Predicting Fluid Responsiveness in Children Undergoing Cardiac Surgery After Cardiopulmonary Bypass

Abstract

Dynamic parameters of fluid responsiveness (FR), namely aortic blood flow velocity variation (delta V ), left ventricular velocity-time integral variation (delta VTI), stroke volume variation, and pulse pressure variation (PPV) have demonstrated good diagnostic performance for the prediction of response to fluid loading in mechanically ventilated critically ill adult patients. We aimed to evaluate these parameters in children undergoing cardiac surgery. A retrospective observational study of mechanically ventilated patients weighing less than 20 kg who received a volume expansion (VE) of 10 ml/kg after sternal closure was conducted. A 10% cardiac index (CI) increase divided patients into 7 responders (R) and 9 non-responders (NR). Transesophageal echocardiography and Pressure Recording Analytical Method data were retrieved. The percentage CI increase was 18.6 (12)% in R and 2.9 (5.7)% in NR (p = 0.037). Prior to VE, delta V, delta VTI, PPV, and SPV differed between R and NR (p = 0.045, 0.043, 0.048, 0,037 and 0.044, respectively). Systolic (p = 0.004), diastolic (p = 0.002), mean blood pressure (p = 0.003), delta V (p = 0.03), delta VTI (p = 0.04), CI (p = 0.01), PPV (p = 0.04), SPV (p = 0.04), and dP/dt (maximal pressure-to-time ratio) (p = 0.02) changed the following VE in R patients. Delta V decreased after VE in NR patients (p = 0.004). Delta VTI and PPV showed the highest predictive values, with area under receiver operator characteristic curves of 0.76 (p = 0.049) and 0.76 (p = 0.045), respectively. Delta VTI and PPV were revealed to be potential predictors of FR in ventilated children after cardiac surgery. Their combined evaluation could be useful for fluid management after sternal closure.

Different predictivity of fluid responsiveness by pulse pressure variation in children after surgical repair of ventricular septal defect or tetralogy of Fallot

“…In children after cardiopulmonary bypass, the compliance of chest wall, lung, and arterial vascular system may be much reduced due to systemic inflammatory response and ischemia‐reperfusion injury . As a result, it is not surprising that more recent studies, including ours, have found the predictivity of fluid responsiveness of PPV in this particular group of children …”

“…25 As a result, it is not surprising that more recent studies, including ours, have found the predictivity of fluid responsiveness of PPV in this particular group of children. 9,11,26 5 | CONCLUSION PPV is predictive of fluid responsiveness in VSD and TOF patients following cardiac surgery. The predictivity in VSD patients is with higher magnitude of PPV, ROC curve area, and cutoff value as compared to TOF patients.…”

Hemodynamic monitoring in children with heart disease: Overview of newer technologies

“…Validation of dynamic indictors of filling in children is ongoing, but is complicated by the differences in size, physiology and ventilation practice across age groups. In small cohorts of similar patients, these indicators perform well, but across large heterogeneous populations the aggregate results are less reliable, though still better than the use of the CVP (which approximates a coin toss in its predictive ability in several studies). Clinicians wanting to utilize these metrics in 2019 need to understand them in detail, and the most recent evidence relevant to their pediatric anesthesia practice.…”

Goal directed fluid and hemodynamic therapy with trans-thoracic echocardiographic aortic blood flow peak velocity variation in children and postoperative outcome : A randomized controlled trial protocol

“…Several indices have been studied in children with the aim to determine those which are suitable in pediatric patients. Parameters like pulse pressure variation (PPV) to assess fluid responsiveness remain until now controversial in children [5][6][7][8]. One important aspect is to have a non invasive tool or monitor to determine these parameters.…”

“…A possible non invasive tool is trans-thoracic echocardiography. An indice like trans-thoracic aortic blood flow peak velocity variation (ΔV peak) has been validated as an accurate parameter of fluid responsiveness in ventilated children in several trials [5][6][7][8]. Since this indice has been validated to predict fluid responsiveness in several pediatric studies, it will be integrated in this prospective randomized controlled trial (RCT) to determine the impact of intraoperative goal directed fluid and hemodynamic therapy (GDFHT) with this parameter on postoperative outcome in high risk pediatric patients in major surgery.…”