The Influence of Tidal Volume on the Dynamic Variables of Fluid Responsiveness in Critically Ill Patients

Service d'Anesthésie-Réanimation et Unité Propre de Recherche de l'Enseignement Supérieur-Equipe d'Accueil (UPRES-EA 3540), Le Kremlin Bicêtre, France.
Anesthesia and analgesia (Impact Factor: 3.47). 05/2006; 102(5):1511-7. DOI: 10.1213/01.ane.0000209015.21418.f4
Source: PubMed


Respiratory-related variabilities in stroke volume and arterial pulse pressure (Delta%Pp) are proposed to predict fluid responsiveness. We investigated the influence of tidal volume (Vt) and adrenergic tone on these variables in mechanically ventilated patients. Cyclic changes in aortic velocity-time integrals (Delta%VTI(Ao), echocardiography) and Delta%Pp (catheter) were measured simultaneously before and after intravascular volume expansion, and Vt was randomly varied below and above its basal value. Intravascular volume expansion was performed by hydroxyethyl starch (100 mL, 60 s). Receiver operating characteristic curves were generated for Delta%VTI(Ao), Delta%Pp and left ventricle cross-sectional end-diastolic area (echocardiography), considering the change in stroke volume after intravascular volume expansion (> or =15%) as the response criterion. Covariance analysis was used to test the influence of Vt on Delta%VTI(Ao) and Delta%Pp. Twenty-one patients were prospectively included; 9 patients (43%) were responders to intravascular volume expansion. Delta%VTI(Ao) and Delta%Pp were higher in responders compared with nonresponders. Predictive values of Delta%VTI(Ao) and Delta%Pp were similar (threshold: 20.4% and 10.0%, respectively) and higher than that of left ventricle cross-sectional end-diastolic area at the appropriate level of Vt. Delta%Pp was slightly correlated with norepinephrine dosage. Delta%Pp increased with the increase in the level of Vt both before and after intravascular volume expansion, contrasting with an unexpected stability of Delta%VTI(Ao). In conclusion, Delta%VTI(Ao) and Delta%Pp are good predictors of intravascular fluid responsiveness but the divergent evolution of these two variables when Vt was increased needs further explanation.

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Available from: Cyril Charron
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    • "The tidal volume has been identified as an important factor that can affect the absolute values and accuracy of the parameters derived by heart-lung interaction with the respiratory cycle in adult patients for fluid responsiveness [10,15,16]. According to several articles, when the tidal volume of over at least 7-8 ml per ideal body weight (kg) is applied, the accuracy and predictability of these parameters may increase and the absolute values may increase with an increase in the level of the tidal volume [1,11,15,17]. "
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    ABSTRACT: Background The usefulness of dynamic parameters derived by heart-lung interaction for fluid responsiveness in pediatric patients has been revealed. However, the effects of peak inspiratory pressure (PIP) that could affect the absolute values and the accuracy in pediatric patients have not been well established. Methods Participants were 30 pediatric patients who underwent ventricular septal defect repair. After completion of surgical procedure and sternum closure, mean arterial blood pressure, heart rate, central venous pressure, cardiac output, cardiac index and stroke volume variation (SVV) were measured at PIP 10 cmH2O (PIP10), at PIP 15 cmH2O (PIP15), at PIP 20 cmH2O (PIP20) and at PIP 25 cmH2O (PIP25). Results SVV at PIP15 was larger than that at PIP10 (13.7 ± 2.9% at PIP10 vs 14.7 ± 2.5% at PIP15, P < 0.001) and SVV at PIP20 was larger than that at PIP10 and PIP15 (13.7 ± 2.9% at PIP10 vs 15.4 ± 2.5% at PIP20, P < 0.001; 14.7 ± 2.5% at PIP15 vs 15.4 ± 2.5% at PIP20, P < 0.001) and SVV at PIP25 was larger than that at PIP10 and PIP15 and PIP20 (13.7 ± 2.9% at PIP10 vs 17.4 ± 2.4% at PIP25, P < 0.001; 14.7 ± 2.5% at PIP15 vs 17.4 ± 2.4% at PIP25, P < 0.001; 15.4 ± 2.5% at PIP20 vs 17.4 ± 2.4% at PIP25, P < 0.001). Conclusions SVV is affected by different levels of PIP in same patient and under same volume status. This finding must be taken into consideration when SVV is used to predict fluid responsiveness in mechanically ventilated pediatric patients.
    Full-text · Article · May 2014 · Korean journal of anesthesiology
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    • "This assessment is very important because inadequate fluid replacement or inappropriate infusion of catecholamines can lead to significant adverse effects [1]. Several of these dynamic indices (including those derived by echocardiography) have been validated in ICU patients [2-8]. Indeed, transthoracic echocardiography (TTE) is a valuable, minimally invasive, rapid hemodynamic monitoring tool for use in the ICU. "
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    ABSTRACT: Transthoracic echocardiography (TTE) is a useful tool for minimally invasive hemodynamic monitoring in the ICU. Dynamic indices (such as the inferior vena cava distensibility index (dIVC)) can be used to predict fluid responsiveness in mechanically ventilated patients. Although quantitative use of the dIVC has been validated, the routinely used qualitative (visual) approach had not been assessed prior to the present study. Qualitative and quantitative assessments of the dIVC were compared in a prospective, observational study. After operators with differing levels in critical care echocardiography had derived a qualitative dIVC, the last (expert) operator performed a standard, numerical measurement of the dIVC (referred to as the quantitative dIVC). Two groups of patients were separated in two groups: group (dIVC < 18%) and group (dIVC >= 18%). A total of 114 patients were assessed for inclusion and 97 (63 men and 34 women) were included. The mean sensitivity and specificity values for qualitative assessment of the dIVC by an intensivist were 80.7% and 93.7%, respectively. A qualitative evaluation detected all quantitative dIVCs over 40%. Most of the errors concerned quantitative dIVCs of between 15% and 30%. In the dIVC < 18% group, two qualitative evaluation errors were noted for quantitative dIVCs of between 0% and 10%. The average of positive predictive values and negative predictive values for qualitative assessment of the dIVC by residents, intensivists and cardiologists were respectively 83%, 83% and 90%; and 92%, 94% and 90%. Fleiss' kappa for all operators was estimated to be 0.68, corresponding to substantial agreement. The qualitative dIVC is a rather easy and reliable assessment for extreme numerical values. It has a gray zone between 15% and 30%. The highest and lowest limitations of the gray area are rather tedious to define.Despite reliability of the qualitative assessment when it comes to extreme to numerical values, the quantitative dIVC measurement must always be done within a hemodynamic assessment for intensive care patients. The qualitative approach can be easily integrated into a fast hemodynamic evaluation using portable ultrasound scanner for out of hospital patients.
    Full-text · Article · Jan 2014 · Critical care (London, England)
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    • "The respiratory perturbation should be great enough to cause significant preload alteration in order for clinicians to be able to assess its effects on blood pressure and left ventricular stroke volume. These effects are smaller during quiet spontaneous breathing and are clearly tidal volume dependent during mechanical ventilation [6,16-18,20-22,24,25]. "
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    ABSTRACT: In the assessment of hypovolemia the value of functional hemodynamic monitoring during spontaneous breathing is debated. The aim of our study was to investigate in spontaneously breathing subjects the changes in hemodynamic parameters during graded central hypovolemia and to test whether slow patterned breathing improved the discriminative value of stroke volume (SV), pulse pressure (PP), and their variations (SVV, PPV). In addition, we tested the alterations in labial microcirculation. 20 healthy volunteers participated in our study. Central hypovolemia was induced by lower body negative pressure (LBNP). Continuous signals of ECG, non-invasive blood pressure and central venous pressure were recorded. During baseline and each stage of LBNP the labial microcirculation was investigated by orthogonal polarization spectral imaging, 3 minute periods of patterned breathing at 6 and 15/min respiratory rate were performed, and central venous blood gas analysis was done. Data from baseline and those of different LBNP levels were compared by analysis of variance and those of different breathing rates by t-test. Finally, we performed ROC analysis to assess the discriminative values of SV, PP, SVV and PPV. Moderate central hypovolemia induced by LBNP caused significant, clinically relevant falls in PP (p < 0.05) and SV and central venous oxygen saturation (ScvO2) (p < 0.001). The proportion of perfused vessels (p < 0.001) and microvascular flow index decreased (p < 0.05). PPV increased (p < 0.001), however the magnitude of fluctuations was greater during slow patterned breathing (p < 0.001). SVV increased only during slow patterned breathing (p < 0.001). ROC analysis confirmed the best predictive value for SV (at 56 ml cut-off AUC 0.97, sensitivity 94%, specificity 95%). Slow patterned breathing improved the discriminative value of SVV (p = 0.0023). Functional hemodynamic monitoring with slow patterned breathing to control spontaneous respiration may be worthy for further study in different populations for the assessment of hypovolemia and the prediction of volume responsiveness.
    Full-text · Article · Nov 2013 · BMC Anesthesiology
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