Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock

Abstract

BackgroundInitial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management.MethodsWe evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P.ResultsLVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%.ConclusionsOur results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.

Management of three cardiogenic pulmonary edemas occurring in a patient scheduled for left ventricular assist device implantation: indicators for determining left ventricular assist device pump speed

“…PAWP, LVEDD, and LAD are indices of LV preload. However, CVP and IVCD, which are affected by RV function, are unsuitable for assessing LV preload [6]. In this patient, CVP and IVCD slightly changed because of preserved RV function, whereas the PAWP substantially changed; this is due to the imbalance between the RV output and the sum of the LV and LVAD outputs.…”

The efficacy of inferior vena cava diameters and the jugular vein in assessing fluid resuscitation

“…The CVP significantly increased in our study. But, a retrospective study on 40 patients suffering from septic shock stated that CVP may not be a consistent marker of the preload of the left ventricle for fluid management (12). The mentioned study did indicate that CVP was not appropriate for septic shock.…”

Anaesthetic and cardiopulmonary parameters of dogs administered propofol-acepromazine-butorphanol or propofol-acepromazine-buprenorphine anaesthesia

“…In this study, since the published half-life of propofol is 5 to 10 min, repeat bolus was adopted every 5 min throughout the anaesthetic period. Intravenous (IV) fluids are routinely administered during anaesthesia to maintain venous access as well as circulating blood volume, cardiac output and blood pressure (Sasai et al, 2014). The various types of intravenous fluids used include crystalloid, colloid and whole blood.…”