Fluid Responsiveness In Children Research Articles

Assessing Passive Leg Raise Test in Pediatric Shock Using Electrical Cardiometry

AbstractPassive leg raise (PLR) is widely used to incite an autobolus to assess fluid responsiveness in adults; however, there is a paucity of studies exploring its utility in children. Our study aimed to analyze the efficacy of PLR in determining fluid responsiveness in children presenting with shock using electrical cardiometry. Patients in the age group of 0 to 20 years who presented in shock to our children's hospital emergency department were evaluated. Multiple hemodynamic metrics including, heart rate, systolic/diastolic blood pressure, cardiac output (CO), stroke index, stroke volume (SV), flow time corrected (FTC), and left ventricular ejection time (LVET) were recorded using the noninvasive ICON device and compared at baseline and post-PLR. A total of 68 patients had pre- and post-PLR data available for review between June and July 2022. Median age was 7 years (54% male); most common etiology was hypovolemic (67.6%) shock. Following PLR, there was no significant change in most hemodynamic parameters, including SV and CO; however, there was a significant difference in FTC (301 [pre-PLR] vs. 307 [post-PLR], p = 0.016) (ms) and LVET (232 [pre-PLR] vs. 234 [post-PLR], p = 0.014) (ms). A significantly higher proportion of children diagnosed with septic shock demonstrated fluid responsiveness (ΔSV ≥ 10% from baseline) compared with those with hypovolemic shock (p = 0.036). This study demonstrated no identifiable fluid responsiveness (ΔSV ≥ 10% from baseline) following PLR; however, a significantly higher proportion of children suffering from septic shock demonstrated fluid responsiveness compared with those with hypovolemic shock. Larger studies are needed to further assess the utility of PLR, as well as other modalities, in determining fluid responsiveness in children.

Effect of tidal volume change on pressure-based prediction of fluid responsiveness in children.

It is known that pulse pressure variation and systolic pressure variation cannot predict fluid responsiveness in children. In adults, the ability of these dynamic parameters to predict fluid responsiveness is improved by increasing tidal volume. We planned to investigate whether pulse pressure variation or systolic pressure variation can predict fluid responsiveness in children when augmented by increasing tidal volume by conducting a prospective study. We enrolled children younger than 7 years who underwent cardiac surgery for atrial septal defect or ventricular septal defect. After sternum closure, pulse pressure variation and systolic pressure variation were continuously recorded while changing the tidal volume to 6, 10, and 14 mL/kg. Fluid loading was done with 10 mL/kg of crystalloids for 10 min, and stroke volume index was measured via transesophageal echocardiography. Children whose stroke volume index increased by more than 15% after the fluid loading were defined as responders to fluid therapy. We set primary outcome as the predictability of pulse pressure variation and systolic pressure variation for fluid responsiveness and measured the area under the curve of receiver operating characteristics curve. Twenty-six children were included, of which 15 were responders. At the tidal volume of 14 mL/kg, the area under the curves of receiver operating characteristics curves of pulse pressure variation and systolic pressure variation were 0.576 (p = .517) and 0.548 (p = .678), respectively. The differences in dynamic parameters between responders and nonresponders were not significant. Failure of pulse pressure variation or systolic pressure variation at augmented tidal volume in children may be due to difference in their arterial compliance from those of adults. Large compliance of thoracic wall may be another reason. Augmented pulse pressure variation or systolic pressure variation due to increased tidal volume cannot predict fluid responsiveness in children after simple cardiac surgery.

Assessing Fluid Responsiveness Using Noninvasive Hemodynamic Monitoring in Pediatric Shock: A Review

AbstractNoninvasive hemodynamic monitoring devices have been introduced to better quantify fluid responsiveness in pediatric shock; however, current evidence for their use is inconsistent. This review aims to examine available noninvasive hemodynamic monitoring techniques for assessing fluid responsiveness in children with shock. A comprehensive literature search was conducted using PubMed and Google Scholar, examining published studies until December 31, 2022. Articles were identified using initial keywords: [noninvasive] AND [fluid responsiveness]. Inclusion criteria included age 0 to 18, use of noninvasive techniques, and the emergency department (ED) or pediatric intensive care unit (PICU) settings. Abstracts, review papers, articles investigating intraoperative monitoring, and non-English studies were excluded. The methodological index for nonrandomized studies (MINORS) score was used to assess impact of study bias and all study components were aligned with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Our review yielded 1,353 articles, 17 of which met our inclusion criteria, consisting of 618 patients. All were prospective observational studies performed in the ED (n = 3) and PICU (n = 14). Etiologies of shock were disclosed in 13/17 papers and consisted of patients in septic shock (38%), cardiogenic shock (29%), and hypovolemic shock (23%). Noninvasive hemodynamic monitors included transthoracic echocardiography (TTE) (n = 10), ultrasonic cardiac output monitor (USCOM) (n = 1), inferior vena cava ultrasonography (n = 2), noninvasive cardiac output monitoring (NICOM)/electrical cardiometry (n = 5), and >2 modalities (n = 1). To evaluate fluid responsiveness, most commonly examined parameters included stroke volume variation (n = 6), cardiac index (CI) (n = 6), aortic blood flow peak velocity (∆V peak) (n = 3), and change in stroke volume index (n = 3). CI increase >10% predicted fluid responsiveness by TTE in all ages; however, when using NICOM, this increase was only predictive in children >5 years old. Additionally, ∆SV of 10 to 13% using TTE and USCOM was deemed predictive, while no studies concluded distensibility index by transabdominal ultrasound to be significantly predictive. Few articles explore implications of noninvasive hemodynamic monitors in evaluating fluid responsiveness in pediatric shock, especially in the ED setting. Consensus about their utility remains unclear, reiterating the need for further investigations of efficacy, accuracy, and applicability of these techniques.

Performance of Tools and Measures to Predict Fluid Responsiveness in Pediatric Shock and Critical Illness: A Systematic Review and Meta-Analysis.

In this systematic review and meta-analysis we asked: Do predictors of fluid responsiveness in children perform comparably: 1) in the PICU as in non-PICU settings? 2) in shock states compared with nonshock states? Additionally, 3) is there an association between preload responsiveness and clinical response? Ovid Medline, PubMed, and Embase databases were searched from inception through May 2022. Included studies reported physiological response to IV fluid administration in humans less than 18 years. Only studies reporting an area under the receiver operating characteristic curve (AUROC) were included for descriptive analysis. Only studies for which a se could be estimated were included for meta-analysis. Title, abstract, full text screening, and extraction were completed by two authors (S.B.W., J.M.W.). Variables extracted included predictors ("tools") and outcome measures ("reference tests") of fluid responsiveness, demographic, and clinical variables. We identified 62 articles containing 204 AUROCs for 55 tools, primarily describing mechanically ventilated children in an operating room or PICU. Meta-analysis across all tools showed poor predictive performance (AUROC, 0.66; 95% CI, 0.63-0.69), although individual performance varied greatly (range, 0.49-0.87). After controlling for PICU setting and shock state, PICU setting was associated with decreased predictive performance (coefficient, -0.56; p = 0.0007), while shock state was associated with increased performance (0.54; p = 0.0006). Effect of PICU setting and shock state on each tool was not statistically significant but analysis was limited by sample size. The association between preload responsiveness and clinical response was rarely studied but results did not suggest an association. Ultrasound measurements were prone to inherent test review and incorporation biases. We suggest three opportunities for further research in fluid responsiveness in children: 1) assessing predictive performance of tools during resuscitation in shock states; 2) separating predictive tool from reference test when using ultrasound techniques; and 3) targeting decreasing time in a shock state, rather than just increase in preload.

Accuracy of Respiratory Variation in Inferior Vena Cava Diameter to Predict Fluid Responsiveness in Children Under Mechanical Ventilation.

Proper assessment of fluid responsiveness using accurate predictors is crucial to guide fluid therapy and avoid the serious adverse effects of fluid overload. The main objective of this study was to investigate the accuracy of respiratory variations in inferior vena cava diameter (∆IVC) to predict fluid responsiveness in mechanically ventilated children. This prospective single-center study included 32 children (median age and weight of 17months and 10kg, respectively) who received a fluid infusion of 10ml kg-1 of crystalloid solutions over 10min. ∆IVC and respiratory variation in aortic blood flow peak velocity (∆Vpeak) were determined over one controlled respiratory cycle before and after fluid loading. Thirteen (41%) participants were fluid-responders. ∆IVC, ∆Vpeak, stroke volume index, and cardiac index were found to be predictors of fluid responsiveness. However, the area under the ROC curve of ∆IVC was smaller when compared to ∆Vpeak (0.709 vs. 0.935, p < 0.012). The best cut-off values were 7.7% for ∆IVC (sensitivity, 69.2%; specificity 78.9%, positive predictive value, 69.2%; and negative predictive value, 78.9%) and 18.2% for ∆Vpeak (sensitivity, 84.6%; specificity, 89.5%; positive predictive value, 84.6%; negative predictive value, 89.5%). Changes in stroke volume were positively correlated with ∆IVC (ρ = 0.566, p < 0.001) and ∆Vpeak (ρ = 0.603, p < 0.001). A significant correlation was also found between changes in MAP and ∆Vpeak (ρ = 0.382; p = 0.031), but the same was not observed with ∆IVC (ρ = 0.011; p = 0.951). In conclusion, ∆IVC was found to have a moderate accuracy in predicting fluid responsiveness in mechanically ventilated children and is an inferior predictor when compared to ∆Vpeak.

Fluid responsiveness in children with Septic shock is not a Reliable Predictor of outcome: Single Center Experience

Fluid responsiveness in children with Septic shock is not a Reliable Predictor of outcome: Single Center Experience

Point-of-care ultrasonography to predict fluid responsiveness in children: A systematic review and meta-analysis.

Point-of-care ultrasonography (POCUS) is proposed as a valuable method for hemodynamic monitoring and several ultrasound-based predictors of fluid responsiveness have been studied. The main objective of this study was to assess the accuracy of these predictors in children. PubMed, Embase, Scopus, ClinicalTrials.gov, and Cochrane Library databases were searched for relevant publications through July 2022. Pediatric studies reporting accuracy estimates of ultrasonographic predictors of fluid responsiveness were included since they had used a standard definition of fluid responsiveness and had performed an adequate fluid challenge. Twenty-three studies involving 1028 fluid boluses were included, and 12 predictors were identified. A positive response to fluid infusion was observed in 59.7% of cases. The vast majority of participants were mechanically ventilated (93.4%). The respiratory variation in aortic blood flow peak velocity (∆Vpeak) was the most studied predictor, followed by the respiratory variation in inferior vena cava diameter (∆IVC). The pooled sensitivity and specificity of ∆Vpeak were 0.84 (95% CI, 0.76-0.90) and 0.82 (95% CI, 0.75-0.87), respectively, and the area under the summary receiver operating characteristic curve (AUSROC) was 0.89 (95% CI, 0.86-0.92). The ∆IVC presented a pooled sensitivity and specificity of 0.79 (95% CI, 0.62-0.90) and 0.70 (95% CI, 0.51-0.84), respectively, and an AUSROC of 0.81 (95% CI, 0.78-0.85). Significant heterogeneity in accuracy estimates across studies was observed. POCUS has the potential to accurately predict fluid responsiveness in children. However, only ∆Vpeak was found to be a reliable predictor. There is a lack of evidence supporting the use of POCUS to guide fluid therapy in spontaneously breathing children.

Perioperative fluid management in children: an updated review

Background: Perioperative fluid management in children has been a major topic for debate. Objectives: Our aim is to review the current evidence on perioperative fluid management in children including: type of fluid, administration rates, preoperative fluid intake and monitoring techniques. Design: Narrative review. Method: Following the PRISMA-S guidelines we performed a search (2010-March 2022) in databases Medline (through PubMed) and Cochrane Library. 4297 citations were found and screened by two independent researchers. After screening, 64 articles were withheld for our review. Results: The perioperative administration of isotonic fluids is safer than hypotonic solutions, concerning the development of hyponatremia. A balanced isotonic solution with 1-2,5% glucose should be used as perioperative maintenance IV fluid in children (1 month to 18 years). Colloids can be used in children when inadequate effect in volume correction is achieved with crystalloids. The preferred synthetic colloid for children is a third generation HES in a balanced solution. To date, most clinicians use the “4-2-1 rule” for calculating fluid rate. This may not be the optimal fluid rate, as little research has been done. Preoperative fasting for clear fluids should be limited to 1 hour, children should even be encouraged to drink up until 1 hour before induction. Respiratory variation of aortic blood flow peak velocity (ΔVpeak) with echocardiography is currently the most reliable technique for evaluating fluid responsiveness in children.

Predictive Value of the Respiratory Variation in Inferior Vena Cava Diameter for Ventilated Children With Septic Shock.

ObjectivesThis study aimed to investigate the predictive utility of respiratory variations of inferior vena cava diameters on fluid responsiveness in children with septic shock.DesignA prospective observational single-center study.SettingA pediatric intensive care unit in a tertiary hospital in China.ParticipantsPatients with sepsis shock who require invasive mechanical ventilation were recruited between 1 December 2017 and 1 November 2021.Interventions and MeasurementsVolume expansion (VE) was induced by a 30-min infusion of 20 ml/kg of normal saline. Hemodynamics indexes were obtained through bedside transthoracic echocardiography (TTE) measurement and calculation.ResultsA total of 86 patients were enrolled in this study, among them, 45 patients (52.3%) were considered to be non-responders (NR), with an increase in stroke volume variation (SVV) <15% after VE. Multivariate logistic analysis showed that ΔIVC (adjusted OR = 1.615, 95% CI 1.092–2.215, p = 0.012) was the significant predictor associated with the fluid responsiveness. The area under the ROC of ΔIVC was 0.922 (95% CI: 0.829–1.000, p < 0.01), and the cutoff value of ΔIVC used to predict fluid responsiveness was 28.5%, with a sensitivity and specificity of 95.4 and 68.5%, respectively.ConclusionsThe ΔIVC was found to have a potential value in predicting fluid responsiveness in mechanically ventilated children with septic shock.

The association between carotid flow time and fluid responsiveness in children under general anesthesia

Fluid administration in children undergoing surgery requires precision, however, determining fluid responsiveness can be challenging. Ultrasound has been used widely in the emergency department and intensive care units as a noninvasive, bedside manner of determining volume status, but the intraoperative period presents unique challenges as often the chest and abdomen are inaccessible for ultrasound. We investigate whether carotid artery ultrasound, specifically carotid flow time, can be used to determine fluid responsiveness in children under general anesthesia. Prospective observational study of 87 children ages 1-12 years who were scheduled for elective noncardiac surgery. Ultrasound of the carotid artery and heart was performed at three time points: (1) after inhalational induction of anesthesia with the subject spontaneously breathing, (2) during positive pressure ventilation through endotracheal tube or supraglottic airway with tidal volume set at 8ml/kg with PEEP of 10 cmH2 O, and (3) after a 10ml/kg fluid bolus. Carotid flow time and cardiac output were measured from saved images. Corrected carotid flow time (FTc) increased with initiation of positive pressure ventilation in both fluid responders and nonresponders (352.7 vs. 365.3 msec, p=.005 in fluid responders; 348.3 vs. 365.2 msec, p=.001 in nonresponders). FTc increased after fluid bolus in both responders and nonresponders (365.3 vs. 397.6 msec, p < .001 in fluid responders; 365.2 vs. 397.2 msec, p < .001 in nonresponders). However, baseline FTc during spontaneous ventilation or positive pressure ventilation prior to fluid bolus was not associated with fluid responsiveness. Flow time increases with initiation of positive pressure ventilation and after administration of a fluid bolus. FTc may serve as an indicator of fluid status but does not predict fluid responsiveness in children under general anesthesia.

Carotid doppler ultrasonography as a method to predict fluid responsiveness in mechanically ventilated children.

The aim of this study was to investigate whether respiratory variations in carotid and aortic blood flows measured by Doppler ultrasonography could accurately predict fluid responsiveness in critically ill children. This was a prospective single-center study including mechanically ventilated children who underwent fluid replacement at the discretion of the attending physician. Response to fluid load was defined by a stroke volume increase of more than 15%. Maximum and minimum values of velocity peaks were determined over one controlled respiratory cycle before and after volume expansion. Respiratory changes in velocity peak of the carotid (∆Vpeak_Ca) and aortic (∆Vpeak_Ao) blood flows were calculated as the difference between the maximum and minimum values divided by the mean of the two values and were expressed as a percentage. A total of 30 patients were included, of which twelve (40%) were fluid responders and 18 (60%) non-responders. Before volume expansion, both ∆Vpeak_Ca and ∆Vpeak_Ao were higher in responders than in non-responders (17.1% vs 4.4%; p < .001 and 22.8% vs 6.4%; p < .001, respectively). ∆Vpeak_Ca could effectively predict fluid responsiveness (AUC 1.00, 95% CI 0.88-1.00), as well as ∆Vpeak_Ao (AUC 0.94, 95% CI 0.80-0.99). The best cutoff values were 10.6% for ∆Vpeak_Ca (sensitivity, specificity, positive predictive value and negative predictive value of 100%) and 18.2% for ∆Vpeak_Ao (sensitivity, 91.7%; specificity, 88.9%; positive predictive value, 84.6%; negative predictive value, 94.1%). Volume expansion-induced changes in stroke volume correlated with the ∆Vpeak_Ca and ∆Vpeak_Ao before volume expansion (ρ of 0.70 and 0.61, respectively; p < .001 for both). Analysis of respiratory changes in carotid and aortic blood flows are accurate methods for predicting fluid responsiveness in children under invasive mechanical ventilation.

Non-invasive Cardiac Output Monitoring and Assessment of Fluid Responsiveness in Children With Shock in the Emergency Department.

IntroductionThe assessment of fluid responsiveness is important in the management of shock but conventional methods of assessing fluid responsiveness are often inaccurate. Our study aims to evaluate changes in objective hemodynamic parameters as measured using electrical cardiometry (ICON® monitor) following the fluid bolus in children presenting with shock and to evaluate whether any specific hemodynamic parameter can best predict fluid responsiveness among children with shock.Materials and MethodsWe conducted a prospective observational study in children presenting with shock to our emergency department between June 2020 and March 2021. We collected the parameters such as heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and hemodynamic data such as cardiac output CO), cardiac index (CI), index of contractility (ICON), stroke volume (SV), stroke index (SI), corrected flow time (FTC), systolic time ratio (STR), variation of index of contractility (VIC), stroke volume variation (SVV), systemic vascular resistance (SVR), and thoracic fluid content (TFC) using the ICON monitor before and after fluid bolus (FB). We assessed percent change (Δ) and used paired-sample Student’s t-test to compare pre- and post-hemodynamic data and Mann–Whitney U-test to compare fluid responders and non-responders. P-Values < 0.05 were considered statistically significant.ResultsWe recorded 42 fluid interventions in 40 patients during our study period. The median IQR age was 10.56 (4.8, 14.8) years with male/female ratio (1.2:1). There was a significant decrease in ΔRR [−1.61 (−14.8, 0); p = 0.012], ΔDBP [−5.5 (−14.4, 8); p = 0.027], ΔMAP [−2.2 (−11, 2); p = 0.018], ΔSVR [−5.8 (−20, 5.2); p = 0.025], and ΔSTR [−8.39 (−21, 3); p = 0.001] and significant increase in ΔTFC [6.2 (3.5, 11.4); p = 0.01] following FB. We defined fluid responders by an increase in SV by ≥10% after a single FB of 20 ml/kg crystalloid. Receiver operating curve analysis revealed that among all the parameters, 15% change in ICON had an excellent AUC (0.85) for the fluid responsiveness.ConclusionOur study showed significant changes in objective hemodynamic parameters, such as SVR, STR, and TFC following FB in children presenting with shock. A 15% change in ICON had an excellent predictive performance for the fluid responsiveness among our cohort of pediatric shock.

Prediction of fluid responsiveness following liver compression in pediatric patients with single ventricle physiology.

The role of liver compression in predicting fluid responsiveness in children with a single ventricle has never been evaluated. The purpose of this study was to assess whether blood pressure changes during liver compression predict fluid responsiveness in children with single ventricle physiology. This prospective, interventional study included children aged 3months to 5years who underwent surgery for bidirectional cavopulmonary shunt or extracardiac Fontan operation. Before fluid loading, the right upper abdomen was compressed at 30mmHg for 10s, and changes in the blood pressure waves were recorded before administering 10mlkg-1 of crystalloid solution. Systolic arterial pressure, diastolic arterial pressure, central venous pressure, pleth variability index, respiratory variation in aortic blood flow peak velocity, and stroke volume were measured before and after fluid loading. A volume responder was defined as a patient with >15% increase in stroke volume index. Thirty patients underwent bidirectional cavopulmonary shunt (15 responders and 15 non-responders), and 32 underwent Fontan surgery (17 responders and 15 non-responders). In children with bidirectional cavopulmonary shunt, Δsystolic arterial pressure>8mmHg (sensitivity 76.9% and specificity 93.3%), Δdiastolic arterial pressure>7mmHg (sensitivity 69.2% and specificity 93.3%), and Δmean arterial pressure>7mmHg (sensitivity 69.2% and specificity 100%) during liver compression predicted fluid responsiveness. The areas under the receiver operating characteristic curves of Δsystolic arterial pressure, Δdiastolic arterial pressure, and Δmean arterial pressure were 0.928, 0.859, and 0.874 (all p<.001). In children who underwent Fontan surgery, only Δsystolic arterial pressure>16mmHg was predictive of fluid responsiveness (sensitivity of 41.2% and specificity of 100%), with the areas under the receiver operating characteristic curves curve of 0.786 (p<.001). Pleth variability index and respiratory variation in aortic blood flow peak velocity had no predictive value for fluid responsiveness after both types of surgeries. In BCPS patients, liver compression increases the inferior vena cava flow which directly leads to an increase in preload. On the other hand, blood flow from the liver drains directly into the pulmonary arteries in Fontan circulation. Because of this characteristics for preload determination, the clinical application of liver compression to monitor hemodynamic changes might be more useful in patients with bidirectional cavopulmonary shunt than those with Fontan circulation. Increase in blood pressure induced by liver compression is predictive of fluid responsiveness in children with single ventricle physiology.

Utility of Transfontanelle Ultrasound in Predicting the Fluid Responsiveness in Children After Repair of Congenital Heart Diseases: A Prospective Observational Study

Postoperative fluid management in children undergoing cardiac surgery requires a balanced optimization. The blood flow velocity variation in the internal carotid artery (ΔICA) measured through transfontanelle ultrasound has been shown to predict fluid responsiveness during cardiac surgery. It may provide an excellent window to study fluid responsiveness in infants during the postoperative period when the intensivist is faced with the challenges of poor echocardiographic window. The authors aimed to observe the correlation between ΔICA measured on transfontanelle ultrasound with the respiratory variability of peak aortic blood flow velocity (ΔVpeak) on transthoracic echocardiography as a marker of fluid responsiveness in infants on mechanical ventilation during the postoperative period after cardiac surgery. A prospective observational study. The postcardiac surgery intensive care unit (ICU) of a tertiary care hospital. Thirty infants undergoing congenital cardiac surgery. A fluid bolus of 10 mL/kg administered over 10 minutes at 1 and 6 hours after ICU admission. Patients were categorized into fluid responders and nonresponders based on >15% increase in the indexed stroke volume. A total of 50 fluid boluses were administered in 30 patients. Among these, 22 (73.33%) were responders and 8 (26.67%) were nonresponders. There was moderate correlation between ΔICA and peak aortic blood flow velocity variation (ΔVpeak) (r=0.59, p ≤ 0.001). The ΔVpeak >14.74% had 68% sensitivity and 75% specificity to predict fluid responsiveness (area under the receiver operating characteristic [AUROC], 0.749; p=0.001; positive likelihood ratio, 2.71; negative likelihood ratio, 0.43). The ΔICA >9.85% could predict fluid responsiveness in infants (AUROC, 0.728; p=0.003; 75% sensitivity; 60% specificity; positive likelihood ratio, 1.85; negative likelihood ratio, 0.42). Among children younger than 6 months, ΔICA >9.85% was a better predictor of fluid responsiveness (AUROC, 0.889; p=0.009) than ΔVpeak >15% (AUROC, 0.778; p=0.061). The ICA variability >9.85% measured via transfontanelle ultrasound is a good predictor of fluid responsiveness in infants, especially those younger than 6 months on mechanical ventilation after cardiac surgery.

Dynamic variables predict fluid responsiveness in pre-school and school children undergoing neurosurgery: a prospective observational study.

BackgroundThe evidence that plethysmographic variability index (PVI), pulse pressure variation (PPV), FloTrac/Vigileo-derived stroke volume variation (SVV), and Eadyn (dynamic arterial elastance) predict fluid responsiveness in children is limited by conflicting results. We aim to evaluate their accuracy and reliability to predict fluid responsiveness after induction in children aged 4–9 years undergoing major neurosurgery.MethodsChildren aged 4–9 years undergoing intracranial epileptic foci excision were enrolled. After the induction of anesthesia, fluid loading with 10 mL/kg of Ringer’s solution over 10 min was administered before surgical incision. PVI, PPV, SVV, and Eadyn were measured before and within 5 min after fluid loading. Respiratory variation in aortic blood flow peak velocity (∆Vpeak) >15% at baseline, measured using transthoracic echocardiography, identified fluid “responders”. The abilities of dynamic variables to predict an increase in mean arterial pressure (MAP) of >10% following fluid loading were also assessed.ResultsFourteen (31.8%) of forty-four patients were responders defined by a baseline ∆Vpeak >15%. Before fluid loading, only the PVI value was significantly different between R and NR (P=0.017). Baseline PVI showed fair diagnostic accuracy for fluid responsiveness, with an area under the curve (AUROC) of 0.735 and the cutoff value of 13%. The R group showed a significantly greater absolute change in PPV and SVV after fluid loading from baseline compared with the NR group (P=0.021 and 0.040, respectively). The absolute change in the PPV and SVV values from baseline was greater in R than those in NR (P=0.021 and 0.040, respectively). Twenty (45.5%) showed a MAP increase of >10% following fluid loading and were defined as responders. Baseline ∆Vpeak and SVV showed fair predictive values for a MAP increase of >10% (AUROC =0.758 and 0.715, respectively).ConclusionsPVI at baseline showed fair reliability to predict fluid responsiveness after anesthesia induction in mechanically ventilated children aged 4–9 years undergoing neurosurgery. Baseline ∆Vpeak and SVV were fairly predictive for an increase in MAP following fluid loading.

The clinical value of passive leg raising plus ultrasound to predict fluid responsiveness in children after cardiac surgery

BackgroundThere are few non-invasive monitoring methods that can reliably predict fluid responsiveness (FR) in children. Here, we interrogate the value of doppler ultrasound evaluation of passive leg raising (PLR)-induced changes in stroke volume (SV) and cardiac output (CO) as a predictor of FR in children with mechanical ventilation after congenital cardiac surgery.MethodsA total of 40 children with mechanical ventilation following congenital cardiac surgery, who required volume expansion (VE) were included in this study. Hemodynamic parameters such as heart rate (HR), mean arterial pressure (MAP), SV, and central venous pressure (CVP) were monitored before and after PLR and VE. Besides, we assessed changes in SV and CO by bedside ultrasound. Patients showing > 10 % increase in SV in response to VE were considered to be responders (26 patients), while the rest (14 patients) were defined as non-responders.ResultsOur data demonstrated that ΔSV-PLR and ΔCO- PLR were positively correlated with ΔSV-VE (r = 0.683, p < 0.001 and r = 0.374, p = 0.017, respectively), and the area under the ROC curve (AUC) of ΔSV-PLR was 0.879 (95 % CI [0.745 1.000], p < 0.001). The best cut-off value for ΔSV-PLR in predicting FR was 13 %, with its sensitivity and specificity were 81.8 and 86.3 %, respectively. ΔCVP, ΔHR, and ΔMAP were weak predictors of FR in the children.ConclusionsOur study demonstrated that SV changes, as evaluated by noninvasive ultrasound combined with PLR, could effectively evaluate FR in children under mechanical ventilation after congenital cardiac surgery.

Diagnostic accuracy of stroke volume variation for predicting fluid responsiveness in children undergoing cardiac surgery: A systematic review and meta-analysis.

Stroke volume variation appears to be reliable for predicting fluid responsiveness in adults, and its predictive value in pediatric patients has been recently reported. However, its predictive value in children undergoing cardiac surgery is unclear. A review and meta-analysis were performed on the diagnostic utility of stroke volume variation for predicting fluid responsiveness in children undergoing cardiac surgery. All relevant articles for prospective research assessing the value of stroke volume variation were searched in the Embase, MEDLINE (PubMed), and Cochrane databases through March 2020. The primary outcome was the accuracy of stroke volume variation for predicting fluid responsiveness in children. The combined data were analyzed by a meta-analysis. Publication quality was assessed using the QUADAS (quality assessment for studies of diagnostic accuracy, maximum score) standard guidelines. Six articles were included in the meta-analysis, following the search strategy. A total of 251 children were included from 6 prospective studies. Fluid therapy for all patients used crystalloids or colloids. The results of the analysis revealed a pooled diagnostic odds ratio of 8.23 (95% CI: 3.07-22.11), pooled sensitivity of 0.73 (95% CI: 0.64-0.80), and pooled specificity of 0.66 (95% CI: 0.58-0.74). Additionally, the overall area of the summary receiver operating characteristic curve was 0.78. There was significant moderate heterogeneity in these studies (p<.05, I2 =42.1%) due to thresholds. There was some heterogeneity due to thresholds in the included studies. An evaluation of stroke volume variation may represent a reliable predictor of fluid responsiveness in children undergoing cardiac surgery. After operative cardiac output optimization, the possible impact of goal-directed fluid treatment depending on stroke volume variation on the perioperative outcome in the children population should subsequently be assessed.

Inferior Vena Cava/Abdominal Aorta Ratio as a Guide for Fluid Resuscitation.

Introduction:The fluid therapy is crucial in the treatment of critically ill children. Inadequate or excessive fluid resuscitation leads to increased mortality and morbidity, thus necessitating an accurate parameter for predicting fluid responsiveness when conducting fluid resuscitation. The inferior vena cava/abdominal aorta (IVC/Ao) ratio is suggested as a good guide for fluid resuscitation. However, the cutoff value for predicting fluid responsiveness in children has not been established. Is IVC/Ao ratio can be used to predict fluid responsiveness?Methods:The objective was to determine the accuracy and a cutoff value of IVC/Ao in predicting fluid responsiveness. A prospective cross-sectional study was conducted in the emergency room and the pediatric intensive care unit of the tertiary hospital from March to August 2017. We consecutively enrolled all critically ill children aged 1 month to 18 years' old who were hemodynamically unstable (shock). Measurements of IVC/Ao with ultrasound and stroke volume with ultrasound cardiac output monitor were obtained before and after fluid challenge.Results:Of 167 subjects enrolled in this study, only 58 subjects were included, most of whom were male (58.6%) and ranging in age from 1 to 11 months (32.8%). The mean IVC/Ao ratio before the fluid challenge in the fluid responsive group was 0.70 ± 0.053. The best cutoff of the IVC/Ao ratio is 0.675 with area under the curve 70.8% (95% confidence interval of 54.6%–87%), 75.7% sensitivity, and 61.9% specificity for predicting significant fluid responsiveness.Conclusion:The measurement of IVC/Ao is an accurate, sensitive, and specific parameter to predict fluid responsiveness. The best cut-off for the IVC/Ao ratio is 0.675.

Role of Inferior Vena Cava Parameters as Predictors of Fluid Responsiveness in Pediatric Septic Shock: A Prospective Study

AbstractFluid resuscitation is the initial therapy for septic shock worldwide. Prediction of fluid responsiveness is essential for optimizing fluid administration. Only few pediatric studies have evaluated the role of inferior vena cava (IVC) as a reliable predictor of fluid responsiveness. The aim of this study was to evaluate the role of IVC parameters as predictors of fluid responsiveness in children (under the age of 5 years) having septic shock at different times from admission. A prospective observational study included 51 children having septic shock. It was conducted in the nine-bedded pediatric intensive care unit of a university hospital from January 1, 2018, to the August 31, 2018. Echocardiography was used to assess minimal and maximal IVC diameters and its distensibility index with simultaneous assessment of stroke volume (SV), at 1, 6, and 24 hours from admission. The decision to give fluid in these children was thereby based on the presence of at least one sign of inadequate tissue perfusion. SV was reassessed directly after administration of a fluid bolus of 10 mL/kg over 10 minutes. Fluid responsiveness was considered adequate when there was ≥ 10% increase in SV after fluid bolus. Minimal IVC diameter indexed to body surface area and its distensibility index can be predictors of fluid responsiveness at all times: 1 hour (area under curve [AUC] = 0.88; 95% confidence interval [CI] = 0.77–0.96), 6 hours (AUC = 0.86; 95% CI = 0.67–0.97), and 24 hours (AUC = 0.77; 95% CI = 0.6–0.95). IVC distensibility index can also predict fluid responsiveness at 1 hour (AUC= 0.87; 95% CI = 0.74–0.95), 6 hours (AUC = 0.86; 95% CI = 0.73–0.94), and 24 hours (AUC = 1; 95% CI = 0.77–1). The cutoff points of each parameter differed from time to time (contradicts with previous statement that says it is predictor at all times). The maximum IVC diameter could not predict fluid responsiveness at any time from admission. Minimal IVC diameter and its distensibility index were feasible noninvasive surrogates of fluid responsiveness in pediatric septic shock at different times from admission.

Prediction of fluid responsiveness using lung recruitment manoeuvre in paediatric patients receiving lung-protective ventilation: A prospective observational study.

Pressure-based dynamic variables are poor predictors of fluid responsiveness in children, and their predictability is expected to reduce further during lung-protective ventilation with a low tidal volume. We hypothesised that lung recruitment manoeuvre (LRM)-induced changes in dynamic variables improve their ability to predict fluid responsiveness in children. Prospective observational study. Tertiary care children's hospital, single-centre study performed from June 2017 to May 2019. We included patients less than 7 years of age undergoing cardiac surgery. Neonates and patients with pulmonary hypertension, significant dysrhythmia, ventricular ejection fraction of less than 30% or pulmonary disease were excluded. All patients were provided with lung-protective volume-controlled ventilation (tidal volume 6 ml kg-1, positive end-expiratory pressure 6 cmH2O). A LRM was applied with a continuous inspiratory pressure of 25 cmH2O for 20 s. The ability of dynamic variables to predict fluid responsiveness was evaluated by the area under the receiver operating characteristic curve [area under the curve (AUC)]. Fluid responsiveness was defined as an increase in the cardiac index by more than 15% with crystalloid administration (10 ml kg-1). Thirty patients were included in the final analysis, of whom 19 were responders. The baseline pleth variability index (PVI) (AUC 0.794, 95% confidence interval 0.608 to 0.919, P < 0.001) and LRM-induced PVI (AUC 0.711, 95% confidence interval 0.517 to 0.861, P = 0.026) could predict fluid responsiveness. The respiratory variation of pulse oximetry photoplethysmographic waveform and pulse pressure variation did not predict fluid responsiveness regardless of the LRM. The PVI is effective in predicting fluid responsiveness in paediatric patients with lung-protective ventilation regardless of a LRM. However, the LRM did not improve the ability of the other dynamic variables to predict fluid responsiveness in these patients. www.clinicaltrials.gov identifier: NCT03184961.