Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock

Abstract

A bstract Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods : After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18–65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as “responders.” Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 ( p = 0.016), 0.440 ( p = 0.052), and 0.044 ( p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. How to cite this article: Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al . Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310–316. CTRI/Trial Reg No: www.ctri.nic.in, CTRI/2017/11/010434

Questioning the Role of Carotid Artery Ultrasound in Assessing Fluid Responsiveness in Critical Illness: A Systematic Review and Meta-Analysis

“…The majority were unspecified/heterogeneous [ 9 , 25 , 29 , 32 , 34 , 35 , 37 , 39 ] or septic shock [ 26 , 30 , 31 , 33 , 36 , 40 ], with a minority of studies having cohorts of patients with haemorrhagic shock [ 27 ] or cardiogenic shock [ 38 ]. A fluid challenge was administered either by crystalloid bolus [ 27 – 31 , 34 , 37 , 40 ], passive leg raise (PLR) [ 25 , 26 , 32 , 38 , 39 ], or a combination of the two [ 9 , 33 , 35 , 36 ]. Crystalloid volume was determined by weight (6-7 ml/kg) or a predetermined value (200 ml–500 ml).…”

“…Crystalloid volume was determined by weight (6-7 ml/kg) or a predetermined value (200 ml–500 ml). The reference standards most commonly used were left ventricular outflow tract (LVOT) velocity time integral (VTI) [ 26 , 27 , 31 , 33 , 34 , 37 , 38 ] and noninvasive cardiac output monitor (NICOM) (Cheetah Medical, Inc) [ 9 , 25 , 28 , 29 ], with some studies used pulmonary artery catheter (PAC) [ 32 , 36 , 40 ], pulse contour cardiac output (PiCCO) (PULSION Medical Systems AG, Munich, Germany) [ 30 , 35 ], and FloTrac (Edwards Lifesciences, Irvine, CA, USA) [ 39 ].…”

Carotid Doppler ultrasound for non-invasive haemodynamic monitoring: a narrative review

“…Thirteen studies were conducted on ICU patients in either septic, cardiogenic or undifferentiated shock, and reported a median AUROC of 0.88 (IQR: 0.76-0.99), a sensitivity of 83% (IQR: 72%-94%), and a specificity of 86% (IQR:78%-94%). However, one study that compared septic shock patients with healthy controls found that AUROC predicting FR was lowest in the shock cohort (Chowhan et al 2021).…”

An Introduction to Statistics: Choosing the Correct Statistical Test

“…Chowhan et al compared the efficacy of left ventricular outflow tract velocity time integral (LVOTVTI) and carotid artery velocity time integral (CAVTI) as predictors of fluid responsiveness in patients with sepsis and septic shock. 6 Patients were divided into three groups— sepsis, septic shock, and controls. Since there were three groups, comparisons of numerical variables were done using analysis of variance (for normally distributed data) or Kruskal–Wallis test (for skewed data).…”

“…These represented paired readings from the same individual and comparison of prereading and postreading was performed using the paired t -test. 6 Verma et al evaluated the role of physiotherapy on oxygen requirements and physiological parameters in patients with COVID-19. 7 Each patient had pretreatment and post-treatment data for heart rate and oxygen supplementation recorded on day 1 and day 14.…”