Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai, Miyagi, 980-8574 Japan.
Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574 Japan.
J Intensive Care. 2013 Nov 28;1(1):11. doi: 10.1186/2052-0492-1-11. eCollection 2013.
In patients with severe sepsis, depression of cardiac performance is common and is often associated with left ventricular (LV) dilatation to maintain stroke volume. Although it is essential to optimize cardiac preload to maintain tissue perfusion in patients with severe sepsis, the optimal preload remains unknown. This study aimed to evaluate the reliability of global end-diastolic volume index (GEDI) as a parameter of cardiac preload in the early phase of severe sepsis.
Ninety-three mechanically ventilated patients with acute lung injury/acute respiratory distress syndrome secondary to sepsis were enrolled for subgroup analysis in a multicenter, prospective, observational study. Patients were divided into two groups-with sepsis-induced myocardial dysfunction (SIMD) and without SIMD (non-SIMD)-according to a threshold LV ejection fraction (LVEF) of 50% on the day of enrollment. Both groups were further subdivided according to a threshold stroke volume variation (SVV) of 13% as a parameter of fluid responsiveness.
On the day of enrollment, there was a positive correlation (r = 0.421, p = 0.045) between GEDI and SVV in the SIMD group, whereas this paradoxical correlation was not found in the non-SIMD group and both groups on day 2. To evaluate the relationship between attainment of cardiac preload optimization and GEDI value, GEDI with SVV ≤13% and SVV >13% was compared in both the SIMD and non-SIMD groups. SVV ≤13% implies the attainment of cardiac preload optimization. Among patients with SIMD, GEDI was higher in patients with SVV >13% than in patients with SVV ≤13% on the day of enrollment (872 [785-996] mL/m(2) vs. 640 [597-696] mL/m(2); p < 0.001); this finding differed from the generally recognized relationship between GEDI and SVV. However, GEDI was not significantly different between patients with SVV ≤13% and SVV >13% in the non-SIMD group on the day of enrollment and both groups on day 2.
In the early phase of severe sepsis in mechanically ventilated patients, there was no constant relationship between GEDI and fluid reserve responsiveness, irrespective of the presence of SIMD. GEDI should be used as a cardiac preload parameter with awareness of its limitations.
在严重脓毒症患者中，心脏功能抑制很常见，且常伴有左心室（LV）扩张以维持每搏量。尽管为维持严重脓毒症患者的组织灌注而优化心脏前负荷至关重要，但最佳前负荷仍不明确。本研究旨在评估全心舒张末期容积指数（GEDI）作为严重脓毒症早期心脏前负荷参数的可靠性。
93 例因脓毒症导致急性肺损伤/急性呼吸窘迫综合征而接受机械通气的患者，被纳入一项多中心前瞻性观察性研究的亚组分析。根据入组日 LV 射血分数（LVEF）是否＜50%，将患者分为脓毒症诱导心肌功能障碍（SIMD）组和非 SIMD 组（非 SIMD 组）。根据作为液体反应性参数的每搏量变异度（SVV）是否＜13%，两组患者进一步分为亚组。
SIMD 组患者入组日 GEDI 与 SVV 呈正相关（r=0.421，p=0.045），而非 SIMD 组和两组患者次日均未发现这种矛盾相关性。为评估实现心脏前负荷优化与 GEDI 值之间的关系，对比了 SIMD 和非 SIMD 两组患者中 GEDI 值与 SVV 分别为≤13%和＞13%时的关系。SVV≤13%提示达到心脏前负荷优化。在 SIMD 患者中，与 SVV≤13%的患者相比，SVV＞13%的患者入组日 GEDI 更高（872[785-996]ml/m2比 640[597-696]ml/m2；p＜0.001）；这一发现与普遍认为的 GEDI 与 SVV 之间的关系不同。然而，非 SIMD 组患者入组日和次日两组患者中，SVV≤13%和 SVV＞13%患者的 GEDI 无显著差异。
在机械通气严重脓毒症患者的早期阶段，无论是否存在 SIMD，GEDI 与液体储备反应性之间均无恒定关系。使用 GEDI 作为心脏前负荷参数时，应认识到其局限性。
