popular fluid challenge method. More simple techniques have been recently introduced such as the mini-fluid challenge and 10-s fluid challenge. The main limitation of fluid challenge techniques is the need to trace the effect of the fluid challenges on SV (or any of its derivatives) using a real-time monitor. More research is needed in the field of FR taking into consideration not only the accuracy of the method but also the ease of implementation, the applicability on a wider range of patients, the time needed to apply each method, and the feasibility of its application by acute care physicians with moderate and low experience.
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Affiliation(s)
- Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
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15
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Feissel M, Aho LS, Georgiev S, Tapponnier R, Badie J, Bruyère R, Quenot JP. Pulse Wave Transit Time Measurements of Cardiac Output in Septic Shock Patients: A Comparison of the Estimated Continuous Cardiac Output System with Transthoracic Echocardiography. PLoS One 2015; 10:e0130489. [PMID: 26126112 PMCID: PMC4488420 DOI: 10.1371/journal.pone.0130489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/19/2015] [Indexed: 12/29/2022] Open
Abstract
Background We determined reliability of cardiac output (CO) measured by pulse wave transit time cardiac output system (esCCO system; COesCCO) vs transthoracic echocardiography (COTTE) in mechanically ventilated patients in the early phase of septic shock. A secondary objective was to assess ability of esCCO to detect change in CO after fluid infusion. Methods Mechanically ventilated patients admitted to the ICU, aged >18 years, in sinus rhythm, in the early phase of septic shock were prospectively included. We performed fluid infusion of 500ml of crystalloid solution over 20 minutes and recorded CO by EsCCO and TTE immediately before (T0) and 5 minutes after (T1) fluid administration. Patients were divided into 2 groups (responders and non-responders) according to a threshold of 15% increase in COTTE in response to volume expansion. Results In total, 25 patients were included, average 64±15 years, 15 (60%) were men. Average SAPSII and SOFA scores were 55±21.3 and 13±2, respectively. ICU mortality was 36%. Mean cardiac output at T0 was 5.8±1.35 L/min by esCCO and 5.27±1.17 L/min by COTTE. At T1, respective values were 6.63 ± 1.57 L/min for esCCO and 6.10±1.29 L/min for COTTE. Overall, 12 patients were classified as responders, 13 as non-responders by the reference method. A threshold of 11% increase in COesCCO was found to discriminate responders from non-responders with a sensitivity of 83% (95% CI, 0.52-0.98) and a specificity of 77% (95% CI, 0.46-0.95). Conclusion We show strong correlation esCCO and echocardiography for measuring CO, and change in CO after fluid infusion in ICU patients.
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Affiliation(s)
- Marc Feissel
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Ludwig Serge Aho
- Service d’Epidémiologie et d’Hygiène Hospitalière, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
| | - Stefan Georgiev
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Romain Tapponnier
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Julio Badie
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Rémi Bruyère
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
- INSERM Centre de Recherche UMR866, Université de Bourgogne, Dijon, France
| | - Jean-Pierre Quenot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
- INSERM Centre de Recherche UMR1347, Université de Bourgogne, Dijon, France
- * E-mail:
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Ibarra-Estrada MÁ, López-Pulgarín JA, Mijangos-Méndez JC, Díaz-Gómez JL, Aguirre-Avalos G. Respiratory variation in carotid peak systolic velocity predicts volume responsiveness in mechanically ventilated patients with septic shock: a prospective cohort study. Crit Ultrasound J 2015; 7:29. [PMID: 26123610 PMCID: PMC4485670 DOI: 10.1186/s13089-015-0029-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/07/2015] [Indexed: 02/06/2023] Open
Abstract
Background The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. Methods We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter. Results Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77–0.95); followed by stroke volume variation (0.72, 95 % CI 0.63–0.88), passive leg raising (0.69, 95 % CI 0.56–0.80), and pulse pressure variation (0.63, 95 % CI 0.49–0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001). Conclusions ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.
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Affiliation(s)
- Miguel Á Ibarra-Estrada
- Intensive Care Unit, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Hospital 278, El Retiro, Specialties Building, Floor 1, Guadalajara, Jalisco, 44280, Mexico,
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Gerlach RM, Barrus AB, Ramzy D, Hernandez Conte A, Khoche S, McCartney SL, Swaminathan M. CASE 7---2015: Perioperative Considerations for a Cardiac Paraganglioma...Not Just Another Cardiac Mass. J Cardiothorac Vasc Anesth 2015; 29:1065-70. [PMID: 25980595 DOI: 10.1053/j.jvca.2015.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Danny Ramzy
- Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Swapnil Khoche
- University of California, San Diego Medical Center, San Diego, CA
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