Value In Predicting Fluid Responsiveness Research Articles

Advanced Hemodynamic Monitoring in Polytraumatized Patients: A Comprehensive Review

INTRODUCTION Advanced hemodynamic monitoring plays a crucial role in optimizing the perioperative management of polytraumatized patients, allowing for real-time assessment of cardiovascular status and guiding goal-directed therapy. Traditional monitoring methods, while widely used, have significant limitations that may hinder their effectiveness in dynamic trauma scenarios. The introduction of non-invasive technologies such as continuous non-invasive arterial pressure monitoring and impedance cardiography has improved hemodynamic assessment, providing valuable insights with reduced procedural risks. Despite these advancements, challenges remain in terms of accuracy, clinical integration, and training requirements. OBJETIVE To evaluate the efficacy and applicability of advanced hemodynamic monitoring techniques during anesthesia in polytraumatized patients, highlighting their impact on perioperative outcomes. METHODS This is a narrative review which included studies in the MEDLINE – PubMed (National Library of Medicine, National Institutes of Health), COCHRANE, EMBASE and Google Scholar databases, using as descriptors: “Polytrauma anesthesia” AND “Advanced hemodynamic monitoring” OR “Goal-directed therapy” OR “Non-invasive cardiac output monitoring” OR “Trauma resuscitation strategies” in the last years. RESULTS AND DISCUSSION Results demonstrate that the application of advanced hemodynamic monitoring techniques enhances intraoperative hemodynamic stability and reduces perioperative complications by enabling individualized fluid management and early detection of deterioration. Studies indicate that dynamic indices such as stroke volume variation and pulse pressure variation offer superior predictive value for fluid responsiveness compared to static parameters. However, the widespread implementation of these technologies is influenced by economic constraints, technological limitations, and the need for specialized expertise. CONCLUSION In conclusion, advanced hemodynamic monitoring significantly contributes to improving outcomes in polytraumatized patients under anesthesia by providing continuous and accurate cardiovascular data. Addressing the challenges of implementation through structured training programs and cost-benefit analyses is essential for broader clinical adoption. Future research should focus on refining these technologies to enhance their reliability and applicability across diverse trauma care settings.

Fluid therapy in ICU – A review

The most common indications of fluid resuscitation in critical care settings are severe hypovolemia, sepsis, trauma, burns, and perioperative fluid loss. Evaluation of intravascular volume status and the ability for identifying patients who might profit from volume expansion is vital. Traditional markers such as central venous pressure and pulmonary capillary wedge pressure have poor predictive value for fluid responsiveness. Dynamic indices such as pulse pressure variation, stroke volume variation, tidal volume challenge, and passive leg raise test are recommended to predict fluid responsiveness over static markers. The next perplexing part of fluid therapy is the choice of fluid resuscitation. The simplest answer is to provide crystalloids and avoid synthetic colloids (hydroxyethyl startch, gelatin, and dextran). Among the colloids, albumin has a role in certain clinical conditions in critical care settings. Between normal saline and buffered solutions, buffered solutions have the advantage of reducing acid–base disturbances, and chloride burden, and are likely to prevent renal failure. However, the advantage of buffered solutions did not consistently show up in large randomized controlled trials. Although administering fluids is a common therapeutic approach in critical care settings, administering fluids excessively has been linked to fatal outcomes. The resuscitation, optimization, stabilization, and evacuation concept describes the use of a dynamic fluid strategy to optimize benefits and prevent the negative effects of fluid overload. After receiving a patient in an emergency room or intensive care unit with hemodynamic instability, the first thing that comes to mind is whether or not the patient would benefit from fluid administration. How to predict fluid responsiveness? What type of fluids should be administered? When to stop administering fluids and start evacuation are vital questions confronted in day-to-day practice. In this article, we would like to discuss these issues and provide recommendations for current practices.

Prediction of fluid responsiveness for patients in shock using a ventilator disconnection test combined with the pulse contour-derived cardiac index.

Finding a simple and reliable method to predict and assess fluid responsiveness has long been of clinical interest. To investigate the predictive value of a ventilator disconnection (DV) test combined with the pulse contour-derived cardiac output (PiCCO) index on fluid responsiveness for patients in shock. Thirty-two patients were chosen for the study. Patients who were in shock, received mechanical ventilation, and met the inclusion criteria were selected. Patients were divided into a fluid-responsive group (14 patients) and fluid-unresponsive group (18 patients) based on whether the increase in cardiac index (Δ CI) was > 10% or not, respectively, following the fluid challenge test. Changes in heart rate, pulse oximeter-measured oxygen saturation, mean arterial pressure (MAP), and CI before and after passive leg raising (PLR), DV, and fluid challenge tests were observed. We used Pearson's correlation coefficient to analyze an increase in the MAP (Δ MAP) and Δ CI before and after the PLR, DV, and fluid challenge tests; the sensitivity and specificity of the Δ MAP and Δ CI in the PLR and DV tests for predicting fluid response were also analyzed by plotting the receiver operating characteristic (ROC) curves. CI results in the PLR and DV tests, as well as the fluid challenge test, were significantly higher in the fluid-responsive group compared with before the test (P< 0.05). The Δ CI before and after the PLR, DV, and fluid challenge tests were positively correlated among patients in the fluid-responsive group. The area under the ROC curve for the post-PLR test CI and the post-DV CI for predicting fluid responsiveness was 0.869 (95% confidence interval (CI) [0.735-1.000, P= 0.000]) and 0.937 (95% CI [0.829-1.000, P= 0.000]), respectively, in patients in the fluid-responsive group. The sensitivity and specificity of the post-DV CI for predicting fluid responsiveness in all patients was 100.0% and 88.9%, respectively, using a 5% increase as the cut-off value. Application of DV, combined with PiCCO, has a high predictive value for fluid responsiveness among patients in shock.

Internal jugular vein distensibility variation and inferior vena cava collapsibility variation with fluid resuscitation as an indicator for fluid management in spontaneously breathing septic patients

BackgroundSepsis is one of the leading causes of death in ICU patients. Fluid resuscitation is the main target in septic patients. Proper fluid administration is needed in septic patients to overcome generalized vasodilatation and capillary leak, this capillary leak itself may cause tissue edema and worsen septic patients. On the other hand, vasopressors may improve tissue perfusion or worsen tissue hypoxia. Therefore, predictors for fluid responsiveness are urgently needed. However, many studies have found static indicators useless. That is why dynamic predictors for fluid responsiveness are attracting growing interest to optimize patients.Our goal is to assess the predictive power of internal jugular vein distensibility index and inferior vena cava collapsibility index for fluid responsiveness in spontaneously breathing septic patients.Forty adult septic patients were enrolled from a single university teaching hospital’s ICU. We measured the Internal jugular distensibility index (IJV-DI) and Inferior vena cava collapsibility index (IVC-CI) in spontaneously breathing septic patients. Patients were considered responders if they had a change in cardiac index (≥ 15%) after fluid resuscitation with 7 ml/kg crystalloid. The main outcome measure is predictive power of Internal jugular vein distensibility index and Inferior vena cava collapsibility index.ResultsData from 40 spontaneously breathing septic patients were analyzed. Sixty percent of the patients were fluid responder. The areas under curve of receiver operating characteristic for Internal jugular vein distensibility index and Inferior vena cava collapsibility index to predict fluid responsiveness were 0.96 and 0.97, respectively. IJV-DI (> 17.56%) was predictive of fluid responsiveness with 95.83% sensitivity and 87.5% specificity. IVC-CI (> 35%) was predictive of fluid responsiveness with 95.8% sensitivity and 93.7% specificity.ConclusionsBoth IJV-DI and IVC-CI have near good predictive value for fluid responsiveness in spontaneously breathing septic patients.

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.

Prediction of Fluid Responsiveness by Stroke Volume Variation in Children Undergoing Fontan Operation.

Background Fontan operation is a palliative medical procedure performed on children with single-ventricle defects. As postoperative success of the procedure largely depends on the preload volume, it is necessary to maintain an appropriate pressure gradient between the systemic vein and the left atrium to ensure the effective volume of systemic circulation. However, there is a lack of effective indexes to evaluate fluid responsiveness in Fontan patients. Stroke volume variation (SVV) is a dynamic hemodynamic parameter based on cardiopulmonary interaction in mechanical ventilation. This study is aimed at validating the sensitivity and specificity of SVV and central venous pressure (CVP) in assessing the fluid responsiveness of Fontan patients. Method Sixty-four children with single ventricle who underwent modified Fontan operation between May 2018 and January 2020 were included in this study. Patients were administered 10 ml·kg−1 albumin for fluid challenge within 10 min after cardiopulmonary bypass. Before and after fluid challenge, the invasive arterial pressure module was connected to MostCare™ equipment to collect the cardiac index (CI) and SVV dynamically in a time window of 30 s at a frequency of 1000 Hz. According to the range of CI change, patients with ΔCI ≥ 15% were classified into the responder (R) group and those with ΔCI < 15% into the nonresponder (NR) group. Using SVV and CVP as indicators, the receiver operating characteristic (ROC) curve of the patients was established, and the area under curve (AUC), diagnostic threshold, sensitivity, and specificity were calculated. Results The SVV values were 16.28% (25th and 75th percentiles 14.17%-19.24%) and 13.68% (25th and 75th percentiles 12.90%-15.89%) before and after fluid challenge treatment in responders, respectively, and the values were 18.60 ± 1.83 mmHg before and 20.20 ± 2.39 mmHg for CVP after treatment. The AUC of SVV was 0.74 (95% confidence interval (CI) 0.54-0.94, P < 0.05), and the cutoff value was 16%, offering a sensitivity of 50% and a specificity of 91.7%. Meanwhile, the AUC of CVP was 0.70 (95% CI 0.50-0.92, P > 0.05), and the cutoff value was 19.5 mmHg, offering a sensitivity of 58% and a specificity of 76%. Conclusion SVV exhibited a good predictive value for fluid responsiveness in pediatric Fontan patients. Appropriate fluid therapy according to SVV could improve the cardiac function of such patients. Trial registration. This study was registered in Chinese Clinical Trail Registry on Jan 26, 2018. Registration number is ChiCTR1800014654. Registry URL is http://www.chictr.org.cn/showproj.aspx?proj=25019. This observational prospective study was approved by the Local Ethics Committee of Shanghai Children's Medical Center affiliated to Shanghai Jiao Tong University (SCMCIRB-K2017035).

Dynamic left intraventricular obstruction in patients with septic shock: pathogenetic role and prognostic implications

Background Left intraventricular flow obstruction (IVO) has been classically described in asymmetric hypertrophic cardiomyopathy, usually at the level of the left ventricular outflow tract (LVOT) or at midcavitary level, which is due to systolic anterior movement of the anterior leaflet of the mitral valve. This phenomenon has also been previously described in certain clinical situations mainly revolving around hypovolemia and catecholamine exposure and recently as a frequent event in patients with septic shock with an important correlation with fluid responsiveness. Multiple studies have demonstrated that static parameters limited the predictive value for fluid responsiveness, whereas dynamic parameters have shown a greater clinical use, including respiratory changes in aortic blood velocity, superior vena cava collapsibility, inferior vena cava (IVC) collapsibility, and changes in stroke volume and Cardiac Output (CO) owing to passive leg raising. Objective This study aimed to assess (a) the prevalence of dynamic IVO in patients with septic shock; (b) relation among IVO, volume status, and fluid responsiveness; and (c) relation between IVO and in-hospital mortality. Patients and methods A total of 40 patients with septic shock were studied over a period of 1 year for the presence of Doppler signs of dynamic IVO, clinical characteristics, hemodynamic parameters, and APACHE II and SOFA scoring. Echocardiographic data including IVC collapsibility, CO, LVOT mean and peak pressure gradient, LVOT maximum velocity, and midcavitary Doppler pattern were recorded initially and following fluid resuscitation (30 ml/kg). Patients were categorized into two groups: group A included patients with IVO and group B included patients without IVO. There was a statistically nonsignificant difference between both groups regarding the baseline demographic, clinical, and hemodynamic parameters. Results A total of 40 (45% were males and 55% females) patients, with a mean age of 52±20 years, were studied, of whom a total of 13 (32%) had IVO versus 27 patients without IVO. Following fluid infusion, as compared with group B, group A showed significantly greater increase in Cardiac Output (COP) (5.85±1.4 vs. 4.4±1.8, P=0.0203) and IVC collapsibility (54.42±6.8 vs 50.56±13, P=0.42). ICU mortality was significantly higher in patients with IVO [10/13 (76.9%)] versus patients without IVO [7/27 (25.9%), P Conclusion Dynamic left IVO is not uncommon in patients with septic shock in ICU. Response to fluid infusion was significantly higher in patients with IVO compared with patients without IVO, pointing to an additional role of fluid resuscitation in patients with sepsis.

Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness

Central venous pressure (CVP) has been shown to have poor predictive value for fluid responsiveness in critically ill patients. We aimed to re-evaluate this in a larger sample subgrouped by baseline CVP values. In April 2015, we systematically searched and included all clinical studies evaluating the value of CVP in predicting fluid responsiveness. We contacted investigators for patient data sets. We subgrouped data as lower (<8 mmHg), intermediate (8-12 mmHg) and higher (>12 mmHg) baseline CVP. We included 51 studies; in the majority, mean/median CVP values were in the intermediate range (8-12 mmHg) in both fluid responders and non-responders. In an analysis of patient data sets (n = 1148) from 22 studies, the area under the receiver operating curve was above 0.50 in the <8 mmHg CVP group [0.57 (95% CI 0.52-0.62)] in contrast to the 8-12 mmHg and >12 mmHg CVP groups in which the lower 95% CI crossed 0.50. We identified some positive and negative predictive value for fluid responsiveness for specific low and high values of CVP, respectively, but none of the predictive values were above 66% for any CVPs from 0 to 20 mmHg. There were less data on higher CVPs, in particular >15 mmHg, making the estimates on predictive values less precise for higher CVP. Most studies evaluating fluid responsiveness reported mean/median CVP values in the intermediate range of 8-12 mmHg both in responders and non-responders. In a re-analysis of 1148 patient data sets, specific lower and higher CVP values had some positive and negative predictive value for fluid responsiveness, respectively, but predictive values were low for all specific CVP values assessed.

Fluid responsiveness predicted by elevation of PEEP in patients with septic shock

The assessment of whether a patient is fluid responsive can be difficult in clinical practice. Invasive filling pressures are inadequate indicators of preload and fluid responsiveness in critically ill patients. Dynamic indices may be unreliable in clinical practice because of arrhythmias or spontaneous breathing efforts. Elevation of positive end-expiratory pressure (PEEP) causes cardiorespiratory interactions, which may produce signs of hypovolaemia. Our aim was to assess whether haemodynamic changes during a short elevation of PEEP would predict fluid responsiveness in patients with septic shock. We performed a prospective observational study in 20 patients with septic shock on mechanical ventilation. We assessed the following changes in haemodynamic variables during a temporary elevation of PEEP from 10 cm H2O to 20 cm H2O during an end-expiratory pause: mean arterial pressure (MAP), systolic arterial pressure, pulse pressure, central venous pressure, pulmonary artery occlusion pressure, left ventricular end diastolic area and aortic velocity-time integral. We defined fluid responsiveness as an increase in cardiac output of 15% to a subsequent fluid challenge. Decrease in MAP related to elevation of PEEP predicted fluid responsiveness (P = 0.003). The best cut-off value of ΔMAP for clinical use was -8%, with a negative predictive value for fluid responsiveness of 100%. In patients with septic shock, the absence of decrease in MAP during an elevation of PEEP may be used to identify patients who will not increase their cardiac output in response to fluid challenge.

Influence of tidal volume for stroke volume variation to predict fluid responsiveness in patients undergoing one-lung ventilation

We designed this study to determine the predictive value for fluid responsiveness of stroke volume variation (SVV) in patients undergoing one-lung ventilation (OLV), ventilated at different tidal volumes. All patients scheduled for pulmonary lobectomy were randomized into two groups according to their tidal volume [group H: tidal volume 8ml/kg (n=36); group L: tidal volume 6ml/kg (n=37)]. After starting OLV, volume loading was performed by administration of 500ml 6% hydroxyethylated starch for 30min. Hemodynamic variables were measured before and after volume loading using the Vigileo-FloTrac system. Patients in both groups were divided into fluid responders and non-responders, and responders were defined as those who demonstrated an increase in cardiac index ≥15% after volume expansion. The area under the receiver operating characteristic curve for SVV to discriminate between responders and non-responders was 0.776 in group H and 0.648 in group L. The optimal threshold value of SVV was 10.5% (sensitivity, 85.7%; specificity, 66.7%) in group H and 8% (sensitivity, 69.5%; specificity, 64.3%) in group L. We found that SVV could predict fluid responsiveness in patients undergoing OLV with acceptable levels of sensitivity and specificity only when tidal volume is at least 8ml/kg.

Ventilation‐induced variation in the arterially determined isovolumic contraction period is an excellent indicator of hemorrhagic shock

The ventilation‐induced relative variation in pre‐ejection period (ΔPEP) has recently been shown to predict fluid responsiveness in patients in shock. We hypothesized that the ventilatory variation in isovolumic contraction period determined by central arterial pulse wave analysis (ΔAIC) is a more sensitive predictor than the peripherally assessed ΔPEP which is influenced by pulse wave travel time and ventricular electro‐mechanical delay.To test this hypothesis we studied the responses of ΔAIC and ΔPEP to a graded hemorrhage protocol, and compared these to the response of the clinically well known pulse pressure variation (ΔPP), which has a high predictive value for fluid responsiveness.A graded hemorrhage protocol (blood withdrawal up to 20ml/kg) was instituted in 7 anesthetized Yorkshire X Landrace pigs. ΔAIC correlated well with ΔPP (r = 0.86, p&lt;0.001) and ΔPEP (r = 0.84, p&lt;0.001). Moreover, the coefficient of variation of ΔAIC (0.50) was found to be significantly lower than that of ΔPEP (0.94, p=0.04).ConclusionsΔAIC can be used to assess the level of hemorrhagic shock in a swine model and appears to be a more sensitive predictor of fluid responsiveness than ΔPEP.