Respiratory variation in carotid peak systolic velocity predicts volume responsiveness in mechanically ventilated patients with septic shock: a prospective cohort study

Miguel Á Ibarra-Estrada, José A López-Pulgarín, Julio C Mijangos-Méndez, José L Díaz-Gómez, Guadalupe Aguirre-Avalos, Miguel Á Ibarra-Estrada, José A López-Pulgarín, Julio C Mijangos-Méndez, José L Díaz-Gómez, Guadalupe Aguirre-Avalos

Abstract

Background: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg.

Methods: We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter.

Results: Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77-0.95); followed by stroke volume variation (0.72, 95 % CI 0.63-0.88), passive leg raising (0.69, 95 % CI 0.56-0.80), and pulse pressure variation (0.63, 95 % CI 0.49-0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001).

Conclusions: ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.

Figures

Fig. 1
Fig. 1
Measurement of variation in carotid peak systolic velocity. At 14 % in this patient
Fig. 2
Fig. 2
Areas under the receiver operating characteristic curve of predictors of fluid responsiveness. The p value indicates comparison between respiratory variation in carotid peak velocity and stroke volume variation (SVV) with the Hanley–McNeil test
Fig. 3
Fig. 3
Correlation between variation in respiratory carotid peak systolic velocity and fluid challenge-induced changes in the stroke volume index
Fig. 4
Fig. 4
Bland–Altman plot for measurements of both observers. There was a mean bias of 0.2, with limits of agreement between −1.9 and 2.3

References

    1. Hofer CK, Cannesson M. Monitoring fluid responsiveness. Acta Anaesthesiol Taiwan. 2011;49:59–65. doi: 10.1016/j.aat.2011.05.001.
    1. Vincent J. Let’s give some fluid and see what happens” versus the “mini-fluid challenge”. Anesthesiology. 2011;115:455–6. doi: 10.1097/ALN.0b013e318229a521.
    1. Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early-goal directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock. 2015;43:68–73. doi: 10.1097/SHK.0000000000000268.
    1. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37:2642–7. doi: 10.1097/CCM.0b013e3181a590da.
    1. Levitov A, Marik PE. Echocardiographic assessment of preload responsiveness in critically ill patients. Cardiol Res Pract. 2012;2012:819696.
    1. Chen C, Kollef MH. Conservative fluid therapy in septic shock: an example of targeted therapeutic minimization. Crit Care. 2014;18:481. doi: 10.1186/s13054-014-0481-5.
    1. Teboul JL, Monnet X. Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care. 2008;14:334–9. doi: 10.1097/MCC.0b013e3282fd6e1e.
    1. Dinh VA, Ko HS, Rao R, Bansal RC, Smith DD, Kim TE, Nguyen HB. Measuring cardiac index with a focused cardiac ultrasound examination in the ED. Am J Emerg Med. 2012;30:1845–51. doi: 10.1016/j.ajem.2012.03.025.
    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.
    1. Huttemann E. Transoesophageal echocardiography in critical care. Minerva Anestesiol. 2006;72:891–913.
    1. Song Y, Kwak YL, Song JW, Kim YJ, Shim JK. Respirophasic carotid artery peak velocity variation as a predictor of fluid responsiveness in mechanically ventilated patients with coronary artery disease. Br J Anaesth. 2014;113:61–6. doi: 10.1093/bja/aeu057.
    1. Monge García MI, Gil Cano A, Díaz Monrové JC. Brachial artery peak velocity variation to predict fluid responsiveness in mechanically ventilated patients. Crit Care. 2009;13(5):R142. doi: 10.1186/cc8027.
    1. Dellinger RP, Levy MM, Rhodes A, Annane D, Geriach H, Opal SM, Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637. doi: 10.1097/CCM.0b013e31827e83af.
    1. Slovut DP, Romero JM, Hannon KM, Dick J, Jaff MR. Detection of common carotid artery stenosis using duplex ultrasonography: a validation study with computed tomographic angiography. J Vasc Surg. 2008;51:65–70. doi: 10.1016/j.jvs.2009.08.002.
    1. Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinski MR, Teboul JL. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134–8. doi: 10.1164/ajrccm.162.1.9903035.
    1. Evans D, Ferraioli G, Snellings J, Levitov A. Volume responsiveness in critically ill patients. J Ultrasound Med. 2014;33:3–7. doi: 10.7863/ultra.33.1.3.
    1. Hanley JA, Mcneil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148:839–43. doi: 10.1148/radiology.148.3.6878708.
    1. Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3:32–5. doi: 10.1002/1097-0142(1950)3:1<32::AID-CNCR2820030106>;2-3.
    1. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–60. doi: 10.1191/096228099673819272.
    1. Fleiss JL, Levin B. The measurement of interrater agreement. In: Fleiss JL, editor. Statistical Methods for Rates and Proportions. 3. Hoboken: John Wiley & Sons; 2003.
    1. Chisholm CB, Dodge WR, Balise RR, Williams SR, Gharahbaghian L, Beraud AS. Focused cardiac ultrasound training: how much is enough? J Emerg Med. 2013;44:818–22. doi: 10.1016/j.jemermed.2012.07.092.
    1. Yong Y, Wu D, Fernandes V, Kopelen HA, Shimoni S, Nagueh SF, Callahan JD, Bruns DE, Shaw LJ, Quinones MA, Zoghbi WA. Diagnostic accuracy and cost-effectiveness of contrast echocardiography on evaluation of cardiac function in technically very difficult patients in the intensive care unit. Am J Cardiol. 2002;89:711–8. doi: 10.1016/S0002-9149(01)02344-X.
    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;119:867–73. doi: 10.1378/chest.119.3.867.
    1. Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31:1195–201. doi: 10.1007/s00134-005-2731-0.
    1. Monnet X, Anguel N, Naudin B, Jabot J, Richard C, Teboul JL. Arterial pressure-based cardiac output in septic patients: different accuracy of pulse contour and uncalibrated pressure waveform devices. Crit Care. 2010;14:R109. doi: 10.1186/cc9058.
    1. Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143:364–70. doi: 10.1378/chest.12-1274.
    1. Dorman T, Breslow MJ, Lipsett PA, Rosenberg JM, Balser JR, Almog Y, Rosenfeld BA. Radial artery pressure monitoring underestimates central arterial pressure during vasopressor therapy in critically ill surgical patients. Crit Care Med. 1998;26:1646–9. doi: 10.1097/00003246-199810000-00014.
    1. Hong SW, Shim JK, Choi YS, Chun DH, Kim JC, Kim BS, Kwak YL. Predictors of ineffectual radial arterial pressure monitoring in valvular heart surgery. J Heart Valve Dis. 2009;18:546–53.
    1. Nunes T, Ladeira R, Bafi A, de Azevedo LC, Machado FR, Freitas FG. Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation. Ann Intensive Care. 2014;4:25. doi: 10.1186/s13613-014-0025-9.
    1. Zhang Z, Lu B, Sheng X, Jin N. Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis. J Anesth. 2011;25:904–16. doi: 10.1007/s00540-011-1217-1.
    1. Biais M, Stecken L, Ottolenghi L, Roullet S, Quinart A, Masson F, Sztark F. The ability of pulse pressure variations obtained with CNAP™ device to predict fluid responsiveness in the operating room. Anesth Analg. 2011;113:523–8.
    1. Solus-Biguenet H, Fleyfel M, Tavernier B, Kipnis E, Onimus J, Robin E, Lebuffe G, Decoene C, Pruvot FR, Vallet B. Non-invasive prediction of fluid responsiveness during major hepatic surgery. Br J Anaesth. 2006;97:808–16. doi: 10.1093/bja/ael250.
    1. Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Esposito DC, Pasqualicci Mde O, Damasceno MC, Schultz MJ. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308:1651–9. doi: 10.1001/jama.2012.13730.
    1. Michard F, Teboul JL, Richard C. Influence of tidal volume on stroke volume variation. Does it really matter? Intensive Care Med. 2003;29:1613. doi: 10.1007/s00134-003-1886-9.
    1. Shim JK, Song JW, Song Y, Kim JH, Kang HM, Kwak YL. Pulse pressure variation is not a valid predictor of fluid responsiveness in patients with elevated left ventricular filling pressure. J Crit Care. 2014;29:987–91. doi: 10.1016/j.jcrc.2014.07.005.
    1. Cameli M, Bigio E, Lisi M, Righini FM, Galderisi M, Franchi F, Scolletta S, Mondillo S (2014) Relationship between pulse pressure variation and echocardiographic indices of left ventricular filling pressure in critically ill patients. Clin Physiol Funct Imaging. 2014 Jun 5. [Epub ahead of print]
    1. Caillard A, Gayat E, Tantot A, Dubreuil G, M’Bakulu E, Madadaki C, Bart F, Bresson D, Froelich S, Mebazaa A, Vallée F (2015) Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis. Br J Anaesth. [Epub ahead of print]
    1. Huber W, Koenig J, Mair S, Schuster T, Saugel B, Eyer F, Phillip V, Schultheiss C, Thies P, Mayr U, Einwächter H, Treiber M, Hoellthaler J, Schmid RM. Predictors of the accuracy of pulse-contour cardiac index and suggestion of a calibration-index: a prospective evaluation and validation study. BMC Anesthesiol. 2015;15:45. doi: 10.1186/s12871-015-0024-x.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel