Fluid management in patients with neurogenic pulmonary edema

Abstract

Objective To characterize the disease of neurogenic pulmonary edema (NPE), and to investigate the optimal fluid therapeutic strategy as well as to assess the role of extravascular lung water index (EVLWI) in management of fluid resuscitation. Methods Data of seven patients with NPE, admitted to our intensive care unit (ICU) from September 2012 to January 2014, were collected and analyzed retrospectively. The continuous cardiac output pulse indication (PICCO) monitoring was implemented as soon as the patients were admitted. Conservative fluid therapeutic strategy was adopted, targeting at decreasing EVLWI as the primary goal and maintaining normal blood volume or mean aortic pressure more than or equal to 65 mmHg as the secondary goal. The hemodynamic parameters and input and output volume of fluid, pulmonary vascular permeability index (PVPI), global end-diastolic volume index (GEDVI), extravascular lung water index (EVLWI), oxygenation index (PaO2/FiO2) and lactic acid (Lac) level, and the chest X ray and cranial CT images were recorded and analyzed. The starting point of the record was defined as the time of NPE occurring, and the ending point as time of discharging from ICU or rectification of hypotension or pulmonary edema. Results In a lot of cases, NPE was secondary to severe traumatic brain injury or acute cerebrovascular diseases, concomitant with severe hypotensive shock and pulmonary capillary leakage with a mean PVPI value of 3.3±1.7. The mean fluid input in 7 patients was (2099±1146) mL/d, and the net fluid balance was achieved in a median of-250 mL/d. The mean value of GEDVI was maintained at a level of (727±149) mL/m2. The mean value of EVLWI declined gradually from (18.0±7.0) mL/kg at the startting point to (10±4.3) mL/kg at the ending point of record, and 5 patients showed significant improvement in lung effusion and brain edema as being illustrated in the chest X ray or CT images, 1 died and the other abandoned therapy; the mean length of ICU stay was 9 days. Pearson correlation analysis showed that EVLWI was correlated with PaO2/FiO2 and PVPI (r=-0.570 and 0.760, respectively, P<0.05). Conclusion Successful management of NPE relies on an elaborate balance of both improvement of cranial perfusion and prevention of pulmonary edema exacerbation; PICCO monitoring is a useful tool in assessment of the blood volume status, and targeting at the decreasing EVLWI as a goal of fluid resuscitation is of benefit to patients with NPE. Key words: Neurogenic pulmonary edema; Fluid resuscitation; Extravascular lung water index