Incidence, predictability, and outcomes of systemic venous congestion following a fluid challenge in initially fluid-tolerant preload-responders after cardiac surgery: a pilot trial

IF 8.8 1区 医学 Q1 CRITICAL CARE MEDICINE Critical Care Pub Date : 2024-10-22 DOI:10.1186/s13054-024-05124-6
Bianca Morosanu, Cosmin Balan, Cristian Boros, Federico Dazzi, Adrian Wong, Francesco Corradi, Serban-Ion Bubenek-Turconi
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Abstract

Fluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes. This single-center, prospective, observational study (May 2023–July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer’s Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS). 45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001). Post-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications. Trial Registration: NCT06440772. Registered 30 May 2024. Retrospectively registered.
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心脏手术后最初耐受液体的前负荷反应者接受液体挑战后全身静脉充血的发生率、可预测性和结果:一项试点试验
液体管理的重点历来是前负荷反应性(PR)。然而,预防液体不耐受,尤其是全身静脉充血(VC)也同样重要。本研究评估了耐受液体的前负荷反应性患者输注 7 毫升/千克晶体液后 VC 的发生率和可预测性及其与不良预后的关系。这项单中心、前瞻性、观察性研究(2023 年 5 月至 2024 年 7 月)连续纳入了 40 例择期开胸手术后入住重症监护室(ICU)6 小时内接受机械通气且出现急性循环衰竭的患者。如果患者同时具有液体耐受性和前负荷反应性,则符合条件。前负荷反应的定义是在被动抬腿(PLR)测试后1分钟左心室流出道速度时间积分(LVOT-VTI)增加≥12%。门静脉搏动指数(PVPI)≥50%定义为VC。患者在 10 分钟内输注 7 毫升/千克林格氏乳酸盐。主要结果是输注后 2 分钟的 VC 发生率(早期 VC)。次要结果包括 20 分钟后的 VC、7 天后急性肾损伤(AKI)和严重 AKI 的发生率以及重症监护室的住院时间(LOS)。45%的患者出现了早期VC,只有5%的患者在20分钟后仍有VC。三分之一的患者出现了AKI,其中17.5%发展为重度AKI。重症监护室的中位住院时间为 4 天。早期VC患者的中心静脉压明显升高,平均灌注压降低,基线右心室功能较差,重度AKI发生率较高。虽然两组患者的 LVOT-VTI 均在 20 分钟内恢复至基线,但早期VC 患者的 PVPI 仍然升高(p < 0.001)。LVOT-VTI 与 PVPI 的回归线显示出相似的斜率(p = 0.755),但截距不同(p < 0.001),这表明尽管基线时存在液体耐受性和 PR,但早期VC 患者的右心室舒张储备(RVDR)降低了。以 44.3% 为阈值,PLR 后 PVPI 预测早期VC 的曲线下面积为 0.998(p < 0.001)。PLR后PVPI能有效预测耐受液体的前负荷反应者的液体诱发的早期VC,并能识别RVDR较差的患者。使用它可以指导心脏手术患者的输液管理,有助于避免不必要的输液和相关并发症。试验注册:NCT06440772。注册日期:2024 年 5 月 30 日。回顾性注册。
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来源期刊
Critical Care
Critical Care 医学-危重病医学
CiteScore
20.60
自引率
3.30%
发文量
348
审稿时长
1.5 months
期刊介绍: Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.
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