Predicting stroke volume and arterial pressure fluid responsiveness in liver cirrhosis patients using dynamic preload variables: A prospective study of diagnostic accuracy

Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis

IMPORTANCE

Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes.

OBJECTIVE

To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients.

REGISTRATION

The protocol was registered at PROSPERO: CRD42019146781.

INFORMATION SOURCES AND SEARCH

PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023.

STUDY SELECTION AND DATA COLLECTION

Prospective and intervention studies were selected.

STATISTICAL ANALYSIS

Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed.

RESULTS

A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89).

CONCLUSIONS

Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.

Evaluation of fluid responsiveness with dynamic superior vena cava collapsibility index in mechanically ventilated patients

BACKGROUND

This study aimed to evaluate the predictive accuracy of the superior vena cava collapsibility index measured by transesophageal echocardiography and compare the index with stroke volume variation measured by FloTrac™/Vigileo™ in mechanically ventilated patients.

METHODS

In the prospective study, a total of 60 patients were enrolled for elective general surgery under mechanical ventilation, where all patients received 10 ml/kg of Ringer's lactate. Five kinds of related data were recorded before and after the fluid challenge, including the superior vena cava collapsibility index (SVC-CI), the ratio of E/e', cardiac index (CI), stroke volume variation (SVV), and central venous pressure (CVP). Based on the collected data after the fluid challenge, we classified the patients as responders (FR group) if their CI increased by at least 15% and the rest were non-responders (NR).

RESULTS

Twenty-five of 52 (48%) of the patients were responders, and 27 were non-responders (52%). The SVC-CI was higher in the responders (41.90 ± 11.48 vs 28.92 ± 9.05%, P < 0.01). SVC-CI was significantly correlated with △CI _FloTrac (r = 0.568, P < 0.01). The area under the ROC curve (AUROC) of SVC-CI was 0.838 (95% CI 0.728 ~ 0.947, P < 0.01) with the optimal cutoff value of 39.4% (sensitivity 64%, specificity 92.6%). And there was no significant difference in E/e' between the two groups (P > 0.05). The best cutoff value for SVV was 12.5% (sensitivity 40%, specificity 89%) with the AUROC of 0.68 (95% CI 0.53 ~ 0.826, P < 0.05).

CONCLUSIONS

The SVC-CI and SVV can predict fluid responsiveness effectively in mechanically ventilated patients. And SVC-CI is superior in predicting fluid responsiveness compared with SVV. The E/e' ratio and CVP cannot predict FR effectively.

TRIAL REGISTRATION

Chinese clinical trial registry (ChiCTR2000034940).

Ability of dynamic preload indices to predict fluid responsiveness in a high femoral-to-radial arterial pressure gradient: a retrospective study

Background

Dynamic preload indices may predict fluid responsiveness in end-stage liver disease. However, their usefulness in patients with altered vascular compliance is uncertain. This study is the first to evaluate whether dynamic indices can reliably predict fluid responsiveness in patients undergoing liver transplantation with a high femoral-to-radial arterial pressure gradient (PG).

Methods

Eighty liver transplant recipients were retrospectively categorized as having a normal (n = 56) or high (n = 24, difference in systolic pressure ≥ 10 mmHg and/or mean pressure ≥ 5 mmHg) femoral-to-radial arterial PG, measured immediately after radial and femoral arterial cannulation. The ability of dynamic preload indices (stroke volume variation, pulse pressure variation [PPV], pleth variability index) to predict fluid responsiveness was assessed before the surgery. Fluid replacement of 500 ml of crystalloid solution was performed over 15 min. Fluid responsiveness was defined as ≥ 15% increase in the stroke volume index. The area under the receiver-operating characteristic curve (AUC) indicated the prediction of fluid responsiveness.

Results

Fourteen patients in the normal, and eight in the high PG group were fluid responders. The AUCs for PPV in the normal, high PG groups and total patients were 0.702 (95% confidence interval [CI] 0.553–0.851, P = 0.008), 0.633 (95% CI 0.384–0.881, P = 0.295) and 0.667 (95% CI 0.537–0.798, P = 0.012), respectively. No other index predicted fluid responsiveness.

Conclusion

PPV can be used as a dynamic index of fluid responsiveness in patients with end-stage liver disease but not in patients with altered vascular compliance.

Dynamic arterial elastance measured with pressure recording analytical method, and mean arterial pressure responsiveness in hypotensive preload dependent patients undergoing cardiac surgery: A prospective cohort study

BACKGROUND

Organ perfusion is a factor of cardiac output and perfusion pressure. Recent evidence shows that dynamic arterial elastance is a reliable index of the interaction between the left ventricle and the arterial system and, in turn, of left ventricular mechanical efficiency. A practical approach to the assessment of dynamic arterial elastance at the bedside is the ratio between pulse pressure variation and stroke volume variation, which might predict the effect of a fluid challenge on the arterial pressure in patients undergoing cardiac surgery.

OBJECTIVE

To evaluate the ability of dynamic arterial elastance, measured by the pressure recording analytical method (PRAM), to predict the response of mean arterial pressure (MAP) to a fluid challenge.

DESIGN

Prospective observational study.

SETTING

Cardiac surgery patients in a university hospital.

PATIENTS

Preload-dependent (pulse pressure variation ≥13%), hypotensive (MAP ≤65 mmHg) patients, without right ventricular dysfunction, at the end of cardiac surgery.

INTERVENTIONS

A 250 ml fluid challenge infused over 3 min.

MAIN OUTCOME MEASURES

A receiver-operating characteristic curve was generated to test the ability of the baseline (before fluid challenge) dynamic arterial elastance (primary endpoint) and all other haemodynamic variables (secondary endpoint) to predict MAP responsiveness (≥10% increase in MAP) after a fluid challenge.

RESULTS

Of 270 patients undergoing cardiac surgery, 97 (35.9%) were preload-dependent, hypotensive and received a fluid challenge. Of these 97 patients, 50 (51%) were MAP responders (≥10% increase in MAP) and 47 (48%) were MAP nonresponders (<10% increase in MAP). Baseline dynamic arterial elastance (mean ± SD) had an area under the curve of 0.64 ± 0.06 [95% confidence interval (CI), 0.53 to 0.73; P = 0.017]. A dynamic arterial elastance at least 1.07 with a grey zone ranging between 0.9 and 1.5 had 86% sensitivity (95% CI, 73 to 94) and 45% specificity (95% CI, 30 to 60) in predicting MAP increase.

CONCLUSION

In a hypotensive preload-dependent cardiac surgery cohort without right ventricular dysfunction, dynamic arterial elastance measured by PRAM can predict pressure response for values greater than 1.5 or less than 0.9.

Dynamic Arterial Elastance as a Ventriculo-Arterial Coupling Index: An Experimental Animal Study

Dynamic arterial elastance (Ea_dyn), the ratio between arterial pulse pressure and stroke volume changes during respiration, has been postulated as an index of the coupling between the left ventricle (LV) and the arterial system. We aimed to confirm this hypothesis using the gold-standard for defining LV contractility, afterload, and evaluating ventricular-arterial (VA) coupling and LV efficiency during different loading and contractile experimental conditions. Twelve Yorkshire healthy female pigs submitted to three consecutive stages with two opposite interventions each: changes in afterload (phenylephrine/nitroprusside), preload (bleeding/fluid bolus), and contractility (esmolol/dobutamine). LV pressure-volume data was obtained with a conductance catheter, and arterial pressures were measured via a fluid-filled catheter in the proximal aorta and the radial artery. End-systolic elastance (Ees), a load-independent index of myocardial contractility, was calculated during an inferior vena cava occlusion. Effective arterial elastance (Ea, an index of LV afterload) was calculated as LV end-systolic pressure/stroke volume. VA coupling was defined as the ratio Ea/Ees. LV efficiency (LV_eff) was defined as the ratio between stroke work and the LV pressure-volume area. Ea_dyn was calculated as the ratio between the aortic pulse pressure variation (PPV) and conductance-derived stroke volume variation (SVV). A linear mixed model was used for evaluating the relationship between Ees, Ea, VA coupling, LV_eff with Ea_dyn. Ea_dyn was inversely related to VA coupling and directly to LV_eff. The higher the Ea_dyn, the higher the LV_eff and the lower the VA coupling. Thus, Ea_dyn, an easily measured parameter at the bedside, may be of clinical relevance for hemodynamic assessment of the unstable patient.

Accuracy of dynamic preload variables for predicting fluid responsiveness in patients with pediatric liver cirrhosis: A prospective study

BACKGROUND

We have previously reported that dynamic preload variables predicted fluid responsiveness in adult patients with liver cirrhosis. However, pediatric patients with cirrhosis may present with unique hemodynamic characteristics, and therefore, the predictive accuracy of these variables in such patients must be clarified.

AIMS

To investigate the accuracy of dynamic preload variables for predicting fluid responsiveness in pediatric patients with cirrhosis.

METHODS

A total of 27 pediatric patients with cirrhosis undergoing orthotopic liver transplantation were enrolled in this study. Patients' pulse pressure variation, stroke volume variation, stroke volume index, and central venous pressure were measured using the calibrated pulse contour cardiac output system. The plethysmographic variability index was measured using a Masimo Radical 7 co-oximeter. During the hepatic dissection phase of the surgery, repeated intraoperative fluid challenges with 10 mL kg^-1 of crystalloid within 15 minutes were administered. Fluid responsiveness was defined as an increase in stroke volume index of ≥15% after fluid challenge.

RESULTS

A total of 61 fluid challenges were administered resulting in 15 fluid responders and 46 fluid nonresponders. Fluid challenge induced significant decreases in all three dynamic preload variables but not in the fluid nonresponders. However, the area under the receiver operating characteristic curves for pulse pressure variation, stroke volume variation, plethysmographic variability index, and central venous pressure for predicting fluid responsiveness were 0.67 (95% confidence interval: 0.52-0.82; P = .0255), 0.68 (95% confidence interval: 0.54-0.83; P = .0140), 0.56 (95% confidence interval: 0.40-0.71; P = .4724), and 0.57 (95% confidence interval: 0.40-0.74; P = .4192), respectively.

CONCLUSIONS

Dynamic preload variables do not predict fluid responsiveness in pediatric patients with liver cirrhosis.

Mini-fluid challenge test predicts stroke volume and arterial pressure fluid responsiveness during spine surgery in prone position: A STARD-compliant diagnostic accuracy study

The study was designed to verify if mini-fluid challenge test is more reliable than dynamic fluid variables in predicting stroke volume (SV) and arterial pressure fluid responsiveness during spine surgery in prone position with low-tidal-volume ventilation.Fifty patients undergoing spine surgery in prone position were included. Fluid challenge with 500 mL of colloid over 15 minutes was given. Changes in SV and systolic blood pressure (SBP) after initial 100 mL were compared with SV, pulse pressure variation (PPV), SV variation (SVV), plethysmographic variability index (PVI), and dynamic arterial elastance (Eadyn) in predicting SV or arterial pressure fluid responsiveness (15% increase or greater).An increase in SV of 5% or more after 100 mL predicted SV fluid responsiveness with area under the receiver operating curve (AUROC) of 0.90 (95% confidence interval [CI], 0.82 to 0.99), which was significantly higher than that of PPV (0.71 [95% CI, 0.57 to 0.86]; P = .01), and SVV (0.72 [95% CI, 0.57 to 0.87]; P = .03). A more than 4% increase in SBP after 100 mL predicted arterial pressure fluid responsiveness with AUROC of 0.86 (95% CI, 0.71-1.00), which was significantly higher than that of Eadyn (0.52 [95% CI, 0.33 to 0.71]; P = .01).Changes in SV and SBP after 100 mL of colloid predicted SV and arterial pressure fluid responsiveness, respectively, during spine surgery in prone position with low-tidal-volume ventilation.

Is dynamic arterial elastance a predictor of an increase in blood pressure after fluid administration in pediatric patients with hypotension? Reanalysis of prospective observational studies

BACKGROUND

Dynamic arterial elastance (Ea_dyn ) has been proposed to predict an increase in mean arterial pressure (MAP) after volume expansion in hypotensive adults. We aimed to evaluate the clinical usefulness of Ea_dyn as a predictor of arterial pressure response after fluid loading in pediatric patients with hypotension.

METHODS

We re-analyzed data of 63 hypotensive children (age, ≤5 years), collected from three previous prospective observational studies about fluid responsiveness. Pulse pressure variation (PPV), stroke volume variation (SVV), and respiratory variation in aortic blood flow velocity (ΔVpeak) were used to calculate Ea_dyn (PPV/SVV) and modified Ea_dyn (PPV/ΔVpeak). Preload-dependent patients were defined as those with ΔVpeak ≥12% before fluid loading. Patients were classified as pressure responders, if their MAP increased ≥15% after fluid administration.

RESULTS

Mean Ea_dyn (SD) was 1.06 (0.47) in pressure responders (n=39) and 0.99 (0.48) in nonresponders (n = 24) (mean difference, 0.08; 95% confidence interval [CI], -0.19-0.34; P = .567). Additionally, mean modified Ea_dyn was 1.27 (0.64) in responders and 1.11 (0.43) in nonresponders (mean difference, 0.17; 95% CI, -0.13-0.46; P = 0.269). Both Ea_dyn (AUC 0.506; 95% confidence interval [CI], 0.337 to 0.675; P = 0.948) and modified Ea_dyn (AUC 0.498; 95% CI, 0.328-0.669; P = 0.983), as well as other dynamic variables, could not predict pressure responsiveness in children. Sub-group analysis revealed similar findings in both in 39 preload-dependent and hypotensive patients (26 pressure responders and 13 nonpressure responders).

CONCLUSION

Both Ea_dyn and modified Ea_dyn cannot predict whether blood pressure increases with fluid administration in pediatric patients with hypotension.

The effects of static and dynamic measurements using transpulmonary thermodilution devices on fluid therapy in septic shock: A systematic review

Transpulmonary thermodilution devices have been widely shown to be accurate in septic shock patients in assessing fluid responsiveness. We conducted a systematic review to assess the relationship between fluid therapy protocols guided by transpulmonary thermodilution devices on fluid balance and the amount of intravenous fluid used in septic shock. We searched MEDLINE, Embase and The Cochrane Library. Studies were eligible for inclusion if they were prospective, parallel trials that were conducted in an intensive care setting in patients with septic shock. The comparator group was either central venous pressure, early goal-directed therapy or pulmonary artery occlusion pressure. Studies assessing only the accuracy of fluid responsiveness prediction by transpulmonary thermodilution devices were excluded. Two reviewers independently performed the search, extracted data and assessed the bias of each study. In total 27 full-text articles were identified for eligibility; of these, nine studies were identified for inclusion in the systematic review. Three of these trials used dynamic parameters derived from transpulmonary thermodilution devices and six used primarily static parameters to guide fluid therapy. There was evidence for a significant reduction in positive fluid balance in four out of the nine studies. From the available studies, the results suggest the benefit of transpulmonary thermodilution monitoring in the septic shock population with regard to reducing positive fluid balance is seen when the devices are utilised for at least 72 hours. Both dynamic and static parameters derived from transpulmonary thermodilution devices appear to lead to a reduction in positive fluid balance in septic shock patients compared to measurements of central venous pressure and early goal-directed therapy.

Changes in dynamic arterial elastance induced by volume expansion and vasopressor in the operating room: a prospective bicentre study

BACKGROUND

Dynamic arterial elastance (Eadyn), defined as the ratio between pulse pressure variations and stroke volume variations, has been proposed to assess functional arterial load. We evaluated the evolution of Eadyn during volume expansion and the effects of neosynephrine infusion in hypotensive and preload-responsive patients.

METHODS

In this prospective bicentre study, we included 56 mechanically ventilated patients in the operating room. Each patient had volume expansion and neosynephrine infusion. Stroke volume and stroke volume variations were obtained using esophageal Doppler, and pulse pressure variations were measured through the arterial line. Pressure response to volume expansion was defined as an increase in mean arterial pressure (MAP) ≥ 10%.

RESULTS

Twenty-one patients were pressure responders to volume expansion. Volume expansion induced a decrease in Eadyn (from 0.69 [0.58-0.85] to 0.59 [0.42-0.77]) related to a decrease in pulse pressure variations more pronounced than the decrease in stroke volume variations. Baseline and changes in Eadyn after volume expansion were related to age, history of arterial hypertension, net arterial compliance and effective arterial elastance. Eadyn value before volume expansion > 0.65 predicted a MAP increase ≥ 10% with a sensitivity of 76% (95% CI 53-92%) and a specificity of 60% (95% CI 42-76%). Neosynephrine infusion induced a decrease in Eadyn (from 0.67 [0.48-0.80] to 0.54 [0.37-0.68]) related to a decrease in pulse pressure variations more pronounced than the decrease in stroke volume variations. Baseline and changes in Eadyn after neosynephrine infusion were only related to heart rate.

CONCLUSION

Eadyn is a potential sensitive marker of arterial tone changes following vasopressor infusion.

Reliability of pleth variability index in predicting preload responsiveness of mechanically ventilated patients under various conditions: a systematic review and meta-analysis

Background

Goal-directed volume expansion is increasingly used for fluid management in mechanically ventilated patients. The Pleth Variability Index (PVI) has been shown to reliably predict preload responsiveness; however, a lot of research on PVI has been published recently, and update of the meta-analysis needs to be completed.

Methods

We searched PUBMED, EMBASE, Cochrane Library, Web of Science (updated to November 7, 2018) and the associated references. Relevant authors and researchers had been contacted for complete data.

Results

Twenty-five studies with 975 mechanically ventilated patients were included in this meta-analysis. The area under the curve (AUC) of receiver operating characteristics (ROC) to predict preload responsiveness was 0.82 (95% confidence interval (CI) 0.79–0.85). The pooled sensitivity was 0.77 (95% CI 0.67–0.85) and the pooled specificity was 0.77 (95% CI 0.71–0.82). The results of subgroup of patients without undergoing surgery (AUC =0.86, Youden index =0.65) and the results of subgroup of patients in ICU (AUC =0.89, Youden index =0.67) were reliable.

Conclusion

The reliability of the PVI is limited, but the PVI can play an important role in bedside monitoring for mechanically ventilated patients who are not undergoing surgery. Patients who are expanded with colloid may be more suitable for PVI.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0744-4) contains supplementary material, which is available to authorized users.

Pleth variability index versus pulse pressure variation for intraoperative goal-directed fluid therapy in patients undergoing low-to-moderate risk abdominal surgery: a randomized controlled trial

Background

Goal-directed fluid therapy (GDFT) based on dynamic indicators of fluid responsiveness has been shown to decrease postoperative complications and hospital length of stay (LOS) in patients undergoing major abdominal surgery. The usefulness of this approach still needs to be clarified in low-to-moderate risk abdominal surgery. Both pulse-pressure variation (PPV) and pleth variability index (PVI) can be used to guide GDFT strategies. The objective of this prospective randomized controlled trial was to determine if the use of PVI guided GDFT, when compared to PPV guided GDFT, would lead to similar hospital LOS in patients undergoing low-to-moderate risk surgery. Secondary outcomes included amount of fluid administered and incidence of postoperative complications.

Methods

Patients were randomized into either PVI or PPV guided GDFT groups. Both received a baseline 2 ml kg^− 1 h^− 1 Lactated Ringer infusion. Additional fluid boluses consisted of 250 mL of colloid that was infused over a 10 min period if PVI was > 15% or PPV was > 13% for at least five minutes. The primary outcome was to determine if hospital LOS, which was defined as the number of days from surgery up to the day the surgeon authorized hospital discharge, was equivalent between the two groups.

Results

A total of 76 patients were included and they were randomized into two groups of 38 patients. Baseline characteristics were similar in both groups. Both PVI and PPV guided GDFT strategies were equivalent for the primary outcome of LOS (median [interquartile range]) (days) 2.5 [2.0–3.3] vs. 3.0 [2.0–5.0], p = 0.230, respectively. Fluids infused, postoperative complications, and all other outcomes were not different between groups.

Conclusion

In patients undergoing low-to-moderate risk abdominal surgery, PVI seems to guide GDFT similarly to PPV in regards to hospital LOS, amount of fluid, and incidence of postoperative complications. However, in low-risk patients undergoing these surgical procedures optimizing stroke volume may have limited impact on outcome.

Trial registration

ClinicalTrials.gov Identifier: NCT02908256, September 2016, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0707-9) contains supplementary material, which is available to authorized users.

Preemptive volume therapy to prevent hemodynamic changes caused by the beach chair position: hydroxyethyl starch 130/0.4 versus Ringer's acetate-a controlled randomized trial

BACKGROUND

Hemodynamic instability frequently occurs in beach chair positioning for surgery, putting patients at risk for cerebral adverse events. This study examined whether preoperative volume loading with crystalloids alone or with a crystalloid-colloid combination can prevent hemodynamic changes that may be causative for unfavorable neurologic outcomes.

METHODS

The study randomly assigned 43 adult patients undergoing shoulder surgery to 3 study groups. Each group received an infusion of 500 mL of Ringer's acetate between induction of anesthesia and being placed in the beach chair position. The crystalloid group received an additional bolus of 1000 mL Ringer's acetate. The hydroxyethyl starch group was administered an additional bolus of 500 mL of 6% hydroxyethyl starch 130/0.4. Hemodynamic monitoring was accomplished via an esophageal Doppler probe. Cerebral oxygen saturation was examined with near-infrared spectroscopy. Changes in stroke volume variation between the prone and beach chair positions were defined as the primary outcome parameter. Secondary outcomes were changes in cardiac output and cerebral oxygen saturation.

RESULTS

The control group was prematurely stopped after enrollment of 4 patients because of adverse events. In the hydroxyethyl starch group, stroke volume variation remained constant during positioning maneuvers (P = .35), whereas a significant increase was observed in the Ringer's acetate group (P < .01; P = .014 for intergroup comparison). This was also valid for changes in cardiac output. Cerebral oxygen saturation significantly decreased in both groups.

CONCLUSIONS

Preprocedural boluses of 500 mL of 6% hydroxyethyl starch 130/0.4 as well as 1000 mL of Ringer's acetate were efficient in preserving hemodynamic conditions during beach chair position.