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Urhan G, Demirel İ, Deniz A, Aksu A, Altun AY, Bolat E, Beştaş A, Altuntaş G. Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy. Obes Surg 2024; 34:1600-1607. [PMID: 38512646 PMCID: PMC11031432 DOI: 10.1007/s11695-024-07154-z] [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: 05/22/2023] [Revised: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Obesity increases the risk of morbidity and mortality during surgical procedures. Goal-directed fluid therapy (GDFT) is a new concept for perioperative fluid management that has been shown to improve patient prognosis. This study aimed to investigate the role of the Pleth Variability Index (PVI), systolic pressure variation (SPV), and pulse pressure variation (PPV) in maintaining tissue perfusion and renal function during GDFT management in patients undergoing laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS Two hundred ten patients were enrolled in our prospective randomized controlled clinical trial. Demographic data, hemodynamic parameters, biochemical parameters, the amount of crystalloid and colloid fluid administered intraoperatively, and the technique of goal-directed fluid management used were recorded. Patients were randomly divided into three groups: PVI (n = 70), PPV (n = 70), and SPV (n = 70), according to the technique of goal-directed fluid management. Postoperative nausea and vomiting, time of return of bowel movement, and hospital stay duration were recorded. RESULTS There was no statistically significant difference between the number of crystalloids administered in all three groups. However, the amount of colloid administered was statistically significantly lower in the SPV group than in the PVI group, and there was no significant difference in the other groups. Statistically, there was no significant difference between the groups in plasma lactate, blood urea, and creatinine levels. CONCLUSION In LSG, dynamic measurement techniques such as PVI, SPV, and PPV can be used in patients with morbid obesity without causing intraoperative and postoperative complications. PVI may be preferred over other invasive methods because it is noninvasive.
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Affiliation(s)
- Gökhan Urhan
- Anesthesiology and Reanimation Department, Elazığ Fethi Sekin City Hospital, Elazig, Turkey
| | - İsmail Demirel
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey
| | - Ahmet Deniz
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey
| | - Ahmet Aksu
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey
| | - Aysun Yıldız Altun
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey
| | - Esef Bolat
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey.
| | - Azize Beştaş
- Anesthesiology and Reanimation Department, School of Medicine, Firat University, Elazig, 23119, Turkey
| | - Gülsüm Altuntaş
- Anesthesiology and Reanimation Department, Medicine Faculty, Firat University, Elazig, Turkey
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Wyffels PAH, De Hert S, Wouters PF. Measurement error of pulse pressure variation. J Clin Monit Comput 2024; 38:313-323. [PMID: 38064135 DOI: 10.1007/s10877-023-01099-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/21/2023] [Indexed: 04/06/2024]
Abstract
Dynamic preload parameters are used to guide perioperative fluid management. However, reported cut-off values vary and the presence of a gray zone complicates clinical decision making. Measurement error, intrinsic to the calculation of pulse pressure variation (PPV) has not been studied but could contribute to this level of uncertainty. The purpose of this study was to quantify and compare measurement errors associated with PPV calculations. Hemodynamic data of patients undergoing liver transplantation were extracted from the open-access VitalDatabase. Three algorithms were applied to calculate PPV based on 1 min observation periods. For each method, different durations of sampling periods were assessed. Best Linear Unbiased Prediction was determined as the reference PPV-value for each observation period. A Bayesian model was used to determine bias and precision of each method and to simulate the uncertainty of measured PPV-values. All methods were associated with measurement error. The range of differential and proportional bias were [- 0.04%, 1.64%] and [0.92%, 1.17%] respectively. Heteroscedasticity influenced by sampling period was detected in all methods. This resulted in a predicted range of reference PPV-values for a measured PPV of 12% of [10.2%, 13.9%] and [10.3%, 15.1%] for two selected methods. The predicted range in reference PPV-value changes for a measured absolute change of 1% was [- 1.3%, 3.3%] and [- 1.9%, 4%] for these two methods. We showed that all methods that calculate PPV come with varying degrees of uncertainty. Accounting for bias and precision may have important implications for the interpretation of measured PPV-values or PPV-changes.
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Affiliation(s)
- Piet A H Wyffels
- Department of Basic and Applied Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Stefan De Hert
- Department of Basic and Applied Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Patrick F Wouters
- Department of Basic and Applied Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Messina A, Uryga A, Giardina A, Ciliberti P, Battaglini D, Patroniti N, Czosnyka M, Monnet X, Cecconi M, Robba C. The effect of passive leg raising test on intracranial pressure and cerebral autoregulation in brain injured patients: a physiological observational study. Crit Care 2024; 28:23. [PMID: 38229147 PMCID: PMC10790469 DOI: 10.1186/s13054-023-04785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The use of the passive leg raising (PLR) is limited in acute brain injury (ABI) patients with increased intracranial pressure (ICP) since the postural change of the head may impact on ICP and cerebral autoregulation. However, the PLR use may prevent a positive daily fluid balance, which had been recently associated to worse neurological outcomes. We therefore studied early and delayed effects of PLR on the cerebral autoregulation of patients recovering from ABI. MATERIALS AND METHODS This is a Prospective, observational, single-center study conducted in critically ill patients admitted with stable ABI and receiving invasive ICP monitoring, multimodal neuromonitoring and continuous hemodynamic monitoring. The fluid challenge consisted of 500 mL of crystalloid over 10 min; fluid responsiveness was defined as cardiac index increase ≥ 10%. Comparisons between different variables at baseline and after PLR were made by paired Wilcoxon signed-rank test. The correlation coefficients between hemodynamic and neuromonitoring variables were assessed using Spearman's rank test. RESULTS We studied 23 patients [12 patients (52.2%) were fluid responders]. The PLR significantly increased ICP [from 13.7 (8.3-16.4) to 15.4 (12.0-19.2) mmHg; p < 0.001], cerebral perfusion pressure (CPP) [from 51.1 (47.4-55.6) to 56.4 (49.6-61.5) mmHg; p < 0.001] and the pressure reactivity index (PRx) [from 0.12 (0.01-0.24) to 0.43 (0.34-0.46) mmHg; p < 0.001]. Regarding Near Infrared Spectroscopy (NIRS)-derived parameters, PLR significantly increased the arterial component of regional cerebral oxygen saturation (O2Hbi) [from 1.8 (0.8-3.7) to 4.3 (2.5-5.6) μM cm; p < 0.001], the deoxygenated hemoglobin (HHbi) [from 1.6 (0.2-2.9) to 2.7 (1.4-4.0) μM cm; p = 0.007] and total hemoglobin (cHbi) [from 3.6 (1.9-5.3) to 7.8 (5.2-10.3): p < 0.001]. In all the patients who had altered autoregulation after PLR, these changes persisted ten minutes afterwards. After the PLR, we observed a significant correlation between MAP and CPP and PRx. CONCLUSIONS In ABI patient with stable ICP, PLR test increased ICP, but mostly within safety values and thresholds. Despite this, cerebral autoregulation was importantly impaired, and this persisted up to 10 min after the end of the maneuvre. Our results discourage the use of PLR test in ABI even when ICP is stable.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy.
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Pietro Ciliberti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Xavier Monnet
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcini 4, Pieve Emanuele, Milan, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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Röwer LM, Radke KL, Hußmann J, Malik H, Eichinger M, Voit D, Wielpütz MO, Frahm J, Klee D, Pillekamp F. First experience with real-time magnetic resonance imaging-based investigation of respiratory influence on cardiac function in pediatric congenital heart disease patients with chronic right ventricular volume overload. Pediatr Radiol 2023; 53:2608-2621. [PMID: 37794175 PMCID: PMC10698081 DOI: 10.1007/s00247-023-05765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Congenital heart disease (CHD) is often associated with chronic right ventricular (RV) volume overload. Real-time magnetic resonance imaging (MRI) enables the analysis of cardiac function during free breathing. OBJECTIVE To evaluate the influence of respiration in pediatric patients with CHD and chronic RV volume overload. METHODS AND MATERIALS RV volume overload patients (n=6) and controls (n=6) were recruited for cardiac real-time MRI at 1.5 tesla during free breathing. Breathing curves from regions of interest reflecting the position of the diaphragm served for binning images in four different tidal volume classes, each in inspiration and expiration. Tidal volumes were estimated from these curves by data previously obtained by magnetic resonance-compatible spirometry. Ventricular volumes indexed to body surface area and Frank-Starling relationships referenced to the typical tidal volume indexed to body height (TTVi) were compared. RESULTS Indexed RV end-diastolic volume (RV-EDVi) and indexed RV stroke volume (RV-SVi) increased during inspiration (RV-EDVi/TTVi: RV load: + 16 ± 4%; controls: + 22 ± 13%; RV-SVi/TTVi: RV load: + 21 ± 6%; controls: + 35 ± 17%; non-significant for comparison). The increase in RV ejection fraction during inspiration was significantly lower in RV load patients (RV load: + 1.1 ± 2.2%; controls: + 6.1 ± 1.5%; P=0.01). The Frank-Starling relationship of the RV provided a significantly reduced slope estimate in RV load patients (inspiration: RV load: 0.75 ± 0.11; controls: 0.92 ± 0.02; P=0.02). CONCLUSION In pediatric patients with CHD and chronic RV volume overload, cardiac real-time MRI during free breathing in combination with respiratory-based binning indicates an impaired Frank-Starling relationship of the RV.
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Affiliation(s)
- Lena Maria Röwer
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Karl Ludger Radke
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Janina Hußmann
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Halima Malik
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Monika Eichinger
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, University Hospital of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Dirk Voit
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Mark Oliver Wielpütz
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, University Hospital of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Jens Frahm
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Dirk Klee
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Frank Pillekamp
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital, Heinrich-Heine-University, Düsseldorf, Germany.
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Messina A, Caporale M, Calabrò L, Lionetti G, Bono D, Matronola GM, Brunati A, Frassanito L, Morenghi E, Antonelli M, Chew MS, Cecconi M. Reliability of pulse pressure and stroke volume variation in assessing fluid responsiveness in the operating room: a metanalysis and a metaregression. Crit Care 2023; 27:431. [PMID: 37940953 PMCID: PMC10631038 DOI: 10.1186/s13054-023-04706-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Pulse pressure and stroke volume variation (PPV and SVV) have been widely used in surgical patients as predictors of fluid challenge (FC) response. Several factors may affect the reliability of these indices in predicting fluid responsiveness, such as the position of the patient, the use of laparoscopy and the opening of the abdomen or the chest, combined FC characteristics, the tidal volume (Vt) and the type of anesthesia. METHODS Systematic review and metanalysis of PPV and SVV use in surgical adult patients. The QUADAS-2 scale was used to assess the risk of bias of included studies. We adopted a metanalysis pooling of aggregate data from 5 subgroups of studies with random effects models using the common-effect inverse variance model. The area under the curve (AUC) of pooled receiving operating characteristics (ROC) curves was reported. A metaregression was performed using FC type, volume, and rate as independent variables. RESULTS We selected 59 studies enrolling 2,947 patients, with a median of fluid responders of 55% (46-63). The pooled AUC for the PPV was 0.77 (0.73-0.80), with a mean threshold of 10.8 (10.6-11.0). The pooled AUC for the SVV was 0.76 (0.72-0.80), with a mean threshold of 12.1 (11.6-12.7); 19 studies (32.2%) reported the grey zone of PPV or SVV, with a median of 56% (40-62) and 57% (46-83) of patients included, respectively. In the different subgroups, the AUC and the best thresholds ranged from 0.69 and 0.81 and from 6.9 to 11.5% for the PPV, and from 0.73 to 0.79 and 9.9 to 10.8% for the SVV. A high Vt and the choice of colloids positively impacted on PPV performance, especially among patients with closed chest and abdomen, or in prone position. CONCLUSION The overall performance of PPV and SVV in operating room in predicting fluid responsiveness is moderate, ranging close to an AUC of 0.80 only some subgroups of surgical patients. The grey zone of these dynamic indices is wide and should be carefully considered during the assessment of fluid responsiveness. A high Vt and the choice of colloids for the FC are factors potentially influencing PPV reliability. TRIAL REGISTRATION PROSPERO (CRD42022379120), December 2022. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=379120.
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Affiliation(s)
- Antonio Messina
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
| | - Mariagiovanna Caporale
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lorenzo Calabrò
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Giulia Lionetti
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Daniele Bono
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Guia Margherita Matronola
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Andrea Brunati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Luciano Frassanito
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Emanuela Morenghi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano - Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
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Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Cruz Martínez LE, Carreño Hernández FL, Santacruz Herrera CA, Ospina-Tascón GA. Variables influencing the prediction of fluid responsiveness: a systematic review and meta-analysis. Crit Care 2023; 27:361. [PMID: 37730622 PMCID: PMC10510289 DOI: 10.1186/s13054-023-04629-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/27/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Prediction of fluid responsiveness in acutely ill patients might be influenced by a number of clinical and technical factors. We aim to identify variables potentially modifying the operative performance of fluid responsiveness predictors commonly used in clinical practice. METHODS A sensitive strategy was conducted in the Medline and Embase databases to search for prospective studies assessing the operative performance of pulse pressure variation, stroke volume variation, passive leg raising (PLR), end-expiratory occlusion test (EEOT), mini-fluid challenge, and tidal volume challenge to predict fluid responsiveness in critically ill and acutely ill surgical patients published between January 1999 and February 2023. Adjusted diagnostic odds ratios (DORs) were calculated by subgroup analyses (inverse variance method) and meta-regression (test of moderators). Variables potentially modifying the operative performance of such predictor tests were classified as technical and clinical. RESULTS A total of 149 studies were included in the analysis. The volume used during fluid loading, the method used to assess variations in macrovascular flow (cardiac output, stroke volume, aortic blood flow, volume‒time integral, etc.) in response to PLR/EEOT, and the apneic time selected during the EEOT were identified as technical variables modifying the operative performance of such fluid responsiveness predictor tests (p < 0.05 for all adjusted vs. unadjusted DORs). In addition, the operative performance of fluid responsiveness predictors was also influenced by clinical variables such as the positive end-expiratory pressure (in the case of EEOT) and the dose of norepinephrine used during the fluid responsiveness assessment for PLR and EEOT (for all adjusted vs. unadjusted DORs). CONCLUSION Prediction of fluid responsiveness in critically and acutely ill patients is strongly influenced by a number of technical and clinical aspects. Such factors should be considered for individual intervention decisions.
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Affiliation(s)
- Jorge Iván Alvarado Sánchez
- Fundación Santa Fe de Bogotá, Department of Intensive Care, Bogotá, Colombia.
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - Juan Daniel Caicedo Ruiz
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan José Diaztagle Fernández
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
- Department of Internal Medicine, Fundación Universitaria de Ciencias de La Salud. Hospital de San José, Bogotá, Colombia
| | - Luís Eduardo Cruz Martínez
- Department of Physiology Sciences, Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | | | | | - Gustavo Adolfo Ospina-Tascón
- Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
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ABDULLAH T, GÖKDUMAN HC, ENİŞTE İA, ATASEVER AG, ALİ A, GÜMÜŞ ÖZCAN F. Novel parameters for predicting fluid responsiveness during the mini fluid challenge and ability of the cardiac power index: an observational cohort study. Turk J Med Sci 2023; 53:1224-1233. [PMID: 38813019 PMCID: PMC10763793 DOI: 10.55730/1300-0144.5688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 10/26/2023] [Accepted: 08/26/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim The percentage change in the stroke volume index (SVI) due to the mini fluid challenge (MFC) (MFC-ΔSVI%) is used commonly in daily practice. However, up to 20% of patients remain in the gray zone of this variable. Thus, it was aimed to compare the MFC-ΔSVI% and the percentage change in the cardiac power index (CPI) due to the MFC (MFC-ΔCPI%) with the baseline values of the pulse pressure variation (PPV) and stroke volume variation (SVV) in terms of their abilities to predict fluid responsiveness. Materials and methods The SVI, CPI, SVV, and PPV were recorded before 100 mL of isotonic saline was infused (MFC), after MFC was completed, and after an additional 400 mL of isotonic saline was infused to complete 500 mL of fluid loading (FL). Patients whose SVI increased more than 15% after the FL were defined as fluid responders. Results Sixty-seven patients completed the study and 35 (52%) of them were responders.The areas under the receiver operating characteristics curves for the MFC-ΔSVI% and MFC-ΔCPI% (0.94; 95% CI: 0.86-0.99 and 0.89; 95% CI: 0.79-0.95, respectively) were significantly higher than those for the SVV and PPV (0.63; 95% CI: 0.50-0.75 and 0.55; 95% CI: 0.42-0.67, respectively) (p < 0.001 for all of the comparisons). The gray zone analysis revealed that the MFC-ΔSVI% values of 12 patients were in the gray zone. Of the 12, the MFC-ΔCPI% values of 7 patients were outside of the gray zone. Conclusion Fluid responsiveness can be predicted more accurately using the MFC-ΔSVI% and MFC-ΔCPI% than using the SVV and PPV. Additionally, concomitant use of the MFC-ΔSVI% and MFC-ΔCPI% is recommended, as this approach diminishes the number of patients in the gray zone.
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Affiliation(s)
- Taner ABDULLAH
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - Hürü Ceren GÖKDUMAN
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - İşbara Alp ENİŞTE
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
| | - Ayşe Gülşah ATASEVER
- Department of Anesthesiology, University Hospitals of the KU Leuven, Leuven,
Belgium
| | - Achmet ALİ
- Department of Anesthesiology and Reanimation, İstanbul Medical Faculty, İstanbul University, İstanbul,
Turkiye
| | - Funda GÜMÜŞ ÖZCAN
- Department of Anesthesiology, İstanbul Başakşehir Çam and Sakura City Hospital, İstanbul,
Turkiye
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Messina A, Sotgiu G, Saderi L, Puci M, Negri K, Robba C, Sanfilippo F, Romagnoli S, Cecconi M. Phenotypes of hemodynamic response to fluid challenge during anesthesia: a cluster analysis. Minerva Anestesiol 2023; 89:653-662. [PMID: 36943710 DOI: 10.23736/s0375-9393.23.16992-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The fluid challenge (FC) response is usually evaluated as binary, which may be inadequate to describe the complex interactions between heart function and vascular tone response after fluid administration. We applied a clustering approach to assess the different phenotypes of cardiovascular responses to FC administration, considering the associations of all the baseline variables potentially influencing pressure and flow response to a FC. Secondarily, we evaluated the reliability of baseline hemodynamic variables in discriminating fluid responsiveness, which is considered the standard approach at the bedside. METHODS Five merged datasets from elective surgical patients receiving a FC dose ≥4 mL/kg, infused over 10 minutes. In a principal component approach, hierarchical clustering was used to define hemodynamic phenotypes of response to FC administration. Hierarchical cluster analysis with Ward linkage was carried out to define similar patient groups using the Gower distance for the mixed combination of continuous and categorical variables. No a priori criteria of fluid responsiveness were applied. The area (AUC) under the pre-FC variables' receiver operating characteristic curves (ROC) was also built to predict fluid responsiveness, defined as SVI ≥10% after FC. RESULTS We analyzed 223 patients. The cluster analysis identified three hemodynamic clusters of patients: cluster 1 (98 patients, 44.0%) showed an average increase of mean arterial pressure (MAP) and Stroke Volume Index (SVI) of 17.3% (11.9-23.1) and 13.1% (0.5-23.4) at the end of FC, respectively. These patients showed baseline flow and pressure variables slightly below physiological ranges, with high pulse pressure variation (PPV). Cluster 2 (68 patients, 30.5%) showed no increase of MAP and SVI at the end of FC. These patients showed baseline flow and pressure variables within physiological ranges, with low hear rate (HR) and PPV. Cluster 3 (57 patients, 25.5%) showed no MAP increase and an SVI increase of 13.1 (2.1-19.6). These patients showed baseline pressure variables within physiological ranges, low flow variables associated to high HR and PPV. The pulse pressure variation (PPV) showed an AUC of 0.82 (0.03), with a grey zone ranging from 6% to 12%, including 86 (38.5%) patients. CONCLUSIONS Clustering analysis identified three hemodynamic clusters with different response phenotypes to FC. This promising approach may enhance the ability to detect fluid responsiveness at the bedside, by considering the specific association of parameters and not the presence of a single one, such as the PPV. In fact, in our cohort the reliability of the PPV was limited, showing high sensibility and specificity only above 12% and below 6%, respectively, and a grey zone including 38.5% of patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy -
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy -
| | - Giovanni Sotgiu
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Mariangela Puci
- Unit of Clinical Epidemiology and Medical Statistics, Department of Medical, Surgical and Experimental, University of Sassari, Sassari, Italy
| | - Katerina Negri
- Department of Anesthesia and Intensive Care, University of Milan, Milan, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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9
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Lee CT, Lin CP, Chan KC, Wu YL, Teng HC, Wu CY. Effects of Goal-Directed Hemodynamic Therapy Using a Noninvasive Finger-Cuff Monitoring Device on Intraoperative Cerebral Oxygenation and Early Delayed Neurocognitive Recovery in Patients Undergoing Beach Chair Position Shoulder Surgery: A Randomized Controlled Trial. Anesth Analg 2023; 136:355-364. [PMID: 36135341 DOI: 10.1213/ane.0000000000006200] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perioperative cerebral desaturation events (CDEs) and delayed neurocognitive recovery are common among patients undergoing beach chair position (BCP) shoulder surgery and may be caused by cerebral hypoperfusion. This study tested the hypothesis that the application of goal-directed hemodynamic therapy (GDHT) would attenuate these conditions. METHODS We randomly assigned 70 adult patients undergoing BCP shoulder surgery to GDHT group or control at a 1:1 ratio. Cerebral oxygenation was monitored using near-infrared spectroscopy, and GDHT was administered using the ClearSight pulse wave analysis system. The primary outcome was CDE duration, whereas the secondary outcomes were CDE occurrence, delayed neurocognitive recovery occurrence, and Taiwanese version of the Quick Mild Cognitive Impairment (Qmci-TW) test score on the first postoperative day (T 2 ) adjusted for the baseline score (on the day before surgery; T 1 ). RESULTS CDE duration was significantly shorter in the GDHT group (0 [0-0] vs 15 [0-75] min; median difference [95% confidence interval], -8 [-15 to 0] min; P = .007). Compared with the control group, fewer patients in the GDHT group experienced CDEs (23% vs 51%; relative risk [95% confidence interval], 0.44 [0.22-0.89]; P = .025) and mild delayed neurocognitive recovery (17% vs 40%; relative risk [95% confidence interval], 0.60 [0.39-0.93]; P = .034). The Qmci-TW scores at T 2 adjusted for the baseline scores at T 1 were significantly higher in the GDHT group (difference in means: 4 [0-8]; P = .033). CONCLUSIONS Implementing GDHT using a noninvasive finger-cuff monitoring device stabilizes intraoperative cerebral oxygenation and is associated with improved early postoperative cognitive scores in patients undergoing BCP shoulder surgery.
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Affiliation(s)
- Chen-Tse Lee
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Peng Lin
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Luen Wu
- Department of Medical Education, National Taiwan University, Taipei, Taiwan
| | - Hsiao-Chun Teng
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yu Wu
- From the Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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10
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Ltaief Z, Ben-Hamouda N, Rancati V, Gunga Z, Marcucci C, Kirsch M, Liaudet L. Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J Clin Med 2022; 11:6407. [PMID: 36362635 PMCID: PMC9658078 DOI: 10.3390/jcm11216407] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/13/2023] Open
Abstract
Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Valentina Rancati
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Ziyad Gunga
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Carlo Marcucci
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
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11
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Messina A, Colombo D, Lionetti G, Calabrò L, Negri K, Robba C, Cammarota G, Costantini E, Cecconi M. Pressure response to fluid challenge administration in hypotensive surgical patients: a post-hoc pharmacodynamic analysis of five datasets. J Clin Monit Comput 2022; 37:449-459. [PMID: 36197548 DOI: 10.1007/s10877-022-00918-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/17/2022] [Indexed: 10/10/2022]
Abstract
In this study we evaluated the effect of fluid challenge (FC) administration in elective surgical patients with low or normal blood pressure. Secondarily, we appraised the pharmacodynamic effect of FC in normotensive and hypotensive patients. We assessed five merged datasets of patients with a baseline mean arterial pressure (MAP) above or below 65 mmHg and assessed the changes of systolic, diastolic, mean and dicrotic arterial pressures, dynamic indexes of fluid responsiveness and arterial elastance over a 10-min infusion. The hemodynamic effect was assessed by considering the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), the time when the maximal value was observed (tmax) and change from baseline at 5-min (d5) after FC end. A stroke volume index increase > 10% with respect to the baseline value after FC administration indicated fluid response. Two hundred-seventeen patients were analysed [102 (47.0%) fluid responders]. On average, FC restored a MAP [Formula: see text] 65 mmHg after 5 min. The AUCs and the dmax of pressure variables and arterial elastance of hypotensive patients were all significantly greater than normotensive patients. Pressure variables and arterial elastance changes in the hypotensive group were all significantly higher at d5 as compared to the normotensive group. In hypotensive patients, FC restores a MAP [Formula: see text] 65 mmHg after 5 min from infusion start. The hemodynamic profile of FC in hypotensive and normotensive patients is different; both the magnitude of pressure augmentation and duration is greater in the hypotensive group.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy. .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy.
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Italy
| | | | | | - Katerina Negri
- Department of Anesthesia and Intensive Care, Università degli studi di Milano, Milan, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | | | | | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano (MI), Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
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12
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De Backer D, Aissaoui N, Cecconi M, Chew MS, Denault A, Hajjar L, Hernandez G, Messina A, Myatra SN, Ostermann M, Pinsky MR, Teboul JL, Vignon P, Vincent JL, Monnet X. How can assessing hemodynamics help to assess volume status? Intensive Care Med 2022; 48:1482-1494. [PMID: 35945344 PMCID: PMC9363272 DOI: 10.1007/s00134-022-06808-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023]
Abstract
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Nadia Aissaoui
- Assistance publique des hôpitaux de Paris (APHP), Cochin Hospital, Intensive Care Medicine, médecine interne reanimation, Université de Paris and Paris Cardiovascular Research Center, INSERM U970, 25 rue Leblanc, 75015, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.,Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Ludhmila Hajjar
- Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Philippe Vignon
- Medical-surgical ICU and Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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13
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Monnet X, Shi R, Teboul JL. Prediction of fluid responsiveness. What’s new? Ann Intensive Care 2022; 12:46. [PMID: 35633423 PMCID: PMC9148319 DOI: 10.1186/s13613-022-01022-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
AbstractAlthough the administration of fluid is the first treatment considered in almost all cases of circulatory failure, this therapeutic option poses two essential problems: the increase in cardiac output induced by a bolus of fluid is inconstant, and the deleterious effects of fluid overload are now clearly demonstrated. This is why many tests and indices have been developed to detect preload dependence and predict fluid responsiveness. In this review, we take stock of the data published in the field over the past three years. Regarding the passive leg raising test, we detail the different stroke volume surrogates that have recently been described to measure its effects using minimally invasive and easily accessible methods. We review the limits of the test, especially in patients with intra-abdominal hypertension. Regarding the end-expiratory occlusion test, we also present recent investigations that have sought to measure its effects without an invasive measurement of cardiac output. Although the limits of interpretation of the respiratory variation of pulse pressure and of the diameter of the vena cava during mechanical ventilation are now well known, several recent studies have shown how changes in pulse pressure variation itself during other tests reflect simultaneous changes in cardiac output, allowing these tests to be carried out without its direct measurement. This is particularly the case during the tidal volume challenge, a relatively recent test whose reliability is increasingly well established. The mini-fluid challenge has the advantage of being easy to perform, but it requires direct measurement of cardiac output, like the classic fluid challenge. Initially described with echocardiography, recent studies have investigated other means of judging its effects. We highlight the problem of their precision, which is necessary to evidence small changes in cardiac output. Finally, we point out other tests that have appeared more recently, such as the Trendelenburg manoeuvre, a potentially interesting alternative for patients in the prone position.
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14
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Şentürk M, Bingül ES, Turhan Ö. Should fluid management in thoracic surgery be goal directed? Curr Opin Anaesthesiol 2022; 35:89-95. [PMID: 34889800 DOI: 10.1097/aco.0000000000001083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed? RECENT FINDINGS 'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks. SUMMARY Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.
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Affiliation(s)
- Mert Şentürk
- Istanbul University, Istanbul Medical Faculty, Department of Anesthesiology and Reanimation, Istanbul, Turkey
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15
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Enevoldsen J, Scheeren TWL, Berg JM, Vistisen ST. Existing fluid responsiveness studies using the mini-fluid challenge may be misleading: Methodological considerations and simulations. Acta Anaesthesiol Scand 2022; 66:17-24. [PMID: 34338314 DOI: 10.1111/aas.13965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/02/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The mini-fluid challenge (MFC) is a clinical concept of predicting fluid responsiveness by rapidly infusing a small amount of intravenous fluids, typically 100 ml, and systematically assessing its haemodynamic effect. The MFC method is meant to predict if a patient will respond to a subsequent, larger fluid challenge, typically another 400 ml, with a significant increase in stroke volume. METHODS We critically evaluated the general methodology of MFC studies, with statistical considerations, secondary analysis of an existing study and simulations. RESULTS Secondary analysis of an existing study showed that the MFC could predict the total fluid response (MFC + 400 ml) with an area under the receiver operator characteristic curve (AUROC) of 0.92, but that the prediction was worse than random for the response to the remaining 400 ml (AUROC = 0.33). In a null simulation with no response to both the MFC and the subsequent fluid challenge, the commonly used analysis could predict fluid responsiveness with an AUROC of 0.73. CONCLUSION Many existing MFC studies are likely overestimating the classification accuracy of the MFC. This should be considered before adopting the MFC into clinical practice. A better study design includes a second, independent measurement of stroke volume after the MFC. This measurement serves as reference for the response to the subsequent fluid challenge.
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Affiliation(s)
- Johannes Enevoldsen
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Thomas W. L. Scheeren
- Department of Anesthesiology University of GroningenUniversity Medical Centre Groningen Groningen The Netherlands
| | - Jonas M. Berg
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
| | - Simon T. Vistisen
- Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Anaesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
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16
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Messina A, Sotgiu G, Saderi L, Cammarota G, Capuano L, Colombo D, Bennett V, Payen D, DE Backer D, Navalesi P, Cecconi M. Does the definition of fluid responsiveness affect passive leg raising reliability? A methodological ancillary analysis from a multicentric study. Minerva Anestesiol 2021; 88:272-281. [PMID: 34709017 DOI: 10.23736/s0375-9393.21.15944-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluid challenge (FC) is often adopted as gold standard used to assess the reliability of passive leg raising (PLR) in predicting fluid responsiveness in the intensive care unit (ICU). This study aimed to address the impact of the different definitions and timings used to assess FC response on PLR reliability. METHODS Ancillary study from a data set of a multicentric study in 85 ICU patient with acute circulatory failure who received a FC (500 mL of crystalloids in 10 minutes) within the first 48h of ICU admission, preceded by PLR in 30 patients. FC response was assessed considering the changes in cardiac index (CI) and stroke volume index (SVI) using different thresholds and at different timepoints. RESULTS The definitions of fluid responsiveness by using CI or SVI with a 15% increase after 10 minutes were associated to the best performances of the PLR [AUC (95% CI) 0.94 (0.83-1.01); vs. AUC (95% CI) 0.95 (0.87-1.02)]. The sensitivity of the PLR by adopting the CI or the SVI as reference variable ranged from 54.1% to 67.6% and from 81.5% to 100.0%; the specificity from 65.9% to 78.0% and from 79.5% to 100.0%, respectively. Considering all the subgroups, the number of responders 10 minutes after FC administration was higher as compared to 15 and 30 minutes (140 vs. 120 and 125, respectively, p < 0.05). CONCLUSIONS The reliability of the PLR test to predict fluid responsiveness depends on the definition of FC adopted. The timing of FC outcome assessment affected the overall fluid responsiveness.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy -
| | - Giovanni Sotgiu
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Laura Saderi
- Research, Medical Education and Professional Development Unit, AOU Sassari, Clinical Epidemiology and Medical Statistics Unit, Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | | | - Lorenzo Capuano
- Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | - Davide Colombo
- Anesthesia and Intensive Care Medicine, Ospedale Ss. Trinità, Borgomanero, Novara, Italy
| | - Victoria Bennett
- Department of Intensive Care Medicine, St George's University Hospital NHS Foundation Trust, London, UK
| | | | - Daniel DE Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Paolo Navalesi
- Section of Anesthesiology and Intensive Care, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
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