Brachial artery peak velocity variation to predict fluid responsiveness in mechanically ventilated patients

Manuel Ignacio Monge García, Anselmo Gil Cano, Juan Carlos Díaz Monrové, Manuel Ignacio Monge García, Anselmo Gil Cano, Juan Carlos Díaz Monrové

Abstract

Introduction: Although several parameters have been proposed to predict the hemodynamic response to fluid expansion in critically ill patients, most of them are invasive or require the use of special monitoring devices. The aim of this study is to determine whether noninvasive evaluation of respiratory variation of brachial artery peak velocity flow measured using Doppler ultrasound could predict fluid responsiveness in mechanically ventilated patients.

Methods: We conducted a prospective clinical research in a 17-bed multidisciplinary ICU and included 38 mechanically ventilated patients for whom fluid administration was planned due to the presence of acute circulatory failure. Volume expansion (VE) was performed with 500 mL of a synthetic colloid. Patients were classified as responders if stroke volume index (SVi) increased >or= 15% after VE. The respiratory variation in Vpeakbrach (DeltaVpeakbrach) was calculated as the difference between maximum and minimum values of Vpeakbrach over a single respiratory cycle, divided by the mean of the two values and expressed as a percentage. Radial arterial pressure variation (DeltaPPrad) and stroke volume variation measured using the FloTrac/Vigileo system (DeltaSVVigileo), were also calculated.

Results: VE increased SVi by >or= 15% in 19 patients (responders). At baseline, DeltaVpeakbrach, DeltaPPrad and DeltaSVVigileo were significantly higher in responder than nonresponder patients [14 vs 8%; 18 vs. 5%; 13 vs 8%; P < 0.0001, respectively). A DeltaVpeakbrach value >10% predicted fluid responsiveness with a sensitivity of 74% and a specificity of 95%. A DeltaPPrad value >10% and a DeltaSVVigileo >11% predicted volume responsiveness with a sensitivity of 95% and 79%, and a specificity of 95% and 89%, respectively.

Conclusions: Respiratory variations in brachial artery peak velocity could be a feasible tool for the noninvasive assessment of fluid responsiveness in patients with mechanical ventilatory support and acute circulatory failure.

Trial registration: ClinicalTrials.gov ID: NCT00890071.

Figures

Figure 1
Figure 1
Comparison of different dynamic indices of preload. Box-and-whisker plots and individual values (open circles) of respiratory variations of brachial peak velocity (ΔVpeakbrach), radial arterial pulse pressure variation (ΔPPrad) and stroke volume variation measured using the FloTrac/Vigileo monitoring system (ΔSVVigileo) before volume expansion (VE), in responder (R, stroke volume index (SVi) ≥15% after VE) and nonresponder (NR, SVi <15% after VE) patients. The central box represents the values from the lower to upper quartile (25th to 75th percentile). The middle line represents the median. A line extends from the minimum to the maximum value.
Figure 2
Figure 2
Illustrative example of Doppler evaluation of brachial artery peak velocity variation in a responder patient and nonresponder patient. In the responder patient (left), volume expansion (VE) induced a decrease of brachial artery peak velocity variation (ΔVpeakbrach) by 15% (from 23% at baseline to 8% after VE) and an increase of stroke volume index and cardiac index by 27% and 12%, respectively. Radial pulse pressure variation (ΔPPrad) and stroke volume variation (ΔSVVigileo) also significantly decreased in the same patient (from 23% to 4%, and from 24% to 11%, respectively). In nonresponder patients (right), VE did not induce any significant change in ΔVpeakbrach (from 9% to 9% after VE), ΔPPrad (from 10% to 8%) or ΔSVVigileo (from 13% to 12%). Neither cardiac index nor stroke volume index increased significantly after VE (6% and 8%, respectively). SVi = stroke volume index.
Figure 3
Figure 3
Comparison of receiver operating characteristics curves to discriminate fluid expansion responders and nonresponders. Area under the receiver operator curve (ROC) for respiratory variations of brachial peak velocity (ΔVpeakbrach) was 0.88, for radial arterial pulse pressure variation (ΔPPrad) it was 0.97, for stroke volume variation measured using the FloTrac/Vigileo monitoring system (ΔSVVigileo) it was 0.89 and for central venous pressure (CVP) it was 0.64.

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