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Campos NB, de Lima LB, Ferraz IDS, Nogueira RJN, Brandão MB, de Souza TH. Accuracy of Respiratory Variation in Inferior Vena Cava Diameter to Predict Fluid Responsiveness in Children Under Mechanical Ventilation. Pediatr Cardiol 2024; 45:1326-1333. [PMID: 36759350 DOI: 10.1007/s00246-023-03115-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
Proper assessment of fluid responsiveness using accurate predictors is crucial to guide fluid therapy and avoid the serious adverse effects of fluid overload. The main objective of this study was to investigate the accuracy of respiratory variations in inferior vena cava diameter (∆IVC) to predict fluid responsiveness in mechanically ventilated children. This prospective single-center study included 32 children (median age and weight of 17 months and 10 kg, respectively) who received a fluid infusion of 10 ml kg-1 of crystalloid solutions over 10 min. ∆IVC and respiratory variation in aortic blood flow peak velocity (∆Vpeak) were determined over one controlled respiratory cycle before and after fluid loading. Thirteen (41%) participants were fluid-responders. ∆IVC, ∆Vpeak, stroke volume index, and cardiac index were found to be predictors of fluid responsiveness. However, the area under the ROC curve of ∆IVC was smaller when compared to ∆Vpeak (0.709 vs. 0.935, p < 0.012). The best cut-off values were 7.7% for ∆IVC (sensitivity, 69.2%; specificity 78.9%, positive predictive value, 69.2%; and negative predictive value, 78.9%) and 18.2% for ∆Vpeak (sensitivity, 84.6%; specificity, 89.5%; positive predictive value, 84.6%; negative predictive value, 89.5%). Changes in stroke volume were positively correlated with ∆IVC (ρ = 0.566, p < 0.001) and ∆Vpeak (ρ = 0.603, p < 0.001). A significant correlation was also found between changes in MAP and ∆Vpeak (ρ = 0.382; p = 0.031), but the same was not observed with ∆IVC (ρ = 0.011; p = 0.951). In conclusion, ∆IVC was found to have a moderate accuracy in predicting fluid responsiveness in mechanically ventilated children and is an inferior predictor when compared to ∆Vpeak.
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Affiliation(s)
- Nathalia Barros Campos
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil
| | - Lícia Bertanha de Lima
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil
| | - Isabel de Siqueira Ferraz
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil
| | - Roberto J N Nogueira
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil
- Department of Pediatrics, School of Medicine, São Leopoldo Mandic, Campinas, SP, Brazil
| | - Marcelo B Brandão
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil
| | - Tiago H de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 126, Tessália Vieira de Camargo Street, Campinas, SP, 13083-887, Brazil.
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Gorga SM, Selewski DT, Goldstein SL, Menon S. An update on the role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2024; 39:2033-2048. [PMID: 37861865 DOI: 10.1007/s00467-023-06161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 10/21/2023]
Abstract
Over the past two decades, our understanding of the impact of acute kidney injury, disorders of fluid balance, and their interplay have increased significantly. In recent years, the epidemiology and impact of fluid balance, including the pathologic state of fluid overload on outcomes has been studied extensively across multiple pediatric and neonatal populations. A detailed understating of fluid balance has become increasingly important as it is recognized as a target for intervention to continue to work to improve outcomes in these populations. In this review, we provide an update on the epidemiology and outcomes associated with fluid balance disorders and the development of fluid overload in children with acute kidney injury (AKI). This will include a detailed review of consensus definitions of fluid balance, fluid overload, and the methodologies to define them, impact of fluid balance on the diagnosis of AKI and the concept of fluid corrected serum creatinine. This review will also provide detailed descriptions of future directions and the changing paradigms around fluid balance and AKI in critical care nephrology, including the incorporation of the sequential utilization of risk stratification, novel biomarkers, and functional kidney tests (furosemide stress test) into research and ultimately clinical care. Finally, the review will conclude with novel methods currently under study to assess fluid balance and distribution (point of care ultrasound and bioimpedance).
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Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, 125 Doughty St., MSC 608 Ste 690, Charleston, SC, 29425, USA.
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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3
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Sampson EG, Butt AL, Tanaka KA, Gomes MW. Does standardization of fluid management reduce blood transfusion in scoliosis surgery?-Comments on Pardessus et al. Paediatr Anaesth 2024; 34:187-188. [PMID: 37916747 DOI: 10.1111/pan.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Emma G Sampson
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Marcos W Gomes
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Dai S, Wang C, Tao X, Shen J, Xu L. Predicting fluid responsiveness in spontaneously breathing parturients undergoing caesarean section via carotid artery blood flow and velocity time integral measured by carotid ultrasound: a prospective cohort study. BMC Pregnancy Childbirth 2024; 24:60. [PMID: 38216901 PMCID: PMC10785346 DOI: 10.1186/s12884-024-06246-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: 06/05/2023] [Accepted: 01/01/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Present evidence suggests that the Doppler ultrasonographic indices, such as carotid artery blood flow (CABF) and velocity time integral (VTI), had the ability to predict fluid responsiveness in non-obstetric patients. The purpose of this study was to assess their capacity to predict fluid responsiveness in spontaneous breathing parturients undergoing caesarean section and to determine the effect of detecting and management of hypovolemia (fluid responsiveness) on the incidence of hypotension after anaesthesia. METHODS A total of 72 full term singleton parturients undergoing elective caesarean section were enrolled in this study. CABF, VTI, and hemodynamic parameters were recorded before and after fluid challenge and assessed by carotid artery ultrasonography. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. RESULTS Thirty-one (43%) patients were fluid responders. The area under the ROC curve to predict fluid responsiveness for CABF and VTI were 0.803 (95% CI, 0.701-0.905) and 0.821 (95% CI, 0.720-0.922). The optimal cut-off values of CABF and VTI for fluid responsiveness was 175.9 ml/min (sensitivity of 74.0%; specificity of 78.0%) and 8.7 cm/s (sensitivity of 67.0%; specificity of 90.0%). The grey zone for CABF and VTI were 114.2-175.9 ml/min and 6.8-8.7 cm/s. The incidence of hypotension after the combined spinal-epidural anaesthesia (CSEA) was significantly higher in the Responders group 25.8% (8/31) than in the Non-Responders group 17.1(7/41) (P < 0.001). The total incidence of hypotension after CSEA of the two groups was 20.8% (15/72). CONCLUSIONS Ultrasound evaluation of CABF and VTI seem to be the feasible parameters to predict fluid responsiveness in parturients undergoing elective caesarean section and detecting and management of hypovolemia (fluid responsiveness) could significantly decrease incidence of hypotension after anaesthesia. TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry (ChiCTR) ( www.chictr.org ), registration number was ChiCTR1900022327 (The website link: https://www.chictr.org.cn/showproj.html?proj=37271 ) and the date of trial registration was in April 5, 2019. This study was performed in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Women's Hospital, Zhejiang University School of Medicine (20,180,120).
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Affiliation(s)
- Shaobing Dai
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chun Wang
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xia Tao
- Department of Ultrasound, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jianjun Shen
- Department of Anaesthesiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Lili Xu
- Department of Anaesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, Zhejiang Province, China.
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Walker SB, Winters JM, Schauer JM, Murphy P, Fawcett A, Sanchez-Pinto LN. Performance of Tools and Measures to Predict Fluid Responsiveness in Pediatric Shock and Critical Illness: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2024; 25:24-36. [PMID: 37462437 PMCID: PMC10794582 DOI: 10.1097/pcc.0000000000003320] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES In this systematic review and meta-analysis we asked: Do predictors of fluid responsiveness in children perform comparably: 1) in the PICU as in non-PICU settings? 2) in shock states compared with nonshock states? Additionally, 3) is there an association between preload responsiveness and clinical response? DATA SOURCES Ovid Medline, PubMed, and Embase databases were searched from inception through May 2022. STUDY SELECTION Included studies reported physiological response to IV fluid administration in humans less than 18 years. Only studies reporting an area under the receiver operating characteristic curve (AUROC) were included for descriptive analysis. Only studies for which a se could be estimated were included for meta-analysis. DATA EXTRACTION Title, abstract, full text screening, and extraction were completed by two authors (S.B.W., J.M.W.). Variables extracted included predictors ("tools") and outcome measures ("reference tests") of fluid responsiveness, demographic, and clinical variables. DATA SYNTHESIS We identified 62 articles containing 204 AUROCs for 55 tools, primarily describing mechanically ventilated children in an operating room or PICU. Meta-analysis across all tools showed poor predictive performance (AUROC, 0.66; 95% CI, 0.63-0.69), although individual performance varied greatly (range, 0.49-0.87). After controlling for PICU setting and shock state, PICU setting was associated with decreased predictive performance (coefficient, -0.56; p = 0.0007), while shock state was associated with increased performance (0.54; p = 0.0006). Effect of PICU setting and shock state on each tool was not statistically significant but analysis was limited by sample size. The association between preload responsiveness and clinical response was rarely studied but results did not suggest an association. Ultrasound measurements were prone to inherent test review and incorporation biases. CONCLUSIONS We suggest three opportunities for further research in fluid responsiveness in children: 1) assessing predictive performance of tools during resuscitation in shock states; 2) separating predictive tool from reference test when using ultrasound techniques; and 3) targeting decreasing time in a shock state, rather than just increase in preload.
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Affiliation(s)
- Sarah B. Walker
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | - Jacob M. Schauer
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Peggy Murphy
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Andrea Fawcett
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
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Sehgal A, Gauli B. Changes in respiratory mechanics in response to crystalloid infusions in extremely premature infants. Am J Physiol Lung Cell Mol Physiol 2023; 325:L819-L825. [PMID: 37933458 DOI: 10.1152/ajplung.00179.2023] [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: 06/08/2023] [Revised: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023] Open
Abstract
Extremely premature infants are at a higher risk of developing respiratory distress syndrome and circulatory impairments in the first few weeks of life. Administration of normal saline boluses to manage hypotension is a common practice in preterm infants. As a crystalloid, a substantial proportion might leak into the interstitium; most consequently the lungs in the preterm cohorts, putatively affecting ventilation. We downloaded and analyzed ventilator mechanics data in infants managed by conventional mechanical ventilation and administered normal saline bolus for clinical reasons. Data were downloaded for 30 min prebolus, 60 min during the bolus followed by 30 min postbolus. Sixteen infants (mean gestational age 25.2 ± 1 wk and birth weight 620 ± 60 g) were administered 10 mL/kg normal saline over 60 min. The most common clinical indication for saline was hypotension. No significant increase was noted in mean blood pressure after the saline bolus. A significant reduction in pulmonary compliance (mL/cmH2O/kg) was noted (0.43 ± 0.07 vs. 0.38 ± 0.07 vs. 0.33 ± 0.07, P = 0.003, ANOVA). This was accompanied by an elevation in the required peak inspiratory pressure to deliver set volume-guarantee (19 ± 2 vs. 22 ± 2 vs. 22 ± 3 mmHg, P < 0.0001, ANOVA), resulting in a higher respiratory severity score. Normal saline infusion therapy was associated with adverse pulmonary mechanics. Relevant pathophysiologic mechanisms might include translocation of fluid across pulmonary capillaries affected by low vascular tone and heightened permeability in extremes of prematurity, back-pressure effects from raised left atrial volume due to immature left-ventricular myocardium; complemented by the effect of cytokine release from positive pressure ventilation.NEW & NOTEWORTHY Administration of saline boluses is common in premature infants although hypovolemia is an uncommon underlying cause of hypotension. This crystalloid can redistribute into pulmonary interstitial space. In the presence of an immature myocardium and diastolic dysfunction, excess fluid can also be "edemagenic." This study on extremely premature infants (25 wk gestation) noted adverse influence on respiratory physiology after saline infusion. Clinicians need to choose judiciously and reconsider routine use of saline boluses in premature infants.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Bishal Gauli
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
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Banothu KK, Sankar J, Pathak M, Kandasamy D, Gupta P, Kabra SK, Lodha R. Utility of Inferior Vena Cava Distensibility and Respiratory Variation in Peak Aortic Blood Flow Velocity to Predict Fluid Responsiveness in Children with Shock. Indian J Pediatr 2023; 90:1077-1082. [PMID: 37277686 DOI: 10.1007/s12098-023-04585-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/17/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the sensitivity and specificity of inferior vena cava (IVC) distensibility index (∆IVC) and respiratory variation in peak aortic blood flow velocity (∆Vpeak) to predict fluid responsiveness in ventilated children with shock and to find out the best cut-off values for predicting fluid responsiveness. METHODS In this prospective observational study, conducted in a pediatric ICU from January 2019 through May 2020, consecutive children aged 2 mo to 17 y with shock requiring fluid bolus were included. ∆IVC and ∆Vpeak were measured before and immediately after 10 ml/kg fluid bolus administration. ∆IVC and ∆Vpeak were compared between responders and non-responders, defined by a change in stroke volume index (SVI) of ≥10%. RESULTS Thirty-seven ventilated children [26 (70.4%) boys] with median age of 60 (36, 108) mo were included. The median (IQR) ∆IVC was 21.7% (14.3, 30.9) and the median (IQR) ΔVpeak was 11.3% (7.2, 15.2). Twenty-three (62%) children were fluid responsive. The median (IQR) ∆IVC was higher in responders compared to non-responders [26% (16.9, 36.5) vs. 17.2% (8.4, 21.9); p = 0.018] and mean (SD) ΔVpeak was higher in responders [13.9% (6.1) vs. 8.4% (3.9), p = 0.004]. The prediction of fluid responsiveness with ΔIVC [ROC curve area 0.73 (0.56-0.9), p = 0.01] and ΔVpeak [ROC curve area 0.78 (0.63-0.94), p = 0.002] was similar. The best cut-off of ∆IVC to predict fluid responsiveness was 23% (sensitivity, 60.8%; specificity, 85.7%) and ΔVpeak was 11.3% (sensitivity, 74%; specificity, 86%). CONCLUSIONS In this study, authors found that ∆IVC and ΔVpeak were good predictors of fluid responsiveness in ventilated children with shock.
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Affiliation(s)
- Kiran Kumar Banothu
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India.
| | - Mona Pathak
- Department of Research & Development, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | | | - Priyanka Gupta
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil Kumar Kabra
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, 3rd floor, Teaching Block, All India Institute of Medical Sciences, New Delhi, India
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Eaddy N, Watene C. Perioperative management of fluids and electrolytes in children. BJA Educ 2023; 23:273-278. [PMID: 37389277 PMCID: PMC10300462 DOI: 10.1016/j.bjae.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 03/28/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- N. Eaddy
- Waikato Hospital, Hamilton, New Zealand
| | - C. Watene
- Waikato Hospital, Hamilton, New Zealand
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Inferior Vena Cava Ultrasonography for Volume Status Evaluation: An Intriguing Promise Never Fulfilled. J Clin Med 2023; 12:jcm12062217. [PMID: 36983218 PMCID: PMC10053997 DOI: 10.3390/jcm12062217] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
The correct determination of volume status is a fundamental component of clinical evaluation as both hypovolaemia (with hypoperfusion) and hypervolaemia (with fluid overload) increase morbidity and mortality in critically ill patients. As inferior vena cava (IVC) accounts for two-thirds of systemic venous return, it has been proposed as a marker of volaemic status by indirect assessment of central venous pressure or fluid responsiveness. Although ultrasonographic evaluation of IVC is relatively easy to perform, correct interpretation of the results may not be that simple and multiple pitfalls hamper its wider application in the clinical setting. In the present review, the basic elements of the pathophysiology of IVC behaviour, potential applications and limitations of its evaluation are discussed.
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Carioca FDL, de Souza FM, de Souza TB, Rubio AJ, Brandão MB, Nogueira RJN, de Souza TH. Point-of-care ultrasonography to predict fluid responsiveness in children: A systematic review and meta-analysis. Paediatr Anaesth 2023; 33:24-37. [PMID: 36222022 DOI: 10.1111/pan.14574] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/29/2022] [Accepted: 10/09/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Point-of-care ultrasonography (POCUS) is proposed as a valuable method for hemodynamic monitoring and several ultrasound-based predictors of fluid responsiveness have been studied. The main objective of this study was to assess the accuracy of these predictors in children. METHODS PubMed, Embase, Scopus, ClinicalTrials.gov, and Cochrane Library databases were searched for relevant publications through July 2022. Pediatric studies reporting accuracy estimates of ultrasonographic predictors of fluid responsiveness were included since they had used a standard definition of fluid responsiveness and had performed an adequate fluid challenge. RESULTS Twenty-three studies involving 1028 fluid boluses were included, and 12 predictors were identified. A positive response to fluid infusion was observed in 59.7% of cases. The vast majority of participants were mechanically ventilated (93.4%). The respiratory variation in aortic blood flow peak velocity (∆Vpeak) was the most studied predictor, followed by the respiratory variation in inferior vena cava diameter (∆IVC). The pooled sensitivity and specificity of ∆Vpeak were 0.84 (95% CI, 0.76-0.90) and 0.82 (95% CI, 0.75-0.87), respectively, and the area under the summary receiver operating characteristic curve (AUSROC) was 0.89 (95% CI, 0.86-0.92). The ∆IVC presented a pooled sensitivity and specificity of 0.79 (95% CI, 0.62-0.90) and 0.70 (95% CI, 0.51-0.84), respectively, and an AUSROC of 0.81 (95% CI, 0.78-0.85). Significant heterogeneity in accuracy estimates across studies was observed. CONCLUSIONS POCUS has the potential to accurately predict fluid responsiveness in children. However, only ∆Vpeak was found to be a reliable predictor. There is a lack of evidence supporting the use of POCUS to guide fluid therapy in spontaneously breathing children.
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Affiliation(s)
- Fernando de Lima Carioca
- Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Fabiana Mendes de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Thalita Belato de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Aline Junqueira Rubio
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Marcelo Barciela Brandão
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Roberto José Negrão Nogueira
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tiago Henrique de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, Brazil
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Loomba RS, Villarreal EG, Farias JS, Flores S, Bronicki RA. Fluid bolus administration in children, who responds and how? A systematic review and meta-analysis. Paediatr Anaesth 2022; 32:993-999. [PMID: 35736026 DOI: 10.1111/pan.14512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fluid boluses are frequently utilized in children. Despite their frequency of use, there is little objective data regarding the utility of fluid boluses, who they benefit the most, and what the effects are. AIMS This study aimed to conduct pooled analyses to identify those who may be more likely to respond to fluid boluses as well as characterize clinical changes associated with fluid boluses. METHODS A systematic review of the literature and meta-analysis was conducted to identify pediatric studies investigating the response to fluid boluses and clinical changes associated with fluid boluses. RESULTS A total of 15 studies with 637 patients were included in the final analyses with a mean age of 650 days ± 821.01 (95% CI 586 to 714) and a mean weight of 10.5 kg ± 7.19 (95% CI 9.94 to 11.1). The mean bolus volume was 12.14 ml/kg ± 4.09 (95% CI 11.8 to 12.5) given over a mean of 19.55 min ± 10.16 (95% CI 18.8 to 20.3). The following baseline characteristics were associated with increased likelihood of response [represented in mean difference (95% CI)]: greater age [207.2 days (140.8 to 273.2)], lower cardiac index [-0.5 ml/min/m2 (-0.9 to -0.3)], and lower stroke volume [-5.1 ml/m2 (-7.9 to -2.3)]. The following clinical parameters significantly changed after a fluid bolus: decreased HR [-5.6 bpm (-9.8 to -1.3)], increased systolic blood pressure [7.7 mmHg (1.0 to 14.4)], increased mean arterial blood pressure [5.5 mmHg (3.1 to 7.8)], increased cardiac index [0.3 ml/min/m2 (0.1 to 0.6)], increased stroke volume [4.3 ml/m2 (3.5 to 5.2)], increased central venous pressure [2.2 mmHg (1.1 to 3.3)], and increased systemic vascular resistance [2.1 woods units/m2 (0.1 to 4.2)]. CONCLUSION Fluid blouses increase arterial blood pressure or cardiac output by 10% in approximately 56% of pediatric patients. Fluid blouses lead to significant decrease in HR and significant increases in cardiac output, stroke volume, and systemic vascular resistance. Limited published data are available on the effects of fluid blouses on systemic oxygen delivery.
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Affiliation(s)
- Rohit S Loomba
- Cardiology, Advocate Children's Hospital, Chicago, Illinois, USA.,Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, Illinois, USA
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, Mexico
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, Mexico
| | - Saul Flores
- Critical Care and Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Ronald A Bronicki
- Critical Care and Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
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12
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Beels M, Stevens S, Saldien V. Perioperative fluid management in children: an updated review. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Perioperative fluid management in children has been a major topic for debate.
Objectives: Our aim is to review the current evidence on perioperative fluid management in children including: type of fluid, administration rates, preoperative fluid intake and monitoring techniques.
Design: Narrative review.
Method: Following the PRISMA-S guidelines we performed a search (2010-March 2022) in databases Medline (through PubMed) and Cochrane Library. 4297 citations were found and screened by two independent researchers. After screening, 64 articles were withheld for our review.
Results: The perioperative administration of isotonic fluids is safer than hypotonic solutions, concerning the development of hyponatremia. A balanced isotonic solution with 1-2,5% glucose should be used as perioperative maintenance IV fluid in children (1 month to 18 years). Colloids can be used in children when inadequate effect in volume correction is achieved with crystalloids. The preferred synthetic colloid for children is a third generation HES in a balanced solution. To date, most clinicians use the “4-2-1 rule” for calculating fluid rate. This may not be the optimal fluid rate, as little research has been done. Preoperative fasting for clear fluids should be limited to 1 hour, children should even be encouraged to drink up until 1 hour before induction. Respiratory variation of aortic blood flow peak velocity (ΔVpeak) with echocardiography is currently the most reliable technique for evaluating fluid responsiveness in children.
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Tripathi S, Osman T, Hafzalah M, Lee K, Whalen DA. Correlation of Ultrasound-Based Hydration Assessment Measures with CVP and Clinical Hydration Status among Children Admitted to the PICU: A Prospective Observational Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1746430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Purpose This article assesses the correlation of respiratory variation in inferior vena cava (IVC) with central venous pressure (CVP) in children. Secondary objective was to evaluate IVC variability with clinical hydration status.
Methods IVC variability was assessed at the subcostal (SC) and right lateral (RL) region, and collapsibility index (CI) (spontaneously breathing) and distensibility index (DI) (positive pressure) and IVC/aortic ratio were calculated. Partial correlations were calculated between CI/DI with CVP adjusting for body mass index and age. Sensitivity of CI and DI to predict clinical dehydration was calculated using receiver operating characteristic curves.
Results A total of 145 ultrasounds were performed on 72 patients (41% positive pressure). Only RL CI in spontaneously breathing patients strongly correlated with CVP (r = –0.65, p < 0.001). A moderate correlation was observed between CI and DI from SC and RL regions (r's = 0.38 and 0.47). Among spontaneously breathing patients, a significant difference was observed in the SC CI based on hydration status. For patients on positive pressure, IVC/aortic ratio had a significant difference. SC CI had the highest area under the curve (0.82) to detect dehydration with 80% sensitivity/87% specificity for a cutoff of 40%.
Conclusion SC CI is the most reliable measure to assess the hydration status of spontaneously breathing children, while the IVC/aortic ratio performs well for patients under positive pressure. RL CI has strong negative correlation with CVP in spontaneously breathing patients.
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Affiliation(s)
- Sandeep Tripathi
- Department of Pediatrics, University of Illinois College of Medicine/OSF HealthCare, Children's Hospital of Illinois, United States
| | - Tara Osman
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, United States
| | - Mina Hafzalah
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Kejin Lee
- Department of Research Services, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
| | - Drew A. Whalen
- Department of Clinical Research, OSF St Francis Medical Center, Peoria, Illinois, United States
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Yamaguchi Y, Moharir A, Kim SS, Wakimoto M, Burrier C, Shafy SZ, Hakim M, Tobias JD. Ultrasound assessment of the inferior vena cava in children: A comparison of sub-xiphoid and right lateral coronal views. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:575-580. [PMID: 34596898 DOI: 10.1002/jcu.23061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/09/2021] [Accepted: 08/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The inferior vena cava collapsibility index (IVCCI) has been used to assess the respiratory variation of the inferior vena cava (IVC) diameter and hence intravascular volume. The sub-xiphoid view (SXV) is the standard view to evaluate the IVC. The right lateral transabdominal view (RLV) has been shown in adults to be an alternative view to evaluate the IVC when the SXV is not feasible. The aim of the study was to compare IVC dimensions from these two views and thus determine whether the RLV view can be used instead of the SXV in pediatric patients. METHODS We conducted a single-center prospective observational crossover study. Study subjects were ASA physical status 1-2 children, 1-12 years of age scheduled for elective surgery under general anesthesia. Anesthesia was maintained by mask with spontaneous ventilation with end-tidal sevoflurane at 2%-5% after the induction of anesthesia. IVCCI was measured using M-mode in both the SXV and RLV. RESULTS The study cohort included 50 children with a mean age of 5.1 years. The median value for the IVCCI-sx was 0.45 (IQR: 0.28-0.70) while the IVCCI-rl was 0.30 (0.19-0.5). The mean difference between the two groups was 0.12 (95% CI: 0.177-0.066, p < .001, two-tailed paired t-test). Spearman's rank correlation coefficient was 0.66. The univariate linear regression model was IVCCIsx = 0.21 + 0.77 × IVCCIrl. CONCLUSIONS IVCCIrl was lower than IVCCIsx. IVCCI measured from the right lateral view tended to overestimate the patient's fluid-responsiveness and therefore these two values are not interchangeable.
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Affiliation(s)
- Yoshikazu Yamaguchi
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alok Moharir
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mayuko Wakimoto
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Candice Burrier
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shabana Z Shafy
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mohammed Hakim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Yenjabog P, Kanchongkittiphon W, Chutipongtanate S, Lertbunrian R, Ungprasert P. Dynamic parameters for fluid responsiveness in mechanically ventilated children: A systematic review. Front Pediatr 2022; 10:1010600. [PMID: 36353262 PMCID: PMC9638161 DOI: 10.3389/fped.2022.1010600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/28/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Fluid administration is the initial step of treatment of unstable pediatric patients. Evaluation of fluid responsiveness is crucial in mechanically ventilated children to avoid fluid overload, which increases mortality. We aim to review and compare the diagnostic performance of dynamically hemodynamic parameters for predicting fluid responsiveness in mechanically ventilated children. DESIGN A systematic review was performed using four electronic databases, including PubMed, EMBASE, Scopus, and Central, for published articles from 1 January 2010 to 31 December 2020. Studies were included if they described diagnostic performance of dynamic parameters after fluid challenge was performed in mechanically ventilated children. SETTINGS Pediatric intensive and cardiac intensive care unit, and operative room. PATIENTS Children aged 1 month to 18 years old who were under mechanical ventilation and required an intravenous fluid challenge. MEASUREMENTS AND MAIN RESULTS Twenty-seven studies were included in the systematic review, which included 1,005 participants and 1,138 fluid challenges. Respiratory variation in aortic peak velocity was reliable among dynamic parameters for predicting fluid responsiveness in mechanically ventilated children. All studies of respiratory variation in aortic peak velocity showed that the area under the receiver operating characteristic curve ranged from 0.71 to 1.00, and the cutoff value for determining fluid responsiveness ranged from 7% to 20%. Dynamic parameters based on arterial blood pressure (pulse pressure variation and stroke volume variation) were also used in children undergoing congenital heart surgery. The plethysmography variability index was used in children undergoing neurological and general surgery, including the pediatric intensive care patients. CONCLUSIONS The respiratory variation in aortic peak velocity exhibited a promising diagnostic performance across all populations in predicting fluid responsiveness in mechanically ventilated children. High sensitivity is advantageous in non-cardiac surgical patients and the pediatric intensive care unit because early fluid resuscitation improves survival in these patients. Furthermore, high specificity is beneficial in congenital heart surgery because fluid overload is particularly detrimental in this group of patients. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206400.
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Affiliation(s)
- Patcha Yenjabog
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wacharoot Kanchongkittiphon
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Chutipongtanate
- Pediatric Translational Research Unit, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Clinical Epidemiology and Biostatistics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
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Voet M, Cornelissen EAM, van der Jagt MFP, Lemson J, Malagon I. Perioperative anesthesia care for the pediatric patient undergoing a kidney transplantation: An educational review. Paediatr Anaesth 2021; 31:1150-1160. [PMID: 34379843 PMCID: PMC9292670 DOI: 10.1111/pan.14271] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 02/06/2023]
Abstract
Living-donor kidney transplantation is the first choice therapy for children with end-stage renal disease and shows good long-term outcome. Etiology of renal failure, co-morbidities, and hemodynamic effects, due to donor-recipient size mismatch, differs significantly from those in adult patients. Despite the complexities related to both patient and surgery, there is a lack of evidence-based anesthesia guidelines for pediatric kidney transplantation. This educational review summarizes the pathophysiological changes to consider and suggests recommendations for perioperative anesthesia care, based on recent research papers.
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Affiliation(s)
- Marieke Voet
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands
| | - Elisabeth A. M. Cornelissen
- Department of Pediatric NephrologyRadboud University Medical CenterAmalia Children’s HospitalNijmegenthe Netherlands
| | - Michel F. P. van der Jagt
- Department of Vascular and Transplant SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Joris Lemson
- Department of Intensive Care MedicineRadboud University Medical CenterNijmegenthe Netherlands
| | - Ignacio Malagon
- Department of Anesthesiology, Pain and Palliative MedicineRadboud University Medical CenterNijmegenthe Netherlands
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Lee EP, Wu HP, Chan OW, Lin JJ, Hsia SH. Hemodynamic monitoring and management of pediatric septic shock. Biomed J 2021; 45:63-73. [PMID: 34653683 PMCID: PMC9133259 DOI: 10.1016/j.bj.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 12/14/2022] Open
Abstract
Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.
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Affiliation(s)
- En-Pei Lee
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine, China Medical University Children Hospital, Taichung, Taiwan; Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Oi-Wa Chan
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, and Pediatric Sepsis Study Group, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Guishan District, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Abstract
OBJECTIVES To describe the hemodynamic response to fluid boluses for hypotension in children in a cardiac ICU. DESIGN A prospective, observational study. SETTING Single-centered cardiac ICU. PATIENTS Children in a cardiac ICU with hypotension. INTERVENTIONS Clinician prescribed fluid bolus. MEASUREMENTS AND MAIN RESULTS Sixty-four fluid boluses were administered to 52 children. Fluid composition was 4% albumin in 36/64 (56%), 0.9% saline in 18/64 (28%), and cardiopulmonary bypass pump blood in 10/64 (16%). The median volume and duration were 5.0 mL/kg (interquartile range, 4.8-5.4) and 8 minutes (interquartile range, 4-19), respectively. Hypovolemia/low filling pressures was the most common additional indication (25/102 [25%]). Mean arterial pressure response, defined as a 10% increase from baseline, occurred in 42/64 (66%) of all fluid boluses at a median time of 6 minutes (interquartile range, 4-11). Mean arterial pressure responders had a median peak increase in the mean arterial pressure of 15 mm Hg (43 mm Hg [interquartile range, 29-50 mm Hg] to 58 mm Hg [interquartile range, 49-65 mm Hg]) at 17 minutes (interquartile range, 14-24 min) compared with 4 mm Hg (48 mm Hg [interquartile range, 40-51 mm Hg] to 52 mm Hg [interquartile range, 45-56 mm Hg]) at 10 minutes (interquartile range, 3-18 min) in nonresponders. Dissipation of mean arterial pressure response, when defined as a subsequent decrement in mean arterial pressure below 10%, 5%, and 2% increases from baseline, occurred in 28/42 (67%), 18/42 (43%), and 13/42 (31%) of mean arterial pressure responders, respectively. Cardiopulmonary bypass pump blood was strongly associated with peak change in mean arterial pressure from baseline (coefficient 11.0 [95% CI, 4.3-17.7]; p = 0.02). Fifty out of 64 (78%) were receiving a vasoactive agent. However, change in vasoactive inotrope score was not associated with change in mean arterial pressure (coefficient 2.3 [95% CI, -2.5 to -7.2]; p = 0.35). Timing from admission, nor fluid bolus duration, influenced mean arterial pressure response. CONCLUSIONS In children with hypotension in a cardiac ICU, the median dose and duration of fluid boluses were 5 mL/kg and 8 minutes. Peak response occurred shortly following administration and commonly returned to baseline.
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Fremuth J, Kobr J, Sasek L, Pizingerova K, Zamboryova J, Sykora J. Ultrasound cardiac output monitoring in mechanically ventilated children. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:428-434. [PMID: 33087939 DOI: 10.5507/bp.2020.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To non-invasively identify the hemodynamic changes in critically ill children during the first 48 h following initiation of mechanical ventilation by the ultrasound cardiac output monitor (USCOM) method and compare the data in children with pulmonary and non-pulmonary pathology. MATERIALS AND METHODS This was a prospective observational study to evaluate the influence of mechanical ventilation on hemodynamic changes and to describe hemodynamic profiles of mechanically ventilated children. A total of 56 children with respiratory failure were included in the present study. Ventilated patients are divided into two groups. Group A (n=36) includes patients with pulmonary pathology. Group B (n=20) consists of patients with extra pulmonary etiology of respiratory failure. Hemodynamic parameters (cardiac index and systemic vascular resistance index) were evaluated using ultrasound cardiac output monitoring (USCOM 1A) immediately following initiation of mechanical ventilation and again at 6, 12, and 48 h. Pharmacological circulatory support (inotropes, vasopressors, levosimendan and phosphodiesterase III inhibitors) was individually and continuously modified based on real-time hemodynamic parameters and optimal fluid balance. RESULTS No significant differences in hemodynamic profiles were found between Group A and Group B. CONCLUSION The protective strategy of mechanical ventilation was not associated with significant differences in hemodynamic profiles between children ventilated for pulmonary and non-pulmonary pathologies. CLINICAL SIGNIFICANCE Hemodynamically unstable children ventilated for pulmonary pathology with the protective strategy of mechanical ventilation had a greater requirement for inotropic and combined inotropic and vasoactive circulatory support than children ventilated for non-pulmonary causes of respiratory failure.
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Affiliation(s)
- Jiri Fremuth
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jiri Kobr
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Lumir Sasek
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Katerina Pizingerova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Jana Zamboryova
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Josef Sykora
- Department of Pediatrics - PICU, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
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The Value of the Inferior Vena Cava Area Distensibility Index and its Diameter Ratio for Predicting Fluid Responsiveness in Mechanically Ventilated Patients. Shock 2020; 52:37-42. [PMID: 31188800 DOI: 10.1097/shk.0000000000001238] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION It is necessary to evaluate fluid responsiveness before fluid resuscitation. We evaluated the value of inferior vena cava (IVC) area respiratory variation and the IVC diameter ratio (IVC DR) for predicting fluid responsiveness in mechanically ventilated patients. METHODS A prospective observational study was performed in the intensive care unit between December 2017 and March 2018. Mechanically ventilated patients were enrolled and received ultrasound monitoring. IVC diameter distensibility index from the subxiphoid area (IVC-sx DDI), IVC diameter distensibility index from the right midaxillary line (IVC-rm DDI), IVC area distensibility index (IVC ADI), and IVC DR in cross-section were calculated by ultrasound monitoring IVC parameters. The enrolled patients were classified as nonresponders group and responders group according to whether the cardiac output increased by >10% after passive leg raising. RESULTS Data from 67 mechanically ventilated patients were analyzed. 55.2% of patients had positive fluid responsiveness. The area of receiver operating characteristic curves evaluating the ability of the IVC-sx DDI, IVC-rm DDI, IVC ADI, and IVC DR to predict the fluid responsiveness were 0.702, 0.686, 0.749, and 0.829, respectively. IVC DR level of 1.43 was predictive of positive fluid responsiveness with 90.0% specificity and 67.6% sensitivity. IVC ADI level of 10.2% was predictive of positive fluid responsiveness with 40.0% specificity and 97.3% sensitivity. CONCLUSIONS IVC ADI and its diameter ratio in cross-section had more value than IVC diameter distensibility index for predicting fluid responsiveness in mechanically ventilated patients.
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Abstract
OBJECTIVES Inferior vena cava ultrasound has been used as a predictor of fluid responsiveness in children. Two ultrasonographic modes can be used to measure the respiratory variation of inferior vena cava diameter: M-mode and B-mode. Inconsistencies in measurements between the modes can result in inaccuracies in commonly used indices that assess fluid responsiveness. Our primary objective was to determine whether there are differences in the ultrasound-based measurements between these two modes of evaluation, which would impact respiratory variation of inferior vena cava diameter calculation. Our secondary objective was to assess inferior vena cava displacements during the respiratory cycle as a possible mechanism for measurement differences between the modes. DESIGN Prospective observational study. SETTING PICU of a tertiary care teaching hospital. PATIENTS Seventy-three children under controlled ventilation (median age of 16 mo and weight of 10 kg). INTERVENTIONS The inferior vena cava diameters were measured using a longitudinal view using B- and M-mode ultrasound. Two respiratory variation of inferior vena cava diameter indices were evaluated: distensibility and respiratory variation. Maximum craniocaudal and mediolateral displacements of the inferior vena cava were measured using the B-mode ultrasound. MEASUREMENTS AND MAIN RESULTS Maximum diameters of the inferior vena cava were similar between the B- and M-modes (7.90 vs 7.90 mm, respectively; p = 0.326), but minimum diameters were smaller when measured by M-mode (6.36 vs 5.00 mm; p = 0.003). When calculated by data obtained from M-mode, respiratory variation of inferior vena cava diameter indices presented significantly higher values compared to B-mode measures (p ≤ 0.001, for both). Median inferior vena cava displacements were 5.00 mm (interquartile range, 3.68-6.26 mm) in the craniocaudal and 0.80 mm (interquartile range, 0.12-1.23 mm) in the mediolateral directions. CONCLUSIONS There is a significant difference between measurements of the minimum inferior vena cava diameter observed in M- and B-mode ultrasound during the respiratory cycle in children under controlled ventilation. This results in imprecise respiratory variation of inferior vena cava diameter indices. Displacements of the inferior vena cava during the respiratory cycle may influence the reliability of ultrasonographic measurements, particularly in M-mode.
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Chen PH, Chan KC, Liao MH, Wu CY. Accuracy of dynamic preload variables for predicting fluid responsiveness in patients with pediatric liver cirrhosis: A prospective study. Paediatr Anaesth 2020; 30:455-461. [PMID: 31900969 DOI: 10.1111/pan.13819] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 12/09/2019] [Accepted: 01/01/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Pin-Hsin Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Min-Hsiu Liao
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Miura K, Harita Y, Takahashi N, Tsurumi H, Yasudo H, Isojima T, Hirata Y, Inuzuka R, Takizawa K, Toyofuku E, Nishimoto H, Takamizawa M, Ando T, Sugawa M, Yanagisawa A, Inatomi J, Nogimori Y, Kinumaki A, Namai Y, Hattori M, Oka A. Nonosmotic secretion of arginine vasopressin and salt loss in hyponatremia in Kawasaki disease. Pediatr Int 2020; 62:363-370. [PMID: 31657491 DOI: 10.1111/ped.14036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 05/30/2019] [Accepted: 09/25/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The precise mechanism of hyponatremia in Kawasaki disease (KD) remains elusive because assessment of volume status based on serial changes in body weight is lacking in previous reports. METHODS Seventeen patients who were diagnosed with KD and hyponatremia (serum sodium levels <135 mmol/L) were analyzed. Volume status was assessed based on serial changes in body weight. Plasma arginine vasopressin (ADH), urine electrolytes, and serum cytokine levels were measured on diagnosis of hyponatremia. An increase in body weight by >3% was defined as hypervolemia and a decrease in body weight by >3% was defined as hypovolemia. RESULTS The volume status was hypervolemic in three patients (18%), euvolemic in 14 (82%), and hypovolemic in none (0%). Five (29%) patients were diagnosed with "syndrome of inappropriate secretion of antidiuretic hormone" (SIADH) and no patients were diagnosed with hypotonic dehydration. The contribution of decreased total exchangeable cations (salt loss) to hyponatremia (5.9% [interquartile range, 4.3%, 6.7%]) was significantly larger than that of increased total body water (-0.7% [-1.8%, 3.1%]) (P = 0.004). Serum interleukin-6 levels were elevated in all of the nine patients who were evaluated. Among the 12 (71%) patients who did not meet the criteria of SIADH and hypotonic dehydration, plasma ADH levels were inappropriately high in ten patients. These patients were also characterized by euvolemic or hypervolemic hyponatremia and salt loss, which might be compatible with a diagnosis of SIADH. CONCLUSIONS Our study shows that hyponatremia in KD is euvolemic or hypervolemic and is associated with nonosmotic secretion of ADH and salt loss in the majority of patients.
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Affiliation(s)
- Kenichiro Miura
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan.,Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yutaka Harita
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Haruko Tsurumi
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Hiroki Yasudo
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | | | - Yoichiro Hirata
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Ryo Inuzuka
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Keiichi Takizawa
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Etsushi Toyofuku
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Hajime Nishimoto
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Masaru Takamizawa
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Taro Ando
- Department of Pediatrics, Yaizu City Hospital, Yaizu, Shizuoka, Japan
| | - Masahiro Sugawa
- Department of Pediatrics, Yaizu City Hospital, Yaizu, Shizuoka, Japan
| | | | - Jun Inatomi
- Department of Pediatrics, Yaizu City Hospital, Yaizu, Shizuoka, Japan
| | | | - Akiko Kinumaki
- Department of Pediatrics, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Yoshiyuki Namai
- Department of Pediatrics, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Akira Oka
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
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Lee JH, Kim EH, Jang YE, Kim HS, Kim JT. Fluid responsiveness in the pediatric population. Korean J Anesthesiol 2019; 72:429-440. [PMID: 31591858 PMCID: PMC6781210 DOI: 10.4097/kja.19305] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/01/2019] [Indexed: 01/23/2023] Open
Abstract
It is challenging to predict fluid responsiveness, that is, whether the cardiac index or stroke volume index would be increased by fluid administration, in the pediatric population. Previous studies on fluid responsiveness have assessed several variables derived from pressure wave measurements, plethysmography (pulse oximeter plethysmograph amplitude variation), ultrasonography, bioreactance data, and various combined methods. However, only the respiratory variation of aortic blood flow peak velocity has consistently shown a predictive ability in pediatric patients. For the prediction of fluid responsiveness in children, flow- or volume-dependent, noninvasive variables are more promising than pressure-dependent, invasive variables. This article reviews various potential variables for the prediction of fluid responsiveness in the pediatric population. Differences in anatomic and physiologic characteristics between the pediatric and adult populations are covered. In addition, some important considerations are discussed for future studies on fluid responsiveness in the pediatric population.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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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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26
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Conlon TW, Lin EE, Bruins BB, Manrique Espinel AM, Muhly WT, Elliott E, Glau C, Himebauch AS, Johnson G, Fiadjoe JE, Lockman JL, Nishisaki A, Schwartz AJ. Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting. Paediatr Anaesth 2019; 29:672-681. [PMID: 30839154 DOI: 10.1111/pan.13625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022]
Abstract
Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice.
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Affiliation(s)
- Thomas W Conlon
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin B Bruins
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ana Maria Manrique Espinel
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Elliott
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gregory Johnson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Justin L Lockman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Jay Schwartz
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mannarino S, Bulzomì P, Codazzi AC, Rispoli GA, Tinelli C, De Silvestri A, Manzoni F, Chiapedi S. Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age. J Cardiol 2019; 74:388-393. [PMID: 30952562 DOI: 10.1016/j.jjcc.2019.02.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/11/2019] [Accepted: 02/28/2019] [Indexed: 01/30/2023]
Abstract
The pediatric ultrasound measurement of the inferior vena cava (IVC) and aorta (AO) with the study of the collapsibility index (CI) and of IVC-to-AO ratio (IVC/AO) can provide clinicians in the acute care setting with information on abnormal volume status but one of the major limitations is a lack of reference normal values by body surface area (BSA) and age. The aim of this study was to provide reference ranges for the sonographic measurement of IVC, AO, and IVC/AO ratio in healthy Caucasian Italian children. METHODS We enrolled prospectively 516 healthy Caucasian Italian children aged between 1 month and 16 years. Echocardiographic IVC and AO diameters were collected and presented separately for children aged ≤1 year and for children aged over 1 year. For children >1 year we categorized subjects into 3 years classes. CI and IVC/AO for the systolic aortic diameter were then calculated. For children over 1 year, age reference ranges were age-related or BSA-related; for children of ≤1 year, reference ranges were determined with their 90% confidence intervals regardless of age and of BSA. RESULTS Tables and charts with reference ranges for all the echocardiographic measurements are presented for children aged >1 year according to age and BSA. The equations to obtain percentile and Z-score for each echocardiographic measurement are provided. The reference ranges for children aged ≤1 year are shown considering the small 90% confidence intervals for upper and lower limits. CI was 30% (SD 17%) in children >1 year and 36% (SD 16%) in children <1 year. IVC/AOs showed age-dependent values from 0.83 (SD 0.20) age <1 year to 1.22 (SD 0.31) in older subjects. CONCLUSIONS We report reliable reference ranges for echocardiographic measurement of IVC, AO, CI, and IVC/AO for a Caucasian Italian healthy pediatric population.
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Affiliation(s)
- Savina Mannarino
- Pediatric Cardiology, Department of Pediatric, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Patrizia Bulzomì
- Pediatric Division, ASST Santi Paolo e Carlo, Presidio Ospedaliero San Carlo Borromeo, Milano, Italy
| | - Alessia Claudia Codazzi
- Pediatric Cardiology, Department of Pediatric, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Gaetana Anna Rispoli
- Pediatric Radiology - Radiodiagnostic Unit, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometry Unit, San Matteo Hospital Foundation, Pavia, Italy
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometry Unit, San Matteo Hospital Foundation, Pavia, Italy.
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, San Matteo Hospital Foundation, Pavia, Italy
| | - Silvia Chiapedi
- Pediatric Cardiology, Department of Pediatric, ASST Ovest Milanese, Legnano Hospital, Legnano, Italy
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28
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Rizza A, Ricci Z. Fluid and Electrolyte Balance. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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29
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Abstract
Monitoring represents a seminal part of modern anesthesia but it is imperative that clinicians and health care staff understand the fundamentals of measurements to correctly understand, apply, and at times discard various monitoring options. The world of measurements is a very precise science that needs to be fully acknowledged. This communication aims at highlighting certain issues relevant to everyday clinical monitoring.
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Affiliation(s)
- Mats Wallin
- Section of Research & Development, Maquet Critical Care AB, Solna, Sweden
| | - Per-Arne Lönnqvist
- Section of Anesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
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30
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de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
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Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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31
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Long E, Duke T, Oakley E, O'Brien A, Sheridan B, Babl FE. Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis. Emerg Med Australas 2018. [PMID: 29520998 DOI: 10.1111/1742-6723.12948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The intent of fluid bolus therapy (FBT) is to increase cardiac output and tissue perfusion, yet only 50% of septic children are fluid responsive. We evaluated respiratory variation of inferior vena cava (IVC) diameter as a predictor of fluid responsiveness. METHODS A prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Patients were spontaneously ventilating children treated with FBT for sepsis-induced acute circulatory failure. IVC ultrasound was performed prior to FBT. Trans-thoracic echocardiography was performed prior to, 5 and 60 min after FBT. IVC collapsibility index and stroke distance were calculated by a blinded Paediatric Emergency Physician and blinded Paediatric Cardiologist, respectively. RESULTS Thirty-nine fluid boluses were recorded in 33 children, 28/39 (72%) of which met criteria for fluid responsiveness at 5 min, which was sustained in 2/28 (7%) of initial fluid responders at 60 min. Sensitivity and specificity (95% confidence interval) of IVC collapsibility index were 0.44 (0.25-0.65) and 0.33 (0.10-0.65) with an area under the receiver operator characteristics curve (95% confidence interval) of 0.38 (0.23-0.55) at 5 min. Test characteristics 60 min after fluid bolus administration were not meaningful because of the infrequency of sustained fluid responsiveness in this patient group. There was no significant correlation between IVC collapsibility and fluid responsiveness at 5 or 60 min. CONCLUSIONS IVC collapsibility has poor test characteristics for predicting fluid responsiveness in spontaneously ventilating children with sepsis.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam O'Brien
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bennett Sheridan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Orso D, Paoli I, Piani T, Cilenti FL, Cristiani L, Guglielmo N. Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018; 35:354-363. [PMID: 29343170 DOI: 10.1177/0885066617752308] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Fluid responsiveness is the ability to increase the cardiac output in response to a fluid challenge. Only about 50% of patients receiving fluid resuscitation for acute circulatory failure increase their stroke volume, but the other 50% may worsen their outcome. Therefore, predicting fluid responsiveness is needed. In this purpose, in recent years, the assessment of the inferior vena cava (IVC) through ultrasound (US) has become very popular. The aim of our work was to systematically review all the previously published studies assessing the accuracy of the diameter of IVC or its respiratory variations measured through US in predicting fluid responsiveness. DATA SOURCES We searched in the MEDLINE (PubMed), Embase, Web of Science databases for all relevant articles from inception to September 2017. STUDY SELECTION Included articles specifically addressed the accuracy of IVC diameter or its respiratory variations assessed by US in predicting the fluid responsiveness in critically ill ventilated or not, adult or pediatric patients. DATA EXTRACTION We included 26 studies that investigated the role of the caval index (IVC collapsibility or distensibility) and 5 studies on IVC diameter. DATA SYNTHESIS We conducted a meta-analysis for caval index with 20 studies: The pooled area under the curve, logarithmic diagnostic odds ratio, sensitivity, and specificity were 0.71 (95% confidence interval [CI]: 0.46-0.83), 2.02 (95% CI: 1.29-2.89), 0.71 (95% CI: 0.62-0.80), and 0.75 (95% CI: 0.64-0.85), respectively. CONCLUSION An extreme heterogeneity of included studies was highlighted. Ultrasound evaluation of the diameter of the IVC and its respiratory variations does not seem to be a reliable method to predict fluid responsiveness.
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Affiliation(s)
- Daniele Orso
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Irene Paoli
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Tommaso Piani
- Division of Pre-Hospital and Retrieval Medicine, Department of Anaesthesia and Intensive Care Medicine, ASUIUD "Santa Maria della Misericordia," Udine, Italy
| | - Francesco L Cilenti
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Lorenzo Cristiani
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
| | - Nicola Guglielmo
- Department of Emergency Medicine, Ospedale Civile di Latisana (UD), A.A.S. 2 "Bassa Friulana-Isontina," Latisana, Udine, Italy
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33
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Vrancken SL, van Heijst AF, de Boode WP. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring. Front Pediatr 2018; 6:87. [PMID: 29675404 PMCID: PMC5895966 DOI: 10.3389/fped.2018.00087] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.
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Affiliation(s)
- Sabine L Vrancken
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arno F van Heijst
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem P de Boode
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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35
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Rizza A, Romagnoli S, Ricci Z. Fluid Status Assessment and Management During the Perioperative Phase in Pediatric Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2016; 30:1085-93. [DOI: 10.1053/j.jvca.2015.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 02/07/2023]
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36
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Ho KM. Pitfalls in haemodynamic monitoring in the postoperative and critical care setting. Anaesth Intensive Care 2016; 44:14-9. [PMID: 26673584 DOI: 10.1177/0310057x1604400104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Haemodynamic monitoring is a vital part of daily practice in anaesthesia and intensive care. Although there is evidence to suggest that goal-directed therapy may improve outcomes in the perioperative period, which haemodynamic targets we should aim at to optimise patient outcomes remain elusive and controversial. This review highlights the pitfalls in commonly used haemodynamic targets, including arterial blood pressure, central venous pressure, cardiac output, central venous oxygen saturation and dynamic haemodynamic indices. Evidence suggests that autoregulation in regional organ circulation may change either due to chronic hypertension or different disease processes such as traumatic brain injury, cerebrovascular ischaemia or haemorrhage; this will influence the preferred blood pressure target. Central venous pressure can be influenced by multiple pathophysiological factors and, unless central venous pressure is very low, it is rarely useful as a predictor for fluid responsiveness. Central venous oxygen saturation can be easily increased by a high arterial oxygen tension, making it useless as a surrogate marker of good cardiac output or systemic oxygen delivery in the presence of hyperoxaemia. Many dynamic haemodynamic indices have been reported to predict fluid responsiveness, but they all have their own limitations. There is also insufficient evidence to support that giving fluid until the patient is no longer fluid responsive can improve patient-centred outcomes. With the exception in the context of preventing contrast-induced nephropathy, large randomised controlled studies suggest that excessive fluid treatment may prolong duration of mechanical ventilation without preventing acute kidney injury in the critically ill.
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Affiliation(s)
- K M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia
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37
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Campagne « survivre au sepsis chez l’enfant ». ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0543-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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