Global End-diastolic Volume Index Research Articles

Individually Optimized Hemodynamic Therapy Reduces Complications and Length of Stay in the Intensive Care Unit

The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure. This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled. Intraoperative need for norepinephrine was decreased in the SG with a mean (±SD) of 9.0 ± 7.6 versus 14.9 ± 11.1 µg/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 ± 6 h; CG, 24 ± 29 h; P < 0.001), and length of ICU stay (SG, 42 ± 19 h; CG, 62 ± 58 h; P = 0.018) were reduced in the SG. Early goal-directed hemodynamic therapy based on cardiac index, stroke volume variation, and optimized global end-diastolic volume index reduces complications and length of ICU stay after cardiac surgery.

Mixed venous O2 saturation and fluid responsiveness after cardiac or major vascular surgery

BackgroundIt is unclear if and how SvO2 can serve as an indicator of fluid responsiveness in patients after cardiac or major vascular surgery.MethodsThis was a substudy of a randomized single-blinded clinical trial reported earlier on critically ill patients with clinical hypovolemia after cardiac or major vascular surgery. Colloid fluid loading was done for 90 min, guided by changes in pulmonary artery occlusion pressure (PAOP) or central venous pressure (CVP). Fluid responsiveness was defined as ≥15% increase in cardiac index (CI). Hemodynamics, including transpulmonary dilution-derived global end-diastolic volume index (GEDVI) and global ejection fraction (GEF), were measured and blood samples taken.ResultsWhereas baseline SvO2 (>70% in 68% of patients) did not differ, the SvO2 increased in patients responding to fluid loading (≥15% in CI in n = 26) versus those not responding (n = 11; P = 0.03). The increase in GEDVI was also greater in responders (P = 0.005). The area under the receiver operating characteristic curve for fluid responsiveness of changes in SvO2 was 0.73 (P = 0.007), with an optimal cutoff of 2%, and of those in GEDVI 0.82 (P < 0.001), while the areas did not differ. However, the value of SvO2 increases to reflect CI increases with fluid loading was greatest when GEF was ≤20% (in 53% of patients).ConclusionsAn increase in SvO2 ≥2%, irrespective of a relatively high baseline value, can thus be used as a monitor of fluid responsiveness in clinically hypovolemic patients after cardiac or major vascular surgery, particularly in those with systolic cardiac dysfunction. Fluid responsiveness concurs with increased tissue O2 delivery.

Prediction of Volume-Responsiveness During One-Lung Ventilation: A Comparison of Static, Volumetric, and Dynamic Parameters of Cardiac Preload

The aim of this study was to evaluate the ability of static, volumetric, and dynamic parameters of cardiac preload to predict volume responsiveness during one-lung ventilation (OLV). Prospective experimental study. Laboratory of the animal facility of the University Medical Center Hamburg-Eppendorf. Twenty-three German domestic pigs. Hypovolemia was induced by withdrawing 20 mL/kg body weight (BW) of blood. OLV was established, and the volume withdrawn was re-transfused in 3 volume-loading steps, each consisting of 7 mL/kg BW. An ultrasonic flow probe around the pulmonary artery was used to measure the stroke-volume index (SVI) and to evaluate the volume response. An increase in the SVI of ≥ 15% was considered a positive response. For each measurement time point, central venous pressure (CVP), left atrial pressure (LAP), the global end-diastolic volume index (GEDI), stroke-volume variation (SVV), and pulse-pressure variation (PPV) were recorded. The ability to predict volume responsiveness was assessed using ROC analysis. A total of 69 volume loading steps were performed, 48 of which showed a positive volume response. ROC analysis revealed the following area under the curve (AUC) values: CVP, 0.88; LAP, 0.65; GEDI, 0.75; SVV, 0.78; and PPV, 0.83. A comparison of the areas under the ROC curves did not reveal any statistically significant differences (p>0.05), with the exception of LAP compared with CVP (p = 0.005). Under these OLV experimental conditions, the volumetric and dynamic parameters of preload, as well as CVP, seemed to be of similar value in predicting volume responsiveness.

Study on factors influencing the failure of PiCCO on weaning from mechanical ventilation in ARDS patients

Objective To analyze and evaluate the variability and effects of extra-vascular lung water index (EVLWI),preload and cardiac function on weaning from mechanical ventilation in patients with ARDS.Methods All patients suffered from ARDS were treated with mechanical ventilation and monitored by pulse indicator continuous cardiac output (PiCCO) till they reached weaning criteria,then spontaneous breathing trial,weauing and extubation were performed in succession.The enrolled patients were divided into two groups,namely success group and failure group according to clinic outcome after weaning in 48 hours.EVLWI,preload markers such as global end-diastolic volume index (GEDI),intrathoracic blood volume index (ITBI),and cardiac function such as cardiac output and cardiac index were compared between two groups before weaning (T0),0.5 h after weaning (T1),0.5 h after extubation (T2),and observational endpoints (T3) (Observational eudpoint is defined as “ before re-intubation” in failure group or 48 h after extubation in succcss group).Results A total of 69 ARDS patients were enrolled from August 2010 to September 2012.Compared with variables before weaning,GEDI and ITBI were markedly higher observed at T1 and T2 (P ＜ 0.05).EVLWI was significantly increased at T1,T2 and T3 (P ＜ 0.01).Increased pulmonary vascular permeability index (PVPI) were also found at T3 (P ＜ 0.05).Compared with the success group,GEDI and ITBI in the failure group were higher at T1,T2 and T3 (P ＜0.05),and EVLWI were significant higher at T2 and T3 (P ＜ 0.05),and increased PVPI at 33 (P ＜0.05).Conclusions Additional volume load may result from weaning off mechanical ventilation and extubation in ARDS patients,and can induce high pulmonary vascular permeability causing pulmonary edema and weaning failure.Therefore,monitoring of EVLWI and preload markers could be valuable to predicting the prognosis of weaning from mechanical ventilation. Key words: Acute respiratory distress syndrome ; Mechanical ventilation; Pulse indicator continuous cardiac output ; Extravascular lung water index

Global end-diastolic volume increases to maintain fluid responsiveness in sepsis-induced systolic dysfunction

BackgroundSepsis-induced cardiac dysfunction may limit fluid responsiveness and the mechanism thereof remains unclear. Since cardiac function may affect the relative value of cardiac filling pressures, such as the recommended central venous pressure (CVP), versus filling volumes in guiding fluid loading, we studied these parameters as determinants of fluid responsiveness, according to cardiac function.MethodsA delta CVP-guided, 90 min colloid fluid loading protocol was performed in 16 mechanically ventilated patients with sepsis-induced hypotension and three 30 min consecutive fluid loading steps of about 450 mL per patient were evaluated. Global end-diastolic volume index (GEDVI), cardiac index (CI) and global ejection fraction (GEF) were assessed from transpulmonary dilution. Baseline and changes in CVP and GEDVI were compared among responding (CI increase ≥10% and ≥15%) and non-responding fluid loading steps, in patient with low (<20%, n = 9) and near-normal (≥20%) GEF (n = 7) at baseline.ResultsA low GEF was in line with other indices of impaired cardiac (left ventricular) function, prior to and after fluid loading. Of 48 fluid loading steps, 9 (of 27) were responding when GEF <20% and 6 (of 21) when GEF ≥20. Prior to fluid loading, CVP did not differ between responding and non-responding steps and levels attained were 23 higher in the latter, regardless of GEF (P = 0.004). Prior to fluid loading, GEDVI (and CI) was higher in responding (1007 ± 306 mL/m2) than non-responding steps (870 ± 236 mL/m2) when GEF was low (P = 0.002), but did not differ when GEF was near-normal. Increases in GEDVI were associated with increases in CI and fluid responsiveness, regardless of GEF (P < 0.001).ConclusionsAs estimated from transpulmonary dilution, about half of patients with sepsis-induced hypotension have systolic cardiac dysfunction. During dysfunction, cardiac dilation with a relatively high baseline GEDVI maintains fluid responsiveness by further dilatation (increase in GEDVI rather than of CVP) as in patients without dysfunction. Absence of fluid responsiveness during systolic cardiac dysfunction may be caused by diastolic dysfunction and/or right ventricular dysfunction.

Multicenter Prospective Cohort Study on Volume Management After Subarachnoid Hemorrhage

Systemic circulation management has not been established for patients with poor grade aneurysmal subarachnoid hemorrhage (SAH) or delayed cerebral ischemia (DCI) after SAH. The aims of the study were to examine hemodynamic variables in these patients and to establish treatment strategies. A multicenter prospective cohort study of hemodynamic variables from days 1 to 14 was performed using a transpulmonary thermodilution system (PiCCO Plus). Parameters were analyzed by Mann-Whitney test. Multivariate analysis was performed to identify parameters involved in onset of DCI. The subjects were 204 patients, including 138 with poor grade SAH (World Federation of Neurological Surgeons grades IV and V) and 52 who developed DCI. The extravascular lung water index, pulmonary vascular permeability index, and systemic vascular resistance index were significantly greater in patients with poor grade SAH compared with those with good grade SAH (World Federation of Neurological Surgeons I-III) on day 2 (P=0.049, P=0.039, and P=0.038). Cardiac index was significantly lower in patients with poor grade SAH on days 1 and 2 (P=0.027 and P=0.011). In patients with DCI, the global end-diastolic volume index was significantly lower than in those without DCI on days 3 to 5 (P=0.0053; P=0.048; and P=0.048). In multivariate analysis, median global end-diastolic volume index, cardiac index, and systemic vascular resistance index at an early stage of SAH (days 3-6) were independently related to onset of DCI (P=0.023, P=0.013, and P=0.003). Patients with poor grade SAH developed heart failure-like afterload mismatch at an early stage, and those with DCI had decreased global end-diastolic volume index (hypovolemia) in the early stage of SAH. http://www.clinicaltrials.gov. Unique identifier: UMIN000003794.

An Assessment of Global End-Diastolic Volume and Extravascular Lung Water Index During One-Lung Ventilation

The thermodilution curve assessed by transpulmonary thermodilution is the basis for calculation of global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI). Until now, it was unclear whether the method is affected by 1-lung ventilation. Therefore, aim of our study was to evaluate the impact of 1-lung ventilation on the thermodilution curve and assessment of GEDI and EVLWI. In 23 pigs, mean transit time, down slope time, and difference in blood temperature (ΔTb) were assessed by transpulmonary thermodilution. "Gold standard" cardiac output was measured by pulmonary artery flowprobe (PAFP) and used for GEDIPAFP and EVLWIPAFP calculations. Measurements were performed during normovolemia during double-lung ventilation (M1), 15 minutes after 1-lung ventilation (M2) and during hypovolemia (blood withdrawal 20 mL/kg) during double-lung ventilation (M3) and again 15 minutes after 1-lung ventilation (M4). Configuration of the thermodilution curve was significantly affected by 1-lung ventilation demonstrated by an increase in ΔTb and a decrease in mean transit time and down slope time (all P < 0.04) during normovolemia and hypovolemia. GEDIPAFP was lower after 1-lung ventilation during normovolemia (M1: 459.9 ± 67.5 mL/m(2); M2: 397.0 ± 54.8 mL/m(2); P = 0.001) and hypovolemia (M3: 300.6 ± 40.9 mL/m(2); M4: 275.2 ± 37.6 mL/m(2); P = 0.03). EVLWIPAFP also decreased after 1-lung ventilation in normovolemia (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) and hypovolemia (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4]) mL/kg; P = 0.0009). Configuration of the thermodilution curve and therefore assessment of GEDI and EVLWI are significantly affected by 1-lung ventilation.

Management of Severe Malaria

Management of Severe Malaria

Fluid Resuscitation of Adults With Severe Falciparum Malaria

To evaluate the efficacy and safety of liberal fluid resuscitation of adults with severe malaria. DESIGN, SETTING, PATIENTS, AND METHODS: Twenty-eight Bangladeshi and Indian adults with severe falciparum malaria received crystalloid resuscitation guided by transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic hemodynamics, microvascular indices and measures of acidosis, renal function, and pulmonary edema were followed prospectively. All patients were hypovolemic (global end-diastolic volume index<680 mL/m) on enrollment. Patients received a median (range) 3230 mL (390-7300) of isotonic saline in the first 6 hours and 5450 mL (710-13,720) in the first 24 hours. With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there was no significant improvement in renal function. Extravascular lung water increased in 17 of 22 liberally resuscitated patients (77%); eight of these patients developed pulmonary edema, five of whom died. All other patients survived. All patients with pulmonary edema during the study were hypovolemic or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in hypovolemic patients before (rs=0.38; p=0.05) and after (rs=0.49; p=0.01) resuscitation but was the strongest predictor of mortality before (chi-square=9.9; p=0.002) and after resuscitation (chi-square=11.1; p<0.001) and correlated with the degree of visualized microvascular sequestration of parasitized erythrocytes at both time points (rs=0.55; p=0.003 and rs=0.43; p=0.03, respectively). Persisting sequestration was evident in 7 of 15 patients (47%) 48 hours after enrollment. Lactic acidosis--the strongest prognostic indicator in adults with severe falciparum malaria--results from sequestration of parasitized erythrocytes in the microcirculation, not from hypovolemia. Liberal fluid resuscitation has little effect on this sequestration and does not improve acid-base status or renal function. Pulmonary edema--secondary to increased pulmonary vascular permeability--is common, unpredictable, and exacerbated by fluid loading. Liberal fluid replacement of adults with severe malaria should be avoided.

Effects of red blood cell transfusion on hemodynamic parameters: a prospective study in intensive care unit patients

BackgroundThe aim of the study was to investigate the effect of red blood cell (RBC) transfusion on hemodynamic parameters including transpulmonary thermodilution (TPTD)-derived variables.MethodsWe compared hemodynamic parameters obtained before and after RBC transfusion (2 RBC units) in 34 intensive care unit (ICU) patients.ResultsDirectly after RBC transfusion, we observed a significant increase in hematocrit (28 ± 3 vs. 22 ± 2%, p < 0.001), hemoglobin (9.4 ± 0.9 vs. 7.6 ± 0.8 g/dL, p < 0.001), arterial oxygen content (CaO2) (12.2 ± 1.2 vs. 9.9 ± 1.0 mL/dL, p < 0.001), and oxygen delivery (DO2) (1073 ± 369 vs. 934 ± 288 mL/min, p < 0.001) compared with baseline. Cardiac output (CO) (8.89 ± 3.06 vs. 9.42 ± 2.75 L/min, p = 0.020), cardiac index (CI) (4.53 ± 1.36 vs. 4.82 ± 1.21 L/min/m2, p = 0.016), and heart rate (91 ± 16 vs. 95 ± 14 bpm, p = 0.007) were significantly lower following RBC transfusion while no significant change in stroke volume (SV) was observed. Mean arterial pressure (MAP) (median 87 vs. 78 mmHg, p < 0.001) and systemic vascular resistance index (SVRI) (median 1212 vs. 1103 dyn*s*cm-5*m2, p = 0.001) significantly increased directly after RBC transfusion. Global end-diastolic volume index (GEDVI), extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI) did not significantly change.ConclusionsIn ICU patients, the transfusion of 2 RBC units induces a significant decrease in CO and CI because of a significant decrease in heart rate (while SV remains unchanged). Despite the decrease in CO, DO2 significantly increases because of a significant increase in CaO2. In addition, RBC transfusion results in a significant increase in MAP and SVRI. No significant changes in TPTD-parameters reflecting cardiac preload (GEDVI), pulmonary edema (EVLWI), and pulmonary vascular permeability (PVPI) are observed following RBC transfusion.

Clinical value of extravascular lung water and preload parameters in weaning of mechanical ventilation in patients with septic shock

To investigate the values of extravascular lung water and preload parameters of weaning from mechanical ventilation on patients with septic shock. A prospective study was conducted. A total of 52 septic shock patients with mechanical ventilation were enrolled from January 2010 to July 2012. All patients were treated and monitored by pulse induced continuous cardiac output (PiCCO) till they reached weaning criteria, and then spontaneous breathing trial (SBT), weaning, and extubation were performed in turn. The enrolled patients were divided into two groups including successful weaning group (n=38) and weaning failure group (n=14) according to clinical manifestations during 48 hours after weaning. Extravascular lung water index (EVLWI), preload parameters such as global end diastolic volume index (GEDVI) and intra-thoracic blood volume index (ITBVI), pulmonary vascular permeability index (PVPI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were compared at the time before weaning, 0.5 hour after weaning, 0.5 hour after extubation, and time of weaning failure or 48 hours after weaning. The patients in weaning failure group were sub-divided into high PVPI group (PVPI≥1.5 ml/m(2)) and low PVPI group (PVPI<1.5 ml/m(2)), the NT-proBNP and pulmonary blood volume (PBV) were compared between two groups. Before weaning, there was no statistical difference in NT-proBNP, volume parameters and EVLWI between two groups. EVLWI, GEDVI, ITBVI, PVPI and log NT-proBNP were gradually increased after weaning and extubation in two groups. The EVLWI, PVPI and log NT-proBNP were significantly higher at end point of observation in weaning failure group compared with those in successful weaning group (EVLWI: 12.81±2.13 ml/kg vs. 8.48±1.53 ml/kg, PVPI: 2.79±1.29 ml/m(2) vs. 2.19±0.94 ml/m(2), log NT-proBNP: 3.72±0.35 vs. 3.44±0.28, P<0.05 or P<0.01). GEDVI, ITBVI at 0.5 hour after weaning and end point of observation in weaning failure group were significantly higher than those in successful weaning group (0.5 hour after extubation: GEDVI 986.29±166.44 ml/m(2) vs. 856.47±149.15 ml/m(2), ITBVI: 1171.07±167.03 ml/m(2) vs. 1045.79±146.09 ml/m(2); end point of observation: GEDVI 957.00±67.25 ml/m(2) vs. 816.86±27.58 ml/m(2), ITBVI: 1184.29±209.68 ml/m(2) vs. 993.79±168.90 ml/m(2), P<0.05 or P<0.01). Sub-analysis showed that in weaning failure group, higher log NT-proBNP and PBV were found in patients with low PVPI compared with those with high PVPI (log NT-proBNP: 4.02±0.11 vs. 3.71±0.23, PBV: 507.19±25.72 ml vs. 347.85±47.52 ml, P<0.05 and P<0.01). Increased EVLW is the reason of pulmonary edema caused by weaning in septic shock patients, to which both hydrostatic and pulmonary permeability may contribute, and the latter could be more important. Monitoring preload parameters could help distinguish the mechanism of pulmonary edema after weaning, which may be useful in treatment.

Application of PiCCO monitoring in patients with neurogenic pulmonary edema

To evaluate the application of pulse induced contour cardiac output (PiCCO) monitoring in patients with neurogenic pulmonary edema (NPE), and to assess the accuracy of capacity parameters such as intra thoracic blood volume index (ITBVI) and global end diastolic volume index (GEDVI) and pressure parameters such as central venous pressure (CVP) in estimating severity of NPE, and to assess the prognostic significance of extravascular lung water index (EVLWI) on patients with NPE. In this prospective study, 36 patients with NPE in the department of neurological intensive care unit (NICU) underwent PiCCO monitoring, including mean arterial pressure (MAP), cardiac index (CI), CVP, ITBVI, GEDVI, EVLWI, pulmonary vascular permeability index (PVPI). The correlation between ITBVI, GEDVI, CVP and EVLWI was assessed. According to the outcome, these patients were divided into nonsurvivor group and survivor group. The change in EVLWI before and after treatment was compared between two groups. ITBVI, GEDVI were significantly and positively correlated with EVLWI, for the former r =0.54, P<0.001, and for the latter r=0.62, P<0.0001, but there was no significant correlation between CVP and EVLWI, r= 0.12, P>0.05. PVPI, EVLWI were significantly and negatively correlated with oxygenation index (PaO2 / FiO2), for the former r=-0.55, P< 0.001, and for the latter r=-0.48, P<0.05. The difference in EVLWI level before treatment between survivor group and nonsurvivor group was not statistically significant (8.6±2.6 ml/kg vs. 9.4±1.8 ml/kg, P>0.05). In survivor group, EVLWI level obviously declined after treatment (6.92±1.64 ml/kg vs. 8.64±2.62 ml/kg, P<0.05), EVLWI level of survivor group was significantly lower than that of nonsurvivor group (6.92±1.64 ml/kg vs. 9.88±2.44 ml/kg, P<0.05). Capacity parameters such as GEDVI, ITBVI can assess EVLWI of NPE patients accurately and reliably. In NPE patients, the higher the PVPI and EVLWI, the lower the PaO2 / FiO2. By dynamic observation of the trends of EVLWI in NPE patients, we are able to assess the prognosis of these patients.

The influence of haemodialysis on haemodynamic measurements using transpulmonary thermodilution in patients with septic shock

Patients with sepsis frequently present with acute renal failure requiring intermittent renal replacement therapy and haemodynamic monitoring. To date, the effect of haemodialysis on PiCCO monitoring has not been determined. To determine the effect of haemodialysis on the measurement of haemodynamic variables using transpulmonary thermodilution. Prospective observational study. Medical ICU in a university hospital. Thirty patients with sepsis and acute renal failure undergoing intermittent haemodialysis. None. Cardiac index, global end-diastolic volume index and extravascular lung water index measured with or without haemodialysis. Significant correlations were found for all variables measured with and without haemodialysis (r = 0.55 to 0.91, P < 0.01). Measurements of cardiac index without and with haemodialysis were significantly different [4.71 vs. 4.18 lmin(-1)m(-2), difference -0.54 (SD 0.70), 95% confidence interval (CI) -0.80 to -0.28; P < 0.01], as were values of global end-diastolic volume index without and with haemodialysis [864.8 vs. 775.3 ml m(-2), difference -89.5 (SD 191.8), 95% CI -161.2 to -17.9; P = 0.02]. Measurements of extravascular lung water index without and with haemodialysis did not differ significantly [10.3 vs. 10.0 ml kg(-1), difference -0.3 (SD 2.0), 95% CI -1.1 to 0.5; P = 0.42]. Although significant correlations were found for cardiac index, global end-diastolic volume index and extravascular lung water index with and without haemodialysis, cardiac index and global end-diastolic volume index were significantly reduced during haemodialysis, but not extravascular lung water index, when measured by the PiCCO system in patients with septic shock. Although differences were small, the variability of within-patient differences may be clinically important and care should be taken in relying solely on such measurements.

Renal replacement therapy with net fluid removal lowers intra-abdominal pressure and volumetric indices in critically ill patients.

BackgroundLittle is known about the effects of renal replacement therapy (RRT) with fluid removal on intra-abdominal pressure (IAP). The global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI) can easily be measured bedside by transpulmonary thermodilution (TPTD). The aim of this study is to evaluate the changes in IAP, GEDVI and EVLWI in critically ill patients receiving slow extended daily dialysis (SLEDD) or continuous venovenous haemofiltration (CVVH) with the intention of net fluid removal.MethodsWe performed a retrospective cohort study in ICU patients who were treated with SLEDD or CVVH and in whom IAP was also measured, and RRT sessions were excluded when the dose of vasoactive medication needed to be changed between the pre- and post-dialysis TPTD measurements and when net fluid loss did not exceed 500 ml. The TPTD measurements were performed within 2 h before and after SLEDD; in case of CVVH, before and after an interval of 12 h.ResultsWe studied 25 consecutive dialysis sessions in nine patients with acute renal failure and cardiogenic or non-cardiogenic pulmonary oedema. The GEDVI and EVLWI values before dialysis were 877 ml/m² and 14 ml/kg, respectively. Average net ultrafiltration per session was 3.6 l, with a net fluid loss 1.9 l. The GEDVI decreased significantly during dialysis, but not more than 47.8 ml/m² (p = 0.008), as also did the EVLWI with 1 ml/kg (p = 0.03). The IAP decreased significantly from 12 to 10.5 mmHg (p < 0.0001).ConclusionsNet fluid removal by SLEDD or CVVH in the range observed in this study decreased IAP, GEDVI and EVLWI in critically ill patients although EVLWI reduction was modest.

Changes in brain natriuretic peptide are correlated with changes in global end-diastolic volume index.

It is believed that the stretch of cardiomyocytes is the most important stimulus of brain natriuretic peptide (BNP) release; however, its correlation with volume status represented by global end diastolic volume index (GEDVI) is less well established. The study aimed to investigate the correlation between the changes in BNP and the changes in GEDVI measured with transpulmonary thermodilution technique. Critically ill patients requiring hemodynamic monitoring (PiCCO system) in a tertiary 18-bed intensive care unit were prospectively enrolled. Hemodynamic variables were measured simultaneously with blood sampling for BNP concentration. Correlations between changes in BNP and changes in GEDVI were tested using pairwise correlation analysis. A total of 46 patients were included in the study. BNP level (median 4,602 pg/mL; IQR 1,988 to 12,439 pg/mL) was markedly elevated in the study population, but was not correlated with GEDVI (rho=-0.09, P=0.56). The changes in BNP (ΔBNP) showed significant correlation with changes in GEDVI (ΔGEDVI) (Figure 2; rho=0.52, P<0.01). Variables including Age (r=0.43, P=0.002), serum creatinine (r=0.36, P=0.012) and cardiac index (CI) (r=-0.35, P=0.016) were also significantly correlated with logBNP. Other variables such as APACHE II score, central venous pressure (CVP), heart rate (HR), intrathoracic blood volume (ITBVI), extravascular lung water (EVLWI) and systemic vascular resistance index (SVRI) were not significantly correlated with logBNP. Changes in BNP concentrations are correlated with changes in GEDVI and serial measurements of BNP concentrations may be a useful tool for monitoring volume status.

Prediction of fluid responsiveness in patients admitted to the medical intensive care unit

PurposeAccurate prediction of fluid responsiveness is of importance in the treatment of patients admitted to the intensive care unit (ICU). We investigated whether physical examination, central venous pressure (CVP), central venous oxygen saturation (ScvO2), passive leg raising (PLR) test, and transpulmonary thermodilution (TPTD)–derived parameters can predict volume responsiveness in patients admitted to the ICU. Materials and MethodsIn this prospective study, structured clinical examination, measurement of CVP and ScvO2, a PLR test, and TPTD measurements were performed in 31 patients. A fluid challenge test was performed in 24 patients (fluid responsiveness was defined as a cardiac index [CI] increase of ≥15%). ResultsPhysical examination, CVP, ScvO2, the PLR test, and the TPTD-derived volumetric preload parameter global end-diastolic volume index showed poor prognostic capabilities regarding prediction of fluid responsiveness. Twenty-nine percent of patients were fluid responsive. There was a statistically significant correlation between the fluid challenge–induced increase in CI and changes in global end-diastolic volume index (r = 0.666, P < .001). In only 17% of patients, CI did not increase after fluid loading. ConclusionsPrediction of fluid responsiveness is difficult using physical examination, CVP, ScvO2, PLR maneuver, or TPTD-derived variables in critically ill patients. A volume challenge test should be considered for the assessment of fluid responsiveness in critically ill patients admitted to the ICU.

Global End-diastolic Volume Is Associated With the Occurrence of Delayed Cerebral Ischemia and Pulmonary Edema After Subarachnoid Hemorrhage

Predictive variables of delayed cerebral ischemia (DCI) and pulmonary edema following subarachnoid hemorrhage (SAH) remain unknown. We aimed to determine associations between transpulmonary thermodilution-derived variables and DCI and pulmonary edema occurrence after SAH. We reviewed 34 consecutive SAH patients monitored by the PiCCO system. Six patients developed DCI at 7 days after SAH on average; 28 did not (non-DCI). We compared the variable measures for 1 day before DCI occurred (DCI day -1) in the DCI group and 6 days after SAH (non-DCI day -1) in the non-DCI group for control. The mean value of the global end-diastolic volume index (GEDI) for DCI day -1 was lower than that for non-DCI day -1 (676 ± 65 vs. 872 ± 85 mL/m, P = 0.04). Central venous pressure (CVP) was not significantly different (7.8 ± 3.1 vs. 9.4 ± 1.9 cm H2O, P = 0.45). At day -1 for both DCI and non-DCI, 11 patients (32%) had pulmonary edema. Global end-diastolic volume index was significantly higher in patients with pulmonary edema than in those without this condition (947 ± 126 vs. 766 ± 81 mL/m, P = 0.02); CVP was not significantly different (8.7 ± 2.8 vs. 9.2 ± 2.1 cm H2O, P = 0.78). Although significant correlation was found between extravascular lung water (EVLW) measures and GEDI (r = 0.58, P = 0.001), EVLW and CVP were not correlated (r = 0.03, P = 0.88). Thus, GEDI might be associated with DCI occurrence and EVLW accumulation after SAH.

792 Predictors of Fluid Response in a Animal Model of Hemorrhagic Shock

Background and AimsPrediction of fluid response is of paramount importance when managing shock. The aim of the present study was to test the hypothesis that pre-infusion values of several hemodynamic...

Comparison of values in critically ill patients for global end-diastolic volume and extravascular lung water measured by transcardiopulmonary thermodilution: A metaanalysis of the literature

IntroductionHemodynamic parameters such as the global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI), derived by transpulmonary thermodilution, have gained increasing interest for guiding fluid therapy in critically ill patients. The proposed normal values (680–800ml/m2 for GEDVI and 3–7ml/kg for EVLWI) are based on measurements in healthy individuals and on expert opinion, and are assumed to be suitable for all patients. We analyzed the published data for GEDVI and EVLWI, and investigated the differences between a cohort of septic patients (SEP) and patients undergoing major surgery (SURG), respectively. MethodsA PubMed literature search for GEDVI, EVLWI or transcardiopulmonary single/double indicator thermodilution was carried out, covering the period from 1990 to 2010. InterventionMeta-regression analysis was performed to identify any differences between the surgical (SURG) and non-surgical septic groups (SEP). ResultsData from 1925 patients corresponding to 64 studies were included. On comparing both groups, mean GEDVI was significantly higher by 94ml/m2 (95%CI: [54; 134]) in SEP compared to SURG patients (788ml/m2 95%CI: [762; 816], vs. 694ml/m2, 95%CI: [678; 711], p<0.001). Mean EVLWI also differed significantly by 3.3ml/kg (95%CI: [1.4; 5.2], SURG 7.2ml/kg, 95%CI: [6.9; 7.6] vs. SEP 11.0ml/kg, 95%CI: [9.1; 13.0], p=0.001). ConclusionsThe published data for GEDVI and EVLWI are heterogeneous, particularly in critically ill patients, and often exceed the proposed normal values derived from healthy individuals. In the group of septic patients, GEDVI and EVLWI were significantly higher than in the group of patients undergoing major surgery. This points to the need for defining different therapeutic targets for different patient populations.

Individualizing hemodynamic optimization during the management of circulatory collapse

The best method of hemodynamic monitoring to guide the resuscitation and management of the critically ill patient is unclear. The evaluated article presents data from a prospective randomized controlled trial that recruited 120 shocked patients (n = 60 in each arm) to compare volume-limited versus pressure-limited hemodynamic management. Patients were randomized into two protocolized fluid therapy algorithms using either the upper limits of hemodynamic indices of arterial pulse contour cardiac output and transpulmonary thermodilution (TPTD) analysis (extra vascular lung water <10 ml/kg and global end-diastolic volume index 850 ml/m2) or pulmonary artery catheter pressures (<18–20 mmHg). Primary outcomes were ventilator-free days, duration of mechanical ventilation, intensive care unit and hospital stay. Secondary outcomes included sequential organ failure assessment scores and mortality. No benefit was found between pulmonary artery catheter and TPTD in the primary outcomes; interestingly, the nonseptic patients who were monitored with TPTD spent longer on mechanical ventilation and in the intensive care unit.