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Fluid challenge: tracking changes in cardiac output with blood pressure monitoring (invasive or non-invasive)

Karim Lakhal| Stephan Ehrmann| Dominique Perrotin| Michel Wolff| Thierry Boulain
Original Article
Volume 39, Issue 11 / November , 2013

Pages 1953 - 1962

Abstract

Purpose

To assess whether invasive and non-invasive blood pressure (BP) monitoring allows the identification of patients who have responded to a fluid challenge, i.e., who have increased their cardiac output (CO).

Methods

Patients with signs of circulatory failure were prospectively included. Before and after a fluid challenge, CO and the mean of four intra-arterial and oscillometric brachial cuff BP measurements were collected. Fluid responsiveness was defined by an increase in CO ≥10 or ≥15 % in case of regular rhythm or arrhythmia, respectively.

Results

In 130 patients, the correlation between a fluid-induced increase in pulse pressure (Δ500mlPP) and fluid-induced increase in CO was weak and was similar for invasive and non-invasive measurements of BP: r² = 0.31 and r² = 0.29, respectively (both p < 0.001). For the identification of responders, invasive Δ500mlPP was associated with an area under the receiver-operating curve (AUC) of 0.82 (0.74–0.88), similar (p = 0.80) to that of non-invasive Δ500mlPP [AUC of 0.81 (0.73–0.87)]. Outside large gray zones of inconclusive values (5–23 % for invasive Δ500mlPP and 4–35 % for non-invasive Δ500mlPP, involving 35 and 48 % of patients, respectively), the detection of responsiveness or unresponsiveness to fluid was reliable. Cardiac arrhythmia did not impair the performance of invasive or non-invasive Δ500mlPP. Other BP-derived indices did not outperform Δ500mlPP.

Conclusions

As evidenced by large gray zones, BP-derived indices poorly reflected fluid responsiveness. However, in our deeply sedated population, a high increase in invasive pulse pressure (>23 %) or even in non-invasive pulse pressure (>35 %) reliably detected a response to fluid. In the absence of a marked increase in pulse pressure (<4–5 %), a response to fluid was unlikely.

Keywords

References

  1. Cannesson M, Le Manach Y, Hofer CK, Goarin JP, Lehot JJ, Vallet B, Tavernier B (2011) Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a “gray zone” approach. Anesthesiology 115:231–241
    • View reference on PubMed
    • View reference on publisher's website
  2. Lakhal K, Ehrmann S, Benzekri-Lefevre D, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Regnier B, Boulain T (2011) Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome. Crit Care 15:R85
    • View reference on PubMed
    • View reference on publisher's website
  3. Mahjoub Y, Pila C, Friggeri A, Zogheib E, Lobjoie E, Tinturier F, Galy C, Slama M, Dupont H (2009) Assessing fluid responsiveness in critically ill patients: false-positive pulse pressure variation is detected by Doppler echocardiographic evaluation of the right ventricle. Crit Care Med 37:2570–2575
    • View reference on PubMed
    • View reference on publisher's website
  4. Mahjoub Y, Touzeau J, Airapetian N, Lorne E, Hijazi M, Zogheib E, Tinturier F, Slama M, Dupont H (2010) The passive leg-raising maneuver cannot accurately predict fluid responsiveness in patients with intra-abdominal hypertension. Crit Care Med 38:1824–1829
    • View reference on PubMed
    • View reference on publisher's website
  5. 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 36:940–948
  6. Vincent JL, Weil MH (2006) Fluid challenge revisited. Crit Care Med 34:1333–1337
    • View reference on PubMed
    • View reference on publisher's website
  7. Cecconi M, Parsons AK, Rhodes A (2011) What is a fluid challenge? Curr Opin Crit Care 17:290–295
    • View reference on PubMed
    • View reference on publisher's website
  8. Convertino VA, Cooke WH, Holcomb JB (2006) Arterial pulse pressure and its association with reduced stroke volume during progressive central hypovolemia. J Trauma 61:629–634
    • View reference on PubMed
    • View reference on publisher's website
  9. Dufour N, Chemla D, Teboul JL, Monnet X, Richard C, Osman D (2011) Changes in pulse pressure following fluid loading: a comparison between aortic root (non-invasive tonometry) and femoral artery (invasive recordings). Intensive Care Med 37:942–949
  10. Monnet X, Letierce A, Hamzaoui O, Chemla D, Anguel N, Osman D, Richard C, Teboul JL (2011) Arterial pressure allows monitoring the changes in cardiac output induced by volume expansion but not by norepinephrine. Crit Care Med 39:1394–1399
    • View reference on PubMed
    • View reference on publisher's website
  11. Pierrakos C, Velissaris D, Scolletta S, Heenen S, De Backer D, Vincent JL (2012) Can changes in arterial pressure be used to detect changes in cardiac index during fluid challenge in patients with septic shock? Intensive Care Med 38:422–428
  12. Le Manach Y, Hofer CK, Lehot JJ, Vallet B, Goarin JP, Tavernier B, Cannesson M (2012) Can changes in arterial pressure be used to detect changes in cardiac output during volume expansion in the perioperative period? Anesthesiology 117:1165–1174
    • View reference on PubMed
    • View reference on publisher's website
  13. Chatterjee A, DePriest K, Blair R, Bowton D, Chin R (2010) Results of a survey of blood pressure monitoring by intensivists in critically ill patients: a preliminary study. Crit Care Med 38:2335–2338
    • View reference on PubMed
    • View reference on publisher's website
  14. Lehman LW, Saeed M, Talmor D, Mark R, Malhotra A (2013) Methods of blood pressure measurement in the ICU. Crit Care Med 41:34–40
    • View reference on PubMed
    • View reference on publisher's website
  15. Lakhal K, Ehrmann S, Benzekri-Lefevre D, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Regnier B, Boulain T (2012) Brachial cuff measurements of blood pressure during passive leg raising for fluid responsiveness prediction. Ann Fr Anesth Reanim 31:e67–e72
    • View reference on PubMed
    • View reference on publisher's website
  16. Lakhal K, Ehrmann S, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Regnier B, Boulain T (2009) Tracking hypotension and dynamic changes in arterial blood pressure with brachial cuff measurements. Anesth Analg 109:494–501
    • View reference on PubMed
    • View reference on publisher's website
  17. Teboul JL, Pinsky MR, Mercat A, Anguel N, Bernardin G, Achard JM, Boulain T, Richard C (2000) Estimating cardiac filling pressure in mechanically ventilated patients with hyperinflation. Crit Care Med 28:3631–3636
    • View reference on PubMed
    • View reference on publisher's website
  18. Teboul JL, Besbes M, Andrivet P, Axler O, Douguet D, Zelter M, Lemaire F, Brun-Buisson C (1992) A bedside index assessing the reliability of pulmonary occlusion pressure measurements during mechanical ventilation with positive end-expiratory pressure. J Crit Care 7:22–29
    • View reference on publisher's website
  19. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ (2005) Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 111:697–716
    • View reference on PubMed
    • View reference on publisher's website
  20. Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL (2000) Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 162:134–138
    • View reference on PubMed
    • View reference on publisher's website
  21. Ostergaard M, Nilsson LB, Nilsson JC, Rasmussen JP, Berthelsen PG (2005) Precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation. Acta Anaesthesiol Scand 49:366–372
    • View reference on PubMed
    • View reference on publisher's website
  22. Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29–36
    • View reference on PubMed
  23. Grimes DA, Schulz KF (2005) Refining clinical diagnosis with likelihood ratios. Lancet 365:1500–1505
    • View reference on PubMed
    • View reference on publisher's website
  24. Chemla D, Hebert JL, Coirault C, Zamani K, Suard I, Colin P, Lecarpentier Y (1998) Total arterial compliance estimated by stroke volume-to-aortic pulse pressure ratio in humans. Am J Physiol 274:H500–H505
    • View reference on PubMed
  25. Lamia B, Chemla D, Richard C, Teboul JL (2005) Clinical review: interpretation of arterial pressure wave in shock states. Crit Care 9:601–606
    • View reference on PubMed
    • View reference on publisher's website
  26. Cecconi M, Rhodes A (2011) Pulse pressure: more than 100 years of changes in stroke volume. Intensive Care Med 37:898–900
  27. Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H (2012) Year in review in Intensive Care Medicine 2011. II. Cardiovascular, infections, pneumonia and sepsis, critical care organization and outcome, education, ultrasonography, metabolism and coagulation. Intensive Care Med 38:345–358
  28. Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alphadolone. Br Med J 2:656–659
    • View reference on PubMed
    • View reference on publisher's website
  29. De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL (2005) Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med 31:517–523
  30. De Backer D, Taccone FS, Holsten R, Ibrahimi F, Vincent JL (2009) Influence of respiratory rate on stroke volume variation in mechanically ventilated patients. Anesthesiology 110:1092–1097
    • View reference on PubMed
    • View reference on publisher's website
  31. Pinsky MR (2007) Heart-lung interactions. Curr Opin Crit Care 13:528–531
    • View reference on PubMed
    • View reference on publisher's website
  32. Monge Garcia MI, Gil Cano A, Gracia Romero M (2011) Dynamic arterial elastance to predict arterial pressure response to volume loading in preload-dependent patients. Crit Care 15:R15
    • View reference on PubMed
    • View reference on publisher's website
  33. Farsky S, Benova K, Krausova D, Sirotiakova J, Vysocanova P (2011) Clinical blood pressure measurement verification when comparing a Tensoval duo control device with a mercury sphygmomanometer in patients suffering from atrial fibrillation. Blood Press Monit 16:252–257
    • View reference on PubMed
    • View reference on publisher's website
  34. Anastas ZM, Jimerson E, Garolis S (2008) Comparison of noninvasive blood pressure measurements in patients with atrial fibrillation. J Cardiovasc Nurs 23:519–524 quiz 525–516
    • View reference on PubMed
    • View reference on publisher's website
  35. Ercole A (2006) Attenuation in invasive blood pressure measurement systems. Br J Anaesth 96:560–562
    • View reference on PubMed
    • View reference on publisher's website
  36. O’Brien E, Atkins N, Stergiou G, Karpettas N, Parati G, Asmar R, Imai Y, Wang J, Mengden T, Shennan A (2010) European Society of Hypertension International Protocol revision 2010 for the validation of blood pressure measuring devices in adults. Blood Press Monit 15:23–38
    • View reference on PubMed
    • View reference on publisher's website
  37. van Montfrans GA (2001) Oscillometric blood pressure measurement: progress and problems. Blood Press Monit 6:287–290
    • View reference on PubMed
    • View reference on publisher's website

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