Abstract
IntroductionAssessing cardiac preload and fluid responsiveness accurately is important when attempting to avoid unnecessary volume replacement in the critically ill patient, which is associated with increased morbidity and mortality. The present clinical trial was designed to compare the reliability of continuous right ventricular end-diastolic volume (CEDV) index assessment based on rapid response thermistor technique, cardiac filling pressures (central venous pressure [CVP] and pulmonary capillary wedge pressure [PCWP]), and transesophageal echocardiographically derived evaluation of left ventricular end-diastolic area (LVEDA) index in predicting the hemodynamic response to volume replacement.MethodsWe studied 21 patients undergoing elective coronary artery bypass grafting. After induction of anesthesia, hemodynamic parameters were measured simultaneously before (T1) and 12 min after volume replacement (T2) by infusion of 6% hydroxyethyl starch 200/0.5 (7 ml/kg) at a rate of 1 ml/kg per min.ResultsThe volume-induced increase in thermodilution-derived stroke volume index (SVITD) was 10% or greater in 19 patients and under 10% in two. There was a significant correlation between changes in CEDV index and changes in SVITD (r2 = 0.55; P < 0.01), but there were no significant correlations between changes in CVP, PCWP and LVEDA index, and changes in SVITD. The only variable apparently indicating fluid responsiveness was LVEDA index, the baseline value of which was weakly correlated with percentage change in SVITD (r2 = 0.38; P < 0.01).ConclusionAn increased cardiac preload is more reliably reflected by CEDV index than by CVP, PCWP, or LVEDA index in this setting of preoperative cardiac surgery, but CEDV index did not reflect fluid responsiveness. The response of SVITD following fluid administration was better predicted by LVEDA index than by CEDV index, CVP, or PCWP.
Highlights
Assessing cardiac preload and fluid responsiveness accurately is important when attempting to avoid unnecessary volume replacement in the critically ill patient, which is associated with increased morbidity and mortality
There was a significant correlation between changes in continuous right ventricular end-diastolic volume (CEDV) index and changes in SVITD (r2 = 0.55; P < 0.01), but there were no significant correlations between changes in CVP, PCWP and left ventricular end-diastolic area (LVEDA) index, and changes in SVITD
An increased cardiac preload is more reliably reflected by CEDV index than by CVP, PCWP, or LVEDA index in this setting of preoperative cardiac surgery, but CEDV index did not reflect fluid responsiveness
Summary
Assessing cardiac preload and fluid responsiveness accurately is important when attempting to avoid unnecessary volume replacement in the critically ill patient, which is associated with increased morbidity and mortality. CCO = continuous cardiac output; CEDV = continuous right ventricular end-diastolic volume; CI = cardiac index; CO = cardiac output; CVP = central venous pressure; HR = heart rate; ICU = intensive care unit; LVEDA = left ventricular end-diastolic area; PAC = pulmonary artery catheter; PCWP = pulmonary capillary wedge pressure; RVEF = right ventricular ejection fraction; RVEDV = right ventricular end-diastolic volume; SV = stroke volume; SVITD = thermodilution-derived stroke volume index; TEE = transesophageal echocardiography. R227 physicians use filling pressures in their decision making regarding volume replacement to improve hemodynamics This accentuates the need for reliable indicators of fluid responsiveness so that needless or even deleterious volume replacement associated with increased morbidity and mortality may be avoided in critically ill patients [4]. Apart from pulse contour analysis, which has never been found in positive-pressure ventilation to reflect actual stroke volume variation [15,16], none of the techniques for assessing preload can be used continuously or routinely in most patients
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