Audimoolam Vinod Kumar, McPhail Mark J W, Willars Chris, Bernal William, Wendon Julia A, Cecconi Maurizio, Auzinger Georg
From the *Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London, UK; †Liver and Anti-viral Centre, St. Mary's Hospital, Imperial College London, Paddington, London, UK; and ‡Anaesthesia and Intensive Care, St. George's Hospital London and St. George's University of London, London, UK.
Anesth Analg. 2017 Feb;124(2):480-486. doi: 10.1213/ANE.0000000000001585.
The profound hemodynamic changes seen in acute liver failure (ALF) resemble the hyperdynamic state found in the later stages of septic shock. Vasopressor support frequently is required after initial volume therapy. Markers of preload dependency have not been studied in this patient group. Dynamic maneuvers such as passive leg raising or end-expiratory hold, which have shown good predictive accuracy in a general intensive care unit population, cannot be considered safe in this cohort because of the concerns of intracranial hypertension.
Mechanically ventilated patients with ALF admitted to a tertiary specialist intensive care unit in shock and multiorgan failure were enrolled. Markers of fluid responsiveness derived from transpulmonary thermodilution, pulse contour analysis, and echocardiography were compared between responders (cardiac index ≥15%) and nonresponders to a colloid fluid challenge (5 mL/kg predicted body weight). The ability to predict fluid responsiveness of stroke volume variation, pulse pressure variation (PPV), and respiratory change in peak (delta V peak) left ventricular outflow tract velocity for preload dependency were analyzed.
Thirty-five patients (mean ± SD age, 38 [14] years, 13 male, 22 female]) were assessed after a single fluid challenge. Ten patients (29%) were fluid responders. Changes in cardiac index and stroke volume index in the cohort of 35 patients were correlated (R = 0.726 [99% confidence interval, 0.401-0.910]; P < .001). PPV predicted fluid responsiveness (area under the receiver operating characteristic curve [AUROC], 0.752 [95% confidence interval, 0.565-0.889]; P = .005; cutoff >9%). The AUROC for stroke volume variation was 0.678 ([95% confidence interval, 0.499-0.825]; P = .084; cutoff >11%). The AUROC for [delta] V peak before fluid bolus was 0.637 (95% confidence interval, 0.413-0.825; P = .322).
PPV based on pulse contour analysis predicted fluid responsiveness in ALF.
急性肝衰竭（ALF）中出现的显著血流动力学变化类似于感染性休克后期的高动力状态。初始容量治疗后常常需要血管升压药支持。在该患者群体中尚未对前负荷依赖性标志物进行研究。诸如被动抬腿或呼气末屏气等动态操作，虽然在一般重症监护病房人群中显示出良好的预测准确性，但由于担心颅内高压，在该队列中不能认为是安全的。
纳入入住三级专科重症监护病房、处于休克和多器官功能衰竭状态的机械通气ALF患者。比较了胶体液冲击（5 mL/kg预测体重）的反应者（心脏指数≥15%）和无反应者之间经肺热稀释、脉搏轮廓分析和超声心动图得出的液体反应性标志物。分析了每搏量变异、脉压变异（PPV）和左心室流出道峰值速度的呼吸变化（ΔV峰值）预测前负荷依赖性液体反应性的能力。
单次液体冲击后评估了35例患者（平均±标准差年龄，38[14]岁，13例男性，22例女性）。10例患者（29%）为液体反应者。35例患者队列中心脏指数和每搏量指数的变化具有相关性（R = 0.726[99%置信区间，0.401 - 0.910]；P <.001）。PPV预测液体反应性（受试者工作特征曲线下面积[AUROC]，0.752[95%置信区间，0.565 - 0.889]；P =.005；临界值>9%）。每搏量变异的AUROC为0.678（[95%置信区间，0.499 - 0.825]；P =.084；临界值>11%）。液体推注前ΔV峰值的AUROC为0.637（95%置信区间，0.413 - 0.825；P =.322）。
基于脉搏轮廓分析的PPV可预测ALF中的液体反应性。
