Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?

Norair Airapetian, Julien Maizel, Ola Alyamani, Yazine Mahjoub, Emmanuel Lorne, Melanie Levrard, Nacim Ammenouche, Aziz Seydi, François Tinturier, Eric Lobjoie, Hervé Dupont, Michel Slama, Norair Airapetian, Julien Maizel, Ola Alyamani, Yazine Mahjoub, Emmanuel Lorne, Melanie Levrard, Nacim Ammenouche, Aziz Seydi, François Tinturier, Eric Lobjoie, Hervé Dupont, Michel Slama

Abstract

Introduction: We have almost no information concerning the value of inferior vena cava (IVC) respiratory variations in spontaneously breathing ICU patients (SBP) to predict fluid responsiveness.

Methods: SBP with clinical fluid need were included prospectively in the study. Echocardiography and Doppler ultrasound were used to record the aortic velocity-time integral (VTI), stroke volume (SV), cardiac output (CO) and IVC collapsibility index (cIVC) ((maximum diameter (IVCmax)- minimum diameter (IVCmin))/ IVCmax) at baseline, after a passive leg-raising maneuver (PLR) and after 500 ml of saline infusion.

Results: Fifty-nine patients (30 males and 29 females; 57 ± 18 years-old) were included in the study. Of these, 29 (49 %) were considered to be responders (≥10 % increase in CO after fluid infusion). There were no significant differences between responders and nonresponders at baseline, except for a higher aortic VTI in nonresponders (16 cm vs. 19 cm, p = 0.03). Responders had a lower baseline IVCmin than nonresponders (11 ± 5 mm vs. 14 ± 5 mm, p = 0.04) and more marked IVC variations (cIVC: 35 ± 16 vs. 27 ± 10 %, p = 0.04). Prediction of fluid-responsiveness using cIVC and IVCmax was low (area under the curve for cIVC at baseline 0.62 ± 0.07; 95 %, CI 0.49-0.74 and for IVCmax at baseline 0.62 ± 0.07; 95 % CI 0.49-0.75). In contrast, IVC respiratory variations >42 % in SBP demonstrated a high specificity (97 %) and a positive predictive value (90 %) to predict an increase in CO after fluid infusion.

Conclusions: In SBP with suspected hypovolemia, vena cava size and respiratory variability do not predict fluid responsiveness. In contrast, a cIVC >42 % may predict an increase in CO after fluid infusion.

Figures

Fig. 1
Fig. 1
Receiver operating characteristic curves for discriminating between volume expansion responders and nonresponders. ∆CO change in CO between baseline and after PLR, VCmax maximum inferior vena cava diameter at baseline, cIVC inferior vena cava collapsibility index at baseline, PLR passive leg raising
Fig. 2
Fig. 2
Inferior vena cava collapsibility index at baseline (expressed as a percentage) in responders and nonresponders. Individual values (open circles) and the mean ± SD per group (filled circles and solid lines). Se sensitivity, Sp specificity. * p <0.05 vs. nonresponders
Fig. 3
Fig. 3
Maximum inferior vena cava diameter at baseline in responders and nonresponders. Individual values (open circles) and the mean ± SD per group (filled circles and solid lines). Se sensitivity, Sp specificity. * p <0.05 vs. nonresponders

References

    1. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121(6):2000–8. doi: 10.1378/chest.121.6.2000.
    1. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296–327. doi: 10.1097/01.CCM.0000298158.12101.41.
    1. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study. Chest. 2000;117:1749–54. doi: 10.1378/chest.117.6.1749.
    1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–75. doi: 10.1056/NEJMoa062200.
    1. Slama M, Masson H, Teboul JL, Arnout ML, Susic D, Frohlich E, et al. Respiratory variations of aortic VTI: a new index of hypovolemia and fluid responsiveness. Am J Physiol Heart Circ Physiol. 2002;283(4):H1729–1733. doi: 10.1152/ajpheart.00308.2002.
    1. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3):867–73. doi: 10.1378/chest.119.3.867.
    1. Monnet X, Bleibtreu A, Ferré A, Dres M, Gharbi R, Richard C, et al. Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance. Crit Care Med. 2012;40(1):152–7. doi: 10.1097/CCM.0b013e31822f08d7.
    1. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35(1):64–8. doi: 10.1097/01.CCM.0000249851.94101.4F.
    1. Arthur ME, Landolfo C, Wade M, Castresana MR. Inferior vena cava diameter (IVCD) measured with transesophageal echocardiography (TEE) can be used to derive the central venous pressure (CVP) in anesthetized mechanically ventilated patients. Echocardiography. 2009;26(2):140–9. doi: 10.1111/j.1540-8175.2008.00772.x.
    1. Jue J, Chung W, Schiller NB. Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation? J Am Soc Echocardiogr. 1992;5(6):613–9. doi: 10.1016/S0894-7317(14)80327-1.
    1. Bendjelid K, Romand JA, Walder B, Suter PM, Fournier G. Correlation between measured inferior vena cava diameter and right atrial pressure depends on the echocardiographic method used in patients who are mechanically ventilated. J Am Soc Echocardiogr. 2002;15(9):944–9. doi: 10.1067/mje.2002.120701.
    1. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30(9):1834–7. doi: 10.1007/s00134-004-2233-5.
    1. Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):1740–6.
    1. Muller L, Bobbia X, Toumi M, Louart G, Molinari N, Ragonnet B, et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012;16(5):R188. doi: 10.1186/cc11672.
    1. Teboul JL, Monnet X. Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care. 2008;14(3):334–9. doi: 10.1097/MCC.0b013e3282fd6e1e.
    1. Vieillard-Baron A, Slama M, Cholley B, Janvier G, Vignon P. Echocardiography in the intensive care unit: from evolution to revolution? Intensive Care Med. 2008;34(2):243–9. doi: 10.1007/s00134-007-0923-5.
    1. Expert Round Table on Ultrasound in ICU International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077–83. doi: 10.1007/s00134-011-2246-9.
    1. Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050–60. doi: 10.1378/chest.08-2305.
    1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–63. doi: 10.1016/j.echo.2005.10.005.
    1. Shala MB, D'Cruz IA, Johns C, Kaiser J, Clark R. Echocardiography of the inferior vena cava, superior vena cava, and coronary sinus in right heart failure. Echocardiography. 1998;15(8):787–94. doi: 10.1111/j.1540-8175.1998.tb00681.x.
    1. Nagueh SF, Kopelen HA, Zoghbi WA. Relation of mean right atrial pressure to echocardiographic and Doppler parameters of right atrial and right ventricular function. Circulation. 1996;93:1160–9. doi: 10.1161/01.CIR.93.6.1160.
    1. Nakao S, Come PC, McKay RG, Ransil BJ. Effects of positional changes on inferior vena caval size and dynamics and correlations with right-sided cardiac pressure. Am J Cardiol. 1987;59(1):125–32. doi: 10.1016/S0002-9149(87)80084-X.
    1. Moreno FL, Hagan AD, Holmen JR, Pryor TA, Strickland RD, Castle CH. Evaluation of size and dynamics of the inferior vena cava as an index of right-sided cardiac function. Am J Cardiol. 1984;53(4):579–85. doi: 10.1016/0002-9149(84)90034-1.
    1. Mintz GS, Kotler MN, Parry WR, Iskandrian AS, Kane SA. Real-time inferior vena caval ultrasonography: normal and abnormal findings and its use in assessing right-heart function. Circulation. 1981;64(5):1018–25. doi: 10.1161/01.CIR.64.5.1018.
    1. Lloyd TC., Jr Effect of inspiration on inferior vena caval blood flow in dogs. J Appl Physiol. 1983;55(6):1701–8.
    1. Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol. 1990;66(4):493–6. doi: 10.1016/0002-9149(90)90711-9.
    1. Amoore JN, Santamore WP. Venous collapse and the respiratory variability in systemic venous return. Cardiovasc Res. 1994;28:472–9. doi: 10.1093/cvr/28.4.472.
    1. Stawicki SP, Braslow BM, Panebianco NL, Kirkpatrick JN, Gracias VH, Hayden GE, et al. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J Am Coll Surg. 2009;209(1):55–61. doi: 10.1016/j.jamcollsurg.2009.02.062.
    1. Brennan JM, Blair JE, Goonewardena S, Ronan A, Shah D, Vasaiwala S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20(7):857–61. doi: 10.1016/j.echo.2007.01.005.
    1. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134(1):172–8. doi: 10.1378/chest.07-2331.
    1. Vieillard-Baron A, Chergui K, Rabiller A, Peyrouset O, Page B, Beauchet A, et al. Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med. 2004;30(9):1734–9. doi: 10.1007/s00134-004-2361-y.
    1. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med. 2007;33(7):1133–8. doi: 10.1007/s00134-007-0642-y.
    1. Préau S, Dewavrin F, Soland V, Bortolotti P, Colling D, Chagnon JL, et al. Hemodynamic changes during a deep inspiration maneuver predict fluid responsiveness in spontaneously breathing patients. Cardiol Res Pract. 2012;2012:191807.
    1. Mandeville JC, Colebourn CL. Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review. Crit Care Res Pract. 2012;2012:513480.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel