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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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Oh AR, Lee JH. Predictors of fluid responsiveness in the operating room: a narrative review. Anesth Pain Med (Seoul) 2023; 18:233-243. [PMID: 37468195 PMCID: PMC10410540 DOI: 10.17085/apm.23072] [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: 06/15/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023] Open
Abstract
Prediction of fluid responsiveness has been considered an essential tool for modern fluid management. However, most studies in this field have focused on patients in intensive care unit despite numerous research throughout several decades. Therefore, the present narrative review aims to show the representative method's feasibility, advantages, and limitations in predicting fluid responsiveness, focusing on the operating room environments. Firstly, we described the predictors of fluid responsiveness based on heart-lung interaction, including pulse pressure and stroke volume variations, the measurement of respiratory variations of inferior vena cava diameter, and the end-expiratory occlusion test and addressed their limitations. Subsequently, the passive leg raising test and mini-fluid challenge tests were also mentioned, which assess fluid responsiveness by mimicking a classic fluid challenge. In the last part of this review, we pointed out the pitfalls of fluid management based on fluid responsiveness prediction, which emphasized the importance of individualized decision-making. Understanding the available representative methods to predict fluid responsiveness and their associated benefits and drawbacks through this review will aid anesthesiologists in choosing the most reliable methods for optimal fluid administration in each patient during anesthesia in the operating room.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, Korea
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3
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Horejsek J, Balík M, Kunstýř J, Michálek P, Brožek T, Kopecký P, Fink A, Waldauf P, Pořízka M. Prediction of Fluid Responsiveness Using Combined End-Expiratory and End-Inspiratory Occlusion Tests in Cardiac Surgical Patients. J Clin Med 2023; 12:jcm12072569. [PMID: 37048651 PMCID: PMC10094769 DOI: 10.3390/jcm12072569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
End-expiratory occlusion (EEO) and end-inspiratory occlusion (EIO) tests have been successfully used to predict fluid responsiveness in various settings using calibrated pulse contour analysis and echocardiography. The aim of this study was to test if respiratory occlusion tests predicted fluid responsiveness reliably in cardiac surgical patients with protective ventilation. This single-centre, prospective study, included 57 ventilated patients after elective coronary artery bypass grafting who were indicated for fluid expansion. Baseline echocardiographic measurements were obtained and patients with significant cardiac pathology were excluded. Cardiac index (CI), stroke volume and stroke volume variation were recorded using uncalibrated pulse contour analysis at baseline, after performing EEO and EIO tests and after volume expansion (7 mL/kg of succinylated gelatin). Fluid responsiveness was defined as an increase in cardiac index by 15%. Neither EEO, EIO nor their combination predicted fluid responsiveness reliably in our study. After a combined EEO and EIO, a cut-off point for CI change of 16.7% predicted fluid responsiveness with a sensitivity of 61.8%, specificity of 69.6% and ROC AUC of 0.593. In elective cardiac surgical patients with protective ventilation, respiratory occlusion tests failed to predict fluid responsiveness using uncalibrated pulse contour analysis.
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Megri M, Fridenmaker E, Disselkamp M. Where Are We Heading With Fluid Responsiveness and Septic Shock? Cureus 2022; 14:e23795. [PMID: 35518529 PMCID: PMC9065654 DOI: 10.7759/cureus.23795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 11/05/2022] Open
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Measurement of Intravascular Volume Status in Infants Undergoing Cranial Vault Reconstruction for Craniosynostosis. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Horejsek J, Kunstyr J, Michalek P, Porizka M. Novel Methods for Predicting Fluid Responsiveness in Critically Ill Patients—A Narrative Review. Diagnostics (Basel) 2022; 12:diagnostics12020513. [PMID: 35204603 PMCID: PMC8871108 DOI: 10.3390/diagnostics12020513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with acute circulatory failure, fluid administration represents a first-line therapeutic intervention for improving cardiac output. However, only approximately 50% of patients respond to fluid infusion with a significant increase in cardiac output, defined as fluid responsiveness. Additionally, excessive volume expansion and associated hyperhydration have been shown to increase morbidity and mortality in critically ill patients. Thus, except for cases of obvious hypovolaemia, fluid responsiveness should be routinely tested prior to fluid administration. Static markers of cardiac preload, such as central venous pressure or pulmonary artery wedge pressure, have been shown to be poor predictors of fluid responsiveness despite their widespread use to guide fluid therapy. Dynamic tests including parameters of aortic blood flow or respiratory variability of inferior vena cava diameter provide much higher diagnostic accuracy. Nevertheless, they are also burdened with several significant limitations, reducing the reliability, or even precluding their use in many clinical scenarios. This non-systematic narrative review aims to provide an update on the novel, less employed dynamic tests of fluid responsiveness evaluation in critically ill patients.
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Affiliation(s)
- Jan Horejsek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
| | - Jan Kunstyr
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
| | - Pavel Michalek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Michal Porizka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.H.); (J.K.); (P.M.)
- Correspondence: ; Tel.: +420-702-089-475
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Huang H, Wu C, Shen Q, Fang Y, Xu H. Value of variation of end-tidal carbon dioxide for predicting fluid responsiveness during the passive leg raising test in patients with mechanical ventilation: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:20. [PMID: 35031070 PMCID: PMC8760720 DOI: 10.1186/s13054-022-03890-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/08/2022] [Indexed: 01/06/2023]
Abstract
Background The ability of end-tidal carbon dioxide (ΔEtCO2) for predicting fluid responsiveness has been extensively studied with conflicting results. This meta-analysis aimed to explore the value of ΔEtCO2 for predicting fluid responsiveness during the passive leg raising (PLR) test in patients with mechanical ventilation. Methods PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched up to November 2021. The diagnostic odds ratio (DOR), sensitivity, and specificity were calculated. The summary receiver operating characteristic curve was estimated, and the area under the curve (AUROC) was calculated. Q test and I2 statistics were used for study heterogeneity and publication bias was assessed by Deeks’ funnel plot asymmetry test. We performed meta-regression analysis for heterogeneity exploration and sensitivity analysis for the publication bias. Results Overall, six studies including 298 patients were included in this review, of whom 149 (50%) were fluid responsive. The cutoff values of ΔEtCO2 in four studies was 5%, one was 5.8% and the other one was an absolute increase 2 mmHg. Heterogeneity between studies was assessed with an overall Q = 4.098, I2 = 51%, and P = 0.064. The pooled sensitivity and specificity for the overall population were 0.79 (95% CI 0.72–0.85) and 0.90 (95% CI 0.77–0.96), respectively. The DOR was 35 (95% CI 12–107). The pooled AUROC was 0.81 (95% CI 0.77–0.84). On meta-regression analysis, the number of patients was sources of heterogeneity. The sensitivity analysis showed that the pooled DOR ranged from 21 to 140 and the pooled AUC ranged from 0.92 to 0.96 when one study was omitted. Conclusions Though the limited number of studies included and study heterogeneity, our meta-analysis confirmed that the ΔEtCO2 performed moderately in predicting fluid responsiveness during the PLR test in patients with mechanical ventilation.
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Affiliation(s)
- Haijun Huang
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, Zhejiang, China
| | - Chenxia Wu
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, Zhejiang, China
| | - Qinkang Shen
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, Zhejiang, China
| | - Yixin Fang
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, Zhejiang, China
| | - Hua Xu
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310018, Zhejiang, China.
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Changes in the Plethysmographic Perfusion Index During an End-Expiratory Occlusion Detect a Positive Passive Leg Raising Test. Crit Care Med 2021; 49:e151-e160. [PMID: 33332814 DOI: 10.1097/ccm.0000000000004768] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The end-expiratory occlusion test for assessing preload responsiveness consists in interrupting mechanical ventilation for 15 seconds at end-expiration and measuring the cardiac index changes. The perfusion index is the ratio between the pulsatile and the nonpulsatile portions of the plethysmography signal and is, in part, determined by stroke volume. We tested whether the end-expiratory occlusion-induced changes in perfusion index could detect a positive passive leg raising test, suggesting preload responsiveness. DESIGN Observational study. SETTING Medical ICU. PATIENTS Thirty-one ventilated patients without atrial fibrillation. INTERVENTIONS We measured perfusion index (Radical-7 device; Masimo Corp., Irvine, CA) and cardiac index (PiCCO2; Pulsion Medical Systems, Feldkirchen, Germany) before and during a passive leg raising test and a 15-second end-expiratory occlusion. MEASUREMENTS AND MAIN RESULTS In 19 patients with a positive passive leg raising test (increase in cardiac index ≥ 10%), compared to the baseline value and expressed as a relative change, passive leg raising increased cardiac index and perfusion index by 17% ± 7% and 49% ± 23%, respectively, In these patients, end-expiratory occlusion increased cardiac index and perfusion index by 6% ± 2% and 11% ± 8%, respectively. In the 12 patients with a negative passive leg raising test, perfusion index did not significantly change during passive leg raising and end-expiratory occlusion. Relative changes in perfusion index and cardiac index observed during all interventions were significantly correlated (r = 0.83). An end-expiratory occlusion-induced relative increase in perfusion index greater than or equal to 2.5% ([perfusion index during end-expiratory occlusion-perfusion index at baseline]/perfusion index at baseline × 100) detected a positive passive leg raising test with an area under the receiver operating characteristic curve of 0.95 ± 0.03. This threshold is larger than the least significant change observed for perfusion index (1.62% ± 0.80%). CONCLUSIONS Perfusion index could be used as a reliable surrogate of cardiac index for performing the end-expiratory occlusion test. Confirming previous results, the relative changes in perfusion index also reliably detected a positive passive leg raising test.
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Mini fluid chAllenge aNd End-expiratory occlusion test to assess flUid responsiVEness in the opeRating room (MANEUVER study): A multicentre cohort study. Eur J Anaesthesiol 2021; 38:422-431. [PMID: 33399372 DOI: 10.1097/eja.0000000000001406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The fluid challenge response in surgical patients can be predicted by functional haemodynamic tests. Two tests, the mini-fluid challenge (mini-FC) and end-expiratory occlusion test (EEOT), have been assessed in a few small single-centre studies with conflicting results. In general, functional haemodynamic tests have not performed reliably in predicting fluid responsiveness in patients undergoing laparotomy. OBJECTIVE This trial is designed to address and compare the reliability of the EEOT and the mini-FC in predicting fluid responsiveness during laparotomy. DESIGN Prospective, multicentre study. SETTING Three university hospitals in Italy. PATIENTS A total of 103 adults patients scheduled for elective laparotomy with invasive arterial monitoring. INTERVENTIONS The study protocol evaluated the changes in the stroke volume index (SVI) 20 s (EEOT20) and 30 s (EEOT30) after an expiratory hold and after a mini-FC of 100 ml over 1 min. Fluid responsiveness required an increase in SVI at least 10% following 4 ml kg-1 of Ringer's solution fluid challenge infused over 10 min. MAIN OUTCOME MEASUREMENTS Haemodynamic data, including SVI, were obtained from pulse contour analysis. The area under the receiver operating characteristic curves of the tests were compared with assess fluid responsiveness. RESULTS Fluid challenge administration induced an increase in SVI at least 10% in 51.5% of patients. The rate of fluid responsiveness was comparable among the three participant centres (P = 0.10). The area under the receiver operating characteristic curves (95% CI) of the changes in SVI after mini-FC was 0.95 (0.88 to 0.98), sensitivity 98.0% (89.5 to 99.6) and specificity 86.8% (75.1 to 93.4) for a cut-off value of 4% of increase in SVI. This was higher than the SVI changes after EEOT20, 0.67 (0.57 to 0.76) and after EEOT30, 0.73 (0.63 to 0.81). CONCLUSION In patients undergoing laparotomy the mini-FC reliably predicted fluid responsiveness with high-sensitivity and specificity. The EEOT showed poor discriminative value and cannot be recommended for assessment of fluid responsiveness in this surgical setting. TRIAL REGISTRATION NCT03808753.
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10
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Mendes RDS, Pelosi P, Schultz MJ, Rocco PRM, Silva PL. Fluids in ARDS: more pros than cons. Intensive Care Med Exp 2020; 8:32. [PMID: 33336259 PMCID: PMC7746428 DOI: 10.1186/s40635-020-00319-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
In acute respiratory distress syndrome (ARDS), increased pulmonary vascular permeability makes the lung vulnerable to edema. The use of conservative as compared to liberal fluid strategies may increase the number of ventilator-free days and survival, as well as reduce organ dysfunction. Monitoring the effects of fluid administration is of the utmost importance; dynamic indexes, such as stroke volume and pulse pressure variations, outperform static ones, such as the central venous pressure. The passive leg raise and end-expiratory occlusion tests are recommended for guiding fluid management decisions. The type of intravenous fluids should also be taken into consideration: crystalloids, colloids, and human albumin have all been used for fluid resuscitation. Recent studies have also shown differences in outcome between balanced and non-balanced intravenous solutions. In preclinical studies, infusion of albumin promotes maintenance of the glycocalyx layer, reduces inflammation, and improves alveolar-capillary membrane permeability. Fluids in ARDS must be administered cautiously, considering hemodynamic and perfusion status, oncotic and hydrostatic pressures, ARDS severity, fluid type, volume and infusion rate, and cardiac and renal function. Of note, no guideline to date has recommended a specific fluid composition for use in ARDS; most physicians currently follow recommendations for sepsis.
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Affiliation(s)
- Renata de S Mendes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Gavelli F, Shi R, Teboul JL, Azzolina D, Monnet X. The end-expiratory occlusion test for detecting preload responsiveness: a systematic review and meta-analysis. Ann Intensive Care 2020; 10:65. [PMID: 32449104 PMCID: PMC7246264 DOI: 10.1186/s13613-020-00682-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis of studies assessing the end-expiratory occlusion test (EEXPO test)-induced changes in cardiac output (CO) measured by any haemodynamic monitoring device, as indicators of preload responsiveness. METHODS MEDLINE, EMBASE and Cochrane Database were screened for original articles. Bivariate random-effects meta-analysis determined the Area under the Summary Receiver Operating Characteristic (AUSROC) curve of EEXPO test-induced changes in CO to detect preload responsiveness, as well as pooled sensitivity and specificity and the best diagnostic threshold. RESULTS Thirteen studies (530 patients) were included. Nine studies were performed in the intensive care unit and four in the operating room. The pooled sensitivity and the pooled specificity for the EEXPO test-induced changes in CO were 0.85 [0.77-0.91] and 0.88 [0.83-0.91], respectively. The AUSROC curve was 0.91 [0.86-0.94] with the best threshold of CO increase at 5.1 ± 0.2%. The accuracy of the test was not different when changes in CO were monitored through pulse contour analysis compared to other methods (AUSROC: 0.93 [0.91-0.95] vs. 0.87 [0.82-0.96], respectively, p = 0.62). Also, it was not different in studies in which the tidal volume was ≤ 7 mL/kg compared to the remaining ones (AUSROC: 0.96 [0.92-0.97] vs. 0.89 [0.82-0.95] respectively, p = 0.44). Subgroup analyses identified one possible source of heterogeneity. CONCLUSIONS EEXPO test-induced changes in CO reliably detect preload responsiveness. The diagnostic performance is not influenced by the method used to track the EEXPO test-induced changes in CO. Trial registration The study protocol was prospectively registered on PROSPERO: CRD42019138265.
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Affiliation(s)
- Francesco Gavelli
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France. .,Emergency Medicine Unit, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy.
| | - Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
| | - Danila Azzolina
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, 28100, Novara, Italy
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Saclay, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, Faculté de Médecine Paris-Saclay, Inserm UMR S_999, 94270, Le Kremlin-Bicêtre, France
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12
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Does End-Expiratory Occlusion Test Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-Analysis. Shock 2020; 54:751-760. [PMID: 32433213 DOI: 10.1097/shk.0000000000001545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We performed a systematic review and meta-analysis of studies investigating the end-expiratory occlusion (EEO) test induced changes in cardiac index (CI) and in arterial pressure as predictors of fluid responsiveness in adults receiving mechanical ventilation. METHODS MEDLINE, EMBASE, Cochrane Database, and Chinese database were screened for relevant original and review articles. The meta-analysis determined the pooled sensitivity, specificity, diagnostic odds ratio, area under the receiver operating characteristic curve (AUROC), and threshold for the EEO test assessed with CI and arterial pressure. In addition, heterogeneity and subgroup analyses were performed. RESULTS We included 13 studies involving 479 adult patients and 523 volume expansion. Statistically significant heterogeneity was identified, and meta-regression indicated that prone position was the major sources of heterogeneity. After removal of the study performed in prone position, heterogeneity became nonsignificant. EEO-induced changes in CI (or surrogate) are accurate for predicting fluid responsiveness in semirecumbent or supine patients, with excellent pooled sensitivity of 92% (95% CI, 0.88-0.95, I = 0.00%), specificity of 89% (95% CI, 0.83-0.93, I = 34.34%), and a summary AUROC of 0.95 (95% CI, 0.93-0.97). The mean threshold was an EEO-induced increase in CI (or surrogate) of more than 4.9 ± 1.5%. EEO test exhibited better diagnostic performance in semirecumbent or supine patients than prone patients, with higher AUROC (0.95 vs. 0.65; P < 0.001). In addition, EEO test exhibited higher specificity (0.93 vs. 0.83, P < 0.001) in patients ventilated with low tidal volume compared with normal or nearly normal tidal volume. However, EEO test was less accurate when its hemodynamic effects were detected on arterial pressure. EEO-induced changes in arterial pressure exhibited a lower sensitivity (0.88 vs. 0.92; P = 0.402), specificity (0.77 vs. 0.90; P = 0.019), and AUROC (0.87 vs. 0.96; P < 0.001) compared with EEO-induced changes in CI (or surrogate). CONCLUSIONS EEO test is accurate to predict fluid responsiveness in semirecumbent or supine patients but not in prone patients. EEO test exhibited higher specificity in patients ventilated with low tidal volume, and its accuracy is better when its hemodynamic effects are assessed by direct measurement of CI than by the arterial pressure.
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Sander M, Schneck E, Habicher M. Management of perioperative volume therapy - monitoring and pitfalls. Korean J Anesthesiol 2020; 73:103-113. [PMID: 32106641 PMCID: PMC7113166 DOI: 10.4097/kja.20022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022] Open
Abstract
Over 300 million surgical procedures are performed every year worldwide. Anesthesiologists play an important role in the perioperative process by assessing the overall risk of surgery and aim to reduce the risk of complications. Perioperative hemodynamic and volume management can help to improve outcomes in perioperative patients. There has been ongoing discussion about goal-directed therapy. However, there is a consensus that fluid overload and severe fluid depletion in the perioperative period are harmful and can lead to adverse outcomes. This article provides an overview of how to evaluate the fluid responsiveness of patients, details which parameters could be used, and what limitations should be noted.
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Affiliation(s)
- Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
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Weil G, Motamed C, Monnet X, Eghiaian A, Le Maho AL. End-Expiratory Occlusion Test to Predict Fluid Responsiveness Is Not Suitable for Laparotomic Surgery. Anesth Analg 2020; 130:151-158. [DOI: 10.1213/ane.0000000000004205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ali A, Aygun E, Abdullah T, Bolsoy-Deveci S, Orhan-Sungur M, Canbaz M, Ozkan Akinci I. A challenge with 5 cmH2O of positive end-expiratory pressure predicts fluid responsiveness in neurosurgery patients with protective ventilation: an observational study. Minerva Anestesiol 2019; 85:1184-1192. [DOI: 10.23736/s0375-9393.19.13721-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Vistisen ST, Enevoldsen JN, Greisen J, Juhl-Olsen P. What the anaesthesiologist needs to know about heart-lung interactions. Best Pract Res Clin Anaesthesiol 2019; 33:165-177. [PMID: 31582096 DOI: 10.1016/j.bpa.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The impact of positive pressure ventilation extends the effect on lungs and gas exchange because the altered intra-thoracic pressure conditions influence determinants of cardiovascular function. These mechanisms are called heart-lung interactions, which conceptually can be divided into two components (1) The effect of positive airway pressure on the cardiovascular system, which may be more or less pronounced under various pathologic cardiac conditions, and (2) The effect of cyclic airway pressure swing on the cardiovascular system, which can be useful in the interpretation of the individual patient's current haemodynamic state. It is imperative for the anaesthesiologist to understand the fundamental mechanisms of heart-lung interactions, as they are a foundation for the understanding of optimal, personalised cardiovascular treatment of patients undergoing surgery in general anaesthesia. The aim of this review is thus to describe what the anaesthesiologist needs to know about heart-lung interactions.
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Affiliation(s)
- Simon T Vistisen
- Institute of Clinical Medicine, Aarhus University, Denmark; Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark.
| | - Johannes N Enevoldsen
- Institute of Clinical Medicine, Aarhus University, Denmark; Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark.
| | - Jacob Greisen
- Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Aarhus University, Denmark.
| | - Peter Juhl-Olsen
- Department of Anaesthesiology & Intensive Care, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Aarhus University, Denmark.
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Gavelli F, Teboul JL, Monnet X. The end-expiratory occlusion test: please, let me hold your breath! Crit Care 2019; 23:274. [PMID: 31391083 PMCID: PMC6686261 DOI: 10.1186/s13054-019-2554-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/24/2019] [Indexed: 01/10/2023] Open
Affiliation(s)
- Francesco Gavelli
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
- Department of Translational Medicine, Emergency Medicine Unit, Università degli Studi del Piemonte Orientale, 28100 Novara, Italy
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, rue du Général Leclerc, F-94270 Le Kremlin-Bicêtre, France
- Faculté de médecine Paris-Sud, Université Paris-Sud, Inserm UMR S_999, F-94270 Le Kremlin-Bicêtre, France
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Messina A, Dell'Anna A, Baggiani M, Torrini F, Maresca GM, Bennett V, Saderi L, Sotgiu G, Antonelli M, Cecconi M. Functional hemodynamic tests: a systematic review and a metanalysis on the reliability of the end-expiratory occlusion test and of the mini-fluid challenge in predicting fluid responsiveness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:264. [PMID: 31358025 PMCID: PMC6664788 DOI: 10.1186/s13054-019-2545-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/17/2019] [Indexed: 01/22/2023]
Abstract
Background Bedside functional hemodynamic assessment has gained in popularity in the last years to overcome the limitations of static or dynamic indexes in predicting fluid responsiveness. The aim of this systematic review and metanalysis of studies is to investigate the reliability of the functional hemodynamic tests (FHTs) used to assess fluid responsiveness in adult patients in the intensive care unit (ICU) and operating room (OR). Methods MEDLINE, EMBASE, and Cochrane databases were screened for relevant articles using a FHT, with the exception of the passive leg raising. The QUADAS-2 scale was used to assess the risk of bias of the included studies. In-between study heterogeneity was assessed through the I2 indicator. Bias assessment graphs were plotted, and Egger’s regression analysis was used to evaluate the publication bias. The metanalysis determined the pooled area under the receiving operating characteristic (ROC) curve, sensitivity, specificity, and threshold for two FHTs: the end-expiratory occlusion test (EEOT) and the mini-fluid challenge (FC). Results After text selection, 21 studies met the inclusion criteria, 7 performed in the OR, and 14 in the ICU between 2005 and 2018. The search included 805 patients and 870 FCs with a median (IQR) of 39 (25–50) patients and 41 (30–52) FCs per study. The median fluid responsiveness was 54% (45–59). Ten studies (47.6%) adopted a gray zone analysis of the ROC curve, and a median (IQR) of 20% (15–51) of the enrolled patients was included in the gray zone. The pooled area under the ROC curve for the end-expiratory occlusion test (EEOT) was 0.96 (95%CI 0.92–1.00). The pooled sensitivity and specificity were 0.86 (95%CI 0.74–0.94) and 0.91 (95%CI 0.85–0.95), respectively, with a best threshold of 5% (4.0–8.0%). The pooled area under the ROC curve for the mini-FC was 0.91 (95%CI 0.85–0.97). The pooled sensitivity and specificity were 0.82 (95%CI 0.76–0.88) and 0.83 (95%CI 0.77–0.89), respectively, with a best threshold of 5% (3.0–7.0%). Conclusions The EEOT and the mini-FC reliably predict fluid responsiveness in the ICU and OR. Other FHTs have been tested insofar in heterogeneous clinical settings and, despite promising results, warrant further investigations. Electronic supplementary material The online version of this article (10.1186/s13054-019-2545-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.
| | - Antonio Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marta Baggiani
- Department of Anesthesiology and Intensive Care Medicine, A.O.U. Maggiore della Carità, Novara, Italy
| | - Flavia Torrini
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Maresca
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Victoria Bennett
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, London, UK
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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Xu LY, Tu GW, Cang J, Hou JY, Yu Y, Luo Z, Guo KF. End-expiratory occlusion test predicts fluid responsiveness in cardiac surgical patients in the operating theatre. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:315. [PMID: 31475185 PMCID: PMC6694235 DOI: 10.21037/atm.2019.06.58] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether a 20-second end-expiratory occlusion (EEO) test can predict fluid responsiveness in cardiac surgery patients in the operating theatre. METHODS This prospective study enrolled 75 mechanically ventilated patients undergoing elective coronary artery bypass grafting surgery. Hemodynamic data coupled with transesophageal echocardiography monitoring of the velocity time integral (VTI) and the peak velocity (Vmax) at the left ventricular outflow tract were collected at each step (baseline 1, EEO, baseline 2 and fluid challenge). Patients were divided into fluid responders (increase in VTI ≥15%) and non-responders (increase in VTI <15%) after a fluid challenge (6 mL 0.9% saline per kg, given in 10 minutes). RESULTS Fluid challenge significantly increased the VTI by more than 15% in 36 (48%) patients (responders). An increase in VTI greater than 5% during the EEO test predicted fluid responsiveness with a sensitivity of 81% and a specificity of 93%. The area under the receiver-operating characteristic curve (AUROC) of ΔVTI-EEO was 0.90 [95% confidence interval (CI): 0.83-0.97]. ΔVmax-EEO was poorly predictive of fluid responsiveness, with an AUC of 0.75 (95% CI: 0.63-0.86). CONCLUSIONS Changes in VTI induced by a 20-second EEO can reliably predict fluid responsiveness in cardiac surgical patients in the operating theatre, whereas the changes in Vmax cannot.
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Affiliation(s)
- Li-Ying Xu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Guo-Wei Tu
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jun-Yi Hou
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ying Yu
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhe Luo
- Department of Crit Care Med, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Department of Crit Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen 361015, China
| | - Ke-Fang Guo
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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21
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Weil G, Motamed C, Eghiaian A, Monnet X, Suria S. Comparison of Proaqt/Pulsioflex® and oesophageal Doppler for intraoperative haemodynamic monitoring during intermediate-risk abdominal surgery. Anaesth Crit Care Pain Med 2019; 38:153-159. [DOI: 10.1016/j.accpm.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
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Esophageal Doppler Can Predict Fluid Responsiveness Through End-Expiratory and End-Inspiratory Occlusion Tests. Crit Care Med 2019; 47:e96-e102. [DOI: 10.1097/ccm.0000000000003522] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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23
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24
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Guinot PG, Marc J, de Broca B, Archange T, Bar S, Abou-Arab O, Dupont H, Fischer MO, Lorne E. The predictability of dynamic preload indices depends on the volume of fluid challenge: A prospective observational study in the operating theater. Medicine (Baltimore) 2018; 97:e12848. [PMID: 30334988 PMCID: PMC6211878 DOI: 10.1097/md.0000000000012848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This study was designed to assess the association between volume of fluid challenge (FC) and predictability of respiratory variation of stroke volume (ΔrespSV) in the operating theater.Patients undergoing intermediate/high-risk surgery and monitored by esophageal Doppler monitoring (EDM) were prospectively included. All patients were under general anesthesia and mechanically ventilated. Exclusion criteria were frequent ectopic beats or preoperative arrhythmia, right ventricular failure, and spontaneous breathing. Hemodynamic parameters and esophageal Doppler indices (SV, cardiac output, ΔrespSV) were collected before, after infusion of 250 mL, and after infusion of 500 mL of crystalloid solution. Responders were defined by a >15% increase of stroke volume after FC at each step.After infusion of a 250 mL FC, 41 patients (32%) were classified as fluid responders (R250). After infusion of a 500 mL FC, 80 patients (63%) were classified as fluid responders (R500). The predictability of ΔrespSV was fair with an area under the curve (AUC) of 0.79 (95% CI 0.71-0.86, P < .001) to predict fluid responsiveness with a 250 mL FC. With an AUC of 0.94 (95% CI 0.88-0.97, P < .0001), ΔrespSV presented an excellent ability to predict fluid responsiveness with a 500-mL FC.Predictability of ΔrespSV changed with the volume of fluid infused to assess fluid responsiveness. The accuracy of ΔrespSV was higher with 500 mL than with 250 mL. Bedside studies evaluating the predictability of dynamic preload indices should define fluid responsiveness as a >15% increase of SV in response to a 500-mL FC.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon University Hospital, Dijon
- INSERM ERI12, Jules Verne University of Picardy
| | - Julien Marc
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Bruno de Broca
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Thomas Archange
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Stéphane Bar
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Osama Abou-Arab
- INSERM ERI12, Jules Verne University of Picardy
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Hervé Dupont
- INSERM ERI12, Jules Verne University of Picardy
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
| | - Marc-Olivier Fischer
- Anaesthesiology and Critical Care Department, university hospital of Caen, Caen, France
| | - Emmanuel Lorne
- INSERM ERI12, Jules Verne University of Picardy
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens
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Biais M, Larghi M, Henriot J, de Courson H, Sesay M, Nouette-Gaulain K. End-Expiratory Occlusion Test Predicts Fluid Responsiveness in Patients With Protective Ventilation in the Operating Room. Anesth Analg 2017; 125:1889-1895. [DOI: 10.1213/ane.0000000000002322] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Toscani L, Aya HD, Antonakaki D, Bastoni D, Watson X, Arulkumaran N, Rhodes A, Cecconi M. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:207. [PMID: 28774325 PMCID: PMC5543539 DOI: 10.1186/s13054-017-1796-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Background The fluid challenge is considered the gold standard for diagnosis of fluid responsiveness. The objective of this study was to describe the fluid challenge techniques reported in fluid responsiveness studies and to assess the difference in the proportion of ‘responders,’ (PR) depending on the type of fluid, volume, duration of infusion and timing of assessment. Methods Searches of MEDLINE and Embase were performed for studies using the fluid challenge as a test of cardiac preload with a description of the technique, a reported definition of fluid responsiveness and PR. The primary outcome was the mean PR, depending on volume of fluid, type of fluids, rate of infusion and time of assessment. Results A total of 85 studies (3601 patients) were included in the analysis. The PR were 54.4% (95% CI 46.9–62.7) where <500 ml was administered, 57.2% (95% CI 52.9–61.0) where 500 ml was administered and 60.5% (95% CI 35.9–79.2) where >500 ml was administered (p = 0.71). The PR was not affected by type of fluid. The PR was similar among patients administered a fluid challenge for <15 minutes (59.2%, 95% CI 54.2–64.1) and for 15–30 minutes (57.7%, 95% CI 52.4–62.4, p = 1). Where the infusion time was ≥30 minutes, there was a lower PR of 49.9% (95% CI 45.6–54, p = 0.04). Response was assessed at the end of fluid challenge, between 1 and 10 minutes, and >10 minutes after the fluid challenge. The proportions of responders were 53.9%, 57.7% and 52.3%, respectively (p = 0.47). Conclusions The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1796-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Toscani
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cristo Re Hospital, Via delle Calasanziane 25, 00167, Rome, Italy
| | - Hollmann D Aya
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK. .,Anaesthetic Department, East Surrey Hospital, Surrey & Sussex Healthcare Trust, Canada Avenue, Redhill, Surrey, RH1 5 RH, UK.
| | - Dimitra Antonakaki
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Cardiology Department, Broomfield Hospital, Mid-Essex Healthcare Trust, Court Road, Broomfield, Chelmsford, CM1 7ET, UK
| | - Davide Bastoni
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK.,Dipartimento di Medicina Sperimentale, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Ximena Watson
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Nish Arulkumaran
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Andrew Rhodes
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, Adult Intensive Care Directorate, St George's University Hospitals, NHS Foundation Trust and St George's University of London, St James Wing, First Floor, Blackshaw Road, London, SW17 0QT, 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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De Broca B, Garnier J, Fischer MO, Archange T, Marc J, Abou-Arab O, Dupont H, Lorne E, Guinot PG. Stroke volume changes induced by a recruitment maneuver predict fluid responsiveness in patients with protective ventilation in the operating theater. Medicine (Baltimore) 2016; 95:e4259. [PMID: 27428237 PMCID: PMC4956831 DOI: 10.1097/md.0000000000004259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
During abdominal surgery, the use of protective ventilation with a low tidal volume, positive expiratory pressure (PEEP) and recruitment maneuvers (RMs) may limit the applicability of dynamic preload indices. The objective of the present study was to establish whether or not the variation in stroke volume (SV) during an RM could predict fluid responsiveness.We prospectively included patients receiving protective ventilation (tidal volume: 6 mL kg, PEEP: 5-7 cmH2O; RMs). Hemodynamic variables, such as heart rate, arterial pressure, SV, cardiac output (CO), respiratory variation in SV (ΔrespSV) and pulse pressure (ΔrespPP), and the variation in SV (ΔrecSV) as well as pulse pressure (ΔrecPP) during an RM were measured at baseline, at the end of the RM, and after fluid expansion. Responders were defined as patients with an SV increase of at least 15% after infusion of 500 mL of crystalloid solution.Thirty-seven (62%) of the 60 included patients were responders. Responders and nonresponders differed significantly in terms of the median ΔrecSV (26% [19-37] vs 10% [4-12], respectively; P < 0.0001). A ΔrecSV value more than 16% predicted fluid responsiveness with an area under the receiver-operating characteristic curve (AU) of 0.95 (95% confidence interval [CI]: 0.91-0.99; P < 0.0001) and a narrow gray zone between 15% and 17%. The area under the curve values for ΔrecPP and ΔrespSV were, respectively, 0.81 (95%CI: 0.7-0.91; P = 0.0001) and 0.80 (95%CI: 0.70-0.94; P < 0.0001). ΔrespPP did not predict fluid responsiveness.During abdominal surgery with protective ventilation, a ΔrecSV value more than 16% accurately predicted fluid responsiveness and had a narrow gray zone (between 15% and 17%). ΔrecPP and ΔrespSV (but not ΔrespPP) were also predictive.
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Affiliation(s)
- Bruno De Broca
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
| | - Jeremie Garnier
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
| | | | - Thomas Archange
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
| | - Julien Marc
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
| | - Osama Abou-Arab
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
| | - Hervé Dupont
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
- INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Emmanuel Lorne
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
- INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Pierre-grégoire Guinot
- Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens
- INSERM U1088, Jules Verne University of Picardy, Amiens, France
- Correspondence: Pierre-Grégoire Guinot, Anesthesiology and Critical Care Department, Amiens University Medical Center, Place Victor Pauchet, Amiens F-80054, France (e-mail: )
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Guinot PG, Guilbart M, Hchikat AH, Trujillo M, Huette P, Bar S, Kirat K, Bernard E, Dupont H, Lorne E. Association Between End-Tidal Carbon Dioxide Pressure and Cardiac Output During Fluid Expansion in Operative Patients Depend on the Change of Oxygen Extraction. Medicine (Baltimore) 2016; 95:e3287. [PMID: 27057894 PMCID: PMC4998810 DOI: 10.1097/md.0000000000003287] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In a model of hemorrhagic shock, end-tidal carbon dioxide tension (EtCO2) has been shown to reflect the dependence of oxygen delivery (DO2) and oxygen consumption (VO2) at the onset of shock. The objectives of the present study were to determine whether variations in EtCO2 during volume expansion (VE) are correlated with changes in oxygen extraction (O2ER) and whether EtCO2 has predictive value in this respect.All patients undergoing cardiac surgery admitted to intensive care unit in whom the physician decided to perform VE were included. EtCO2, cardiac output (CO), blood gas levels, and mean arterial pressure (MAP) were measured before and after VE with 500 mL of lactated Ringer solution. DO2, VO2, and O2ER were calculated from the central arterial and venous blood gas parameters. EtCO2 responders were defined as patients with more than a 4% increase in EtCO2 after VE. A receiver-operating characteristic curve was established for EtCO2, with a view to predicting a variation of more than 10% in O2ER.Twenty-two (43%) of the 51 included patients were EtCO2 responders. In EtCO2 nonresponders, VE increased MAP and CO. In EtCO2 responders, VE increased MAP, CO, EtCO2, and decreased O2ER. Changes in EtCO2 were correlated with changes in CO and O2ER during VE (P < 0.05). The variation of EtCO2 during VE predicted a decrease of over 10% in O2ER (area under the curve [95% confidence interval]: 0.88 [0.77-0.96]; P < 0.0001).During VE, an increase in EtCO2 did not systematically reflect an increase in CO. Only patients with a high O2ER (i.e., low ScvO2 values) display an increase in EtCO2. EtCO2 changes during fluid challenge predict changes in O2ER.
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Affiliation(s)
- Pierre-Grégoire Guinot
- From the Anesthesiology and Critical Care Department (P-GG, MG, AHH, MT, PH, SB, KK, EB, HD, EL), Amiens University Hospital, Amiens, France and INSERM U1088 (P-GG, HD, EL), Jules Verne University of Picardy, Amiens, France
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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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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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Monnet X, Teboul JL. End-expiratory occlusion test: please use the appropriate tools! Br J Anaesth 2015; 114:166-7. [PMID: 25500404 DOI: 10.1093/bja/aeu430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Guinot PG, Godart J, de Broca B, Bernard E, Lorne E, Dupont H. Clinical practice. Br J Anaesth 2014; 114:167-8. [PMID: 25500405 DOI: 10.1093/bja/aeu431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ouattara A, Dewitte A, Rozé H. Intraoperative management of heart-lung interactions: "from hypothetical prediction to improved titration". ACTA ACUST UNITED AC 2014; 33:476-9. [PMID: 25127853 DOI: 10.1016/j.annfar.2014.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Extensive literature describes the suitability of dynamic parameters to predict responsiveness in fluid. However, based on heart-lung interactions, these parameters can have serious limitations, including the use of protective lung ventilation. Although the latter seems to be beneficial for healthy patients undergoing high-risk surgery, the intraoperative interpretation of dynamic parameters to predict fluid responsiveness can be hazardous. In this context, the attending physician could, alternatively, titrate the need of fluids with a small fluid challenge, which remains unaffected by low tidal volume, the presence of arrhythmia, or the presence of spontaneous ventilation. When intraoperative prediction of fluid responsiveness is required in mechanically ventilated patients, "improved" titration should be preferred to a hypothetical prediction.
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Affiliation(s)
- A Ouattara
- Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France; Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU de Bordeaux, avenue Magellan, 33600 Pessac, France.
| | - A Dewitte
- Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France; Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU de Bordeaux, avenue Magellan, 33600 Pessac, France; Université de Bordeaux, bioingénierie tissulaire, U1026, 33000 Bordeaux, France
| | - H Rozé
- Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France; Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU de Bordeaux, avenue Magellan, 33600 Pessac, France
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