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Changes in the mean systemic filling pressure during a fluid challenge in postsurgical intensive care patients

Maurizio Cecconi| Hollmann D. Aya| Martin Geisen| Claudia Ebm| Nick Fletcher| R. Michael Grounds| Andrew Rhodes
Original
Volume 39, Issue 7 / July , 2013

Pages 1299 - 1305

Abstract

Purpose

The difference between mean systemic filling (Pmsf) and central venous pressure (CVP) is the venous return gradient (dVR). The aim of this study is to assess the significance of the Pmsf analogue (Pmsa) and the dVR during a fluid challenge.

Methods

We performed a prospective observational study in postsurgical patients. Patients were monitored with a central venous catheter, a LiDCO™plus and the Navigator™. A 250-ml intravenous fluid challenge was given over 5 min. A positive response to the fluid challenge was defined as either a stroke volume (SV) or cardiac output increase of greater than 10 %.

Results

A total of 101 fluid challenges were observed in 39 patients. In 43 events (42.6 %) the SV and CO increased by more than 10 %. Pmsa increased similarly during a fluid challenge in responders and non-responders (3.1 ± 1.9 vs. 3.1 ± 1.8, p = 0.9), whereas the dVR increased in responders (1.16 ± 0.8 vs. 0.2 ± 1, p < 0.001) as among non-responders CVP increased along with Pmsa (2.9 ± 1.7 vs. 3.1 ± 1.8, p = 0.15). Resistance to venous return did not change immediately after a fluid challenge. Heart performance (Eh) decreased significantly among non-responders (0.41 ± 0.15 vs. 0.34 ± 0.13, p < 0.001) whereas among responders it did not change when compared with baseline value (0.35 ± 0.15 vs. 0.34 ± 0.12, p = 0.15).

Conclusions

The changes in Pmsa and dVR measured at the bedside during a fluid challenge are consistent with the cardiovascular model described by Guyton.

Keywords

References

  1. Patterson SW, Starling EH (1914) On the mechanical factors which determine the output of the ventricles. J Physiol 48(5):357–379
    • View reference on PubMed
  2. Hughes CG, Weavind L, Banerjee A, Mercaldo ND, Schildcrout JS, Pandharipande PP (2010) Intraoperative risk factors for acute respiratory distress syndrome in critically ill patients. Anesth Analg 111(2):464–467
    • View reference on PubMed
    • View reference on publisher's website
  3. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354(24):2564–2575
    • View reference on PubMed
    • View reference on publisher's website
  4. Huang SJ, Hong WC, Han YY, Chen YS, Wen CS, Tsai YS, Tu YK (2006) Clinical outcome of severe head injury using three different ICP and CPP protocol-driven therapies. J Clin Neurosci 13(8):818–822
    • View reference on PubMed
    • View reference on publisher's website
  5. Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL (2008) A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 12(3):R74
    • View reference on PubMed
    • View reference on publisher's website
  6. Bayliss WM, Starling EH (1894) Observations on venous pressures and their relationship to capillary pressures. J Physiol 16(3–4):159–318.7
    • View reference on PubMed
  7. Guyton AC (1968) Regulation of cardiac output. Anesthesiology 29(2):314–326
    • View reference on PubMed
    • View reference on publisher's website
  8. Guyton AC (1955) Determination of cardiac output by equating venous return curves with cardiac response curves. Physiol Rev 35(1):123–129
    • View reference on PubMed
  9. Guyton AC, Lindsey AW, Kaufmann BN (1955) Effect of mean circulatory filling pressure and other peripheral circulatory factors on cardiac output. Am J Physiol 180(3):463–468
    • View reference on PubMed
  10. Guyton AC, Lindsey AW, Kaufmann BN, Abernathy JB (1958) Effect of blood transfusion and hemorrhage on cardiac output and on the venous return curve. Am J Physiol 194(2):263–267
    • View reference on PubMed
  11. Maas JJ, Geerts BF, van den Berg PC, Pinsky MR, Jansen JR (2009) Assessment of venous return curve and mean systemic filling pressure in postoperative cardiac surgery patients. Crit Care Med 37(3):912–918
    • View reference on PubMed
    • View reference on publisher's website
  12. Anderson RM (1993) The gross physiology of the cardiovascular system. Racquet, Tucson
  13. Parkin WG, Leaning MS (2008) Therapeutic control of the circulation. J Clin Monit Comput 22(6):391–400
    • View reference on PubMed
    • View reference on publisher's website
  14. Parkin G, Wright C, Bellomo R, Boyce N (1994) Use of a mean systemic filling pressure analogue during the closed-loop control of fluid replacement in continuous hemodiafiltration. J Crit Care 9(2):124–133
    • View reference on PubMed
    • View reference on publisher's website
  15. Maas JJ, Pinsky MR, Geerts BF, de Wilde RB, Jansen JR (2012) Estimation of mean systemic filling pressure in postoperative cardiac surgery patients with three methods. Intensive Care Med 38(9):1452–1460
  16. Magder S (2005) How to use central venous pressure measurements. Curr Opin Crit Care 11(3):264–270
    • View reference on PubMed
    • View reference on publisher's website
  17. Lakhal K, Ehrmann S, Runge I, Benzekri-Lefevre D, Legras A, Dequin PF, Mercier E, Wolff M, Regnier B, Boulain T (2010) Central venous pressure measurements improve the accuracy of leg raising-induced change in pulse pressure to predict fluid responsiveness. Intensive Care Med 36(6):940–948
  18. Cecconi M, Parsons AK, Rhodes A (2011) What is a fluid challenge? Curr Opin Crit Care 17(3):290–295
    • View reference on PubMed
    • View reference on publisher's website
  19. Vincent JL, Weil MH (2006) Fluid challenge revisited. Crit Care Med 34(5):1333–1337
    • View reference on PubMed
    • View reference on publisher's website
  20. Weil MH, Henning RJ (1979) New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. Anesth Analg 58(2):124–132
    • View reference on PubMed
    • View reference on publisher's website
  21. Kumar A, Anel R, Bunnell E, Habet K, Zanotti S, Marshall S, Neumann A, Ali A, Cheang M, Kavinsky C, Parrillo JE (2004) Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 32(3):691–699
    • View reference on PubMed
    • View reference on publisher's website
  22. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL (2007) Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 35(1):64–68
    • View reference on PubMed
    • View reference on publisher's website
  23. Figg KK, Nemergut EC (2009) Error in central venous pressure measurement. Anesth Analg 108(4):1209–1211
    • View reference on PubMed
    • View reference on publisher's website

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