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

Kuitunen, Anne; Pettilä, Ville; Varpula, Marjut

doi:10.1111/aas.12229

Cited by 26 publications

(26 citation statements)

References 47 publications

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“…Previous authors demonstrated that a brief "PEEP challenge" resulting in hypotension could predict fluid responsiveness. 36 To our knowledge, a similar strategy modifying tidal volumes has not been tried.…”

Section: Discussionmentioning

confidence: 99%

Multiparameter Predictor of Fluid Responsiveness in Cardiac Surgical Patients Receiving Tidal Volumes Less Than 10 mL/kg

Ikeda

Smith

Renehan

et al. 2016

Semin Cardiothorac Vasc Anesth

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Introduction We hypothesize that respiratory variation in the pulmonary artery tracing predicts fluid responsiveness (primary hypothesis) and that inclusion of multiple physiologic waveforms as well as ventilator settings in a predictive model of fluid responsiveness would lead to improvements in the clinical utility of this class of metrics (secondary hypothesis). Methods Blood pressure tracings were prospectively recorded in 35 patients immediately following cardiac surgery. Fluid bolus administration data, ventilator settings, and cardiac output were recorded prospectively before and after fluid boluses given at the discretion of the treating physician. Results We observed statistically significant but limited relationships between pulmonic (r(2) = .26, P = .0052) and systemic (r(2) = .13, P = .011) pulse pressure variation and changes in cardiac index. A multiparameter estimate of fluid responsiveness, which included respiratory variation in central venous pressure and pulmonary artery pressure, indexed tidal volumes, positive end-expiratory pressure, and mean airway pressure, was also correlated with change in cardiac index (r(2) = .42, P = .0056). Using the area under the curve (AUC) technique to compare specificity and sensitivity, dynamic indicators (AUC = 0.74, 0.67, and 0.81 for systemic arterial respiratory [pulse pressure] variation, pulmonic arterial respiratory [pulse pressure] variation, and the multiparameter estimate, respectively) outperformed static estimates (0.49 and 0.48 for central venous pressure and pulmonary artery diastolic pressure, respectively). Conclusion While integration of multiple physiologic waveforms as well as ventilator parameters improves the predictability of fluid responsive metrics in the setting of lung-protective ventilation, the composite index may still be of limited predictive value.

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Section: Discussionmentioning

confidence: 99%

Multiparameter Predictor of Fluid Responsiveness in Cardiac Surgical Patients Receiving Tidal Volumes Less Than 10 mL/kg

Ikeda

Smith

Renehan

et al. 2016

Semin Cardiothorac Vasc Anesth

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show abstract

“…During the last minute of high V T ventilation, measurements of the above-mentioned hemodynamic and respiratory variables, After the V T was returned to 6 ml/kg PBW and all of the hemodynamic variables had returned to baseline values (variations < 10%), VE was performed for 10 minutes using an infusion of 6% hydroxyethyl starch (HES 130/0.4, Volulyte; Fresenius Kabi, Stans, Switzerland) 6 ml/kg PBW. Two sets of measurements (HR, MAP, SVI, PV, PIP, Crs, PPV, and SVV) were performed before (T3, base 2) and 5 minutes after VE (T4) [28,29]. Percentage differences in ODM-derived SVIs before and after VE were used as principal indicators of fluid responsiveness.…”

Section: Study Protocolmentioning

confidence: 99%

Temporary increase in tidal volume to improve the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation

Jiang

Chung

Baik

et al. 2019

Preprint

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Background: Pulse pressure variation (PPV) and stroke volume variation (SVV) induced by mechanical ventilation are widely used as predictors of fluid responsiveness. However, the reliability of these dynamic preload indices is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (VT) in surgical patients. We investigated whether increasing tidal volume (VT) from 6 to 8 ml/kg can improve the predictive power of PPV and SVV during pneurmoperitoneum.Methods: We performed a prospective observational study in patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV, SVV, and the stroke volume index (SVI) were measured at a VT of 6 mL/kg and 3 minutes after increasing the VT to 8 mL/kg. The VT was reduced to 6 mL/kg, and measurements were performed before and 5 minutes after volume expansion (infusing 6% hydroxyethyl starch 6 ml/kg over 10 minutes). Fluid responsiveness was defined as ≥ 15% increase in the SVI. Results: Twenty-four of the 38 patients enrolled in the study were responders. In the receiver operating characteristic curve analysis, the augmented PPV and SVV associated with a temporary increase in VT from 6 to 8 ml/kg improved the predictability of fluid responsiveness, with area under the curve (AUC) values of 0.85 (95% confidence interval (CI), 0.70-0.95, P < 0.0001) and 0.77 (95% CI 0.61-0.89, P = 0.0003), compared to PPV and SVV values (as measured by VT) of 6 ml/kg. The absolute change in PPV and SVV values obtained by transiently increasing VT also predicted fluid responsiveness, with AUC values of 0.95 (95% CI 0.83-0.99, P < 0.0001) and 0.76 (95% CI 0.60-0.89, P = 0.0006). Conclusions: Augmented PPV and SVV values, and absolute changes therein obtained by increasing VT from 6 to 8 ml/kg, predicted fluid responsiveness with high sensitivity and specificity in our surgical population. BackgroundRobot-assisted laparoscopic surgery is increasingly performed due to its many advantages over open surgery, including minimal tissue trauma, fewer surgical complications, and earlier postoperative recovery [1]. However, while pneumoperitoneum is essential for adequate exposure in robot-assisted laparoscopic surgery, it has been associated with increased morbidity such as reduced renal blood

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“…Fluid responsiveness was investigated by means of transesophageal echocardiography in septic shock in three studies published in 2001 and in 2014, respectively, all assessing different parameters. Wilkman et al (13) observed that decreased in mean arterial pressure (MAP) due to an increased in peak end-expiratory pressure (PEEP) predicted fluid responsiveness (cut off value of ΔMAP for clinical use −8%) while Feissel et al (12), in a small subgroup of 19 patients with septic shock and preserved LV systolic function, observed that analysis of respiratory changes in aortic blood velocity was an accurate method for predicting the hemodynamic effects of volume expansion. Different parameters were assessed by Charbonneau et al (11) who observed that variations in superior vena cava diameters (ΔSVC) was significantly more accurate than changes in inferior vena cava width (ΔIVC) in predicting fluid responsiveness in 44 mechanical ventilated septic shock.…”

Section: Editorialmentioning

confidence: 99%

Fluid responsiveness raises many questions—echocardiography may be the answer

Lazzeri

Peris

2017

J. Thorac. Dis.

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

Abstract: 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.

Cited by 26 publications

References 47 publications

Multiparameter Predictor of Fluid Responsiveness in Cardiac Surgical Patients Receiving Tidal Volumes Less Than 10 mL/kg

Multiparameter Predictor of Fluid Responsiveness in Cardiac Surgical Patients Receiving Tidal Volumes Less Than 10 mL/kg

Temporary increase in tidal volume to improve the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation

Fluid responsiveness raises many questions—echocardiography may be the answer

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