De Santis Paolo, De Fazio Chiara, Franchi Federico, Bond Ottavia, Vincent Jean-Louis, Creteur Jacques, Taccone Fabio Silvio, Scolletta Sabino
Department of Intensive Care, Hôpital Erasme, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles, Route de Lennik, 808-1070 Brussels, Belgium.
Department of Medicine, Surgery and Neuroscience, Emergency-Urgency and Organ Transplantation, University Hospital of Siena, 53100 Siena, Italy.
J Clin Med. 2021 Feb 1;10(3):507. doi: 10.3390/jcm10030507.
The aim of the study was to assess the coherence between systemic hemodynamic and microcirculatory response to a fluid challenge (FC) in critically ill patients.
We prospectively collected data in patients requiring a FC whilst cardiac index (CI) and microcirculation were monitored. The sublingual microcirculation was assessed using the incident dark field (IDF) CytoCam device (Braedius Medical, Huizen, The Netherlands). The proportion of small perfused vessels (PPV) was calculated. Fluid responders were defined by at least a 10% increase in CI during FC. Responders according to changes in microcirculation were defined by at least 10% increase in PPV at the end of FC. Cohen's kappa coefficient was measured to assess the agreement to categorize patients as "responders" to FC according to CI and PPV.
A total of 41 FC were performed in 38 patients, after a median time of 1 (0-1) days after ICU admission. Most of the fluid challenges (39/41, 95%) were performed using crystalloids and the median total amount of fluid was 500 (500-500) mL. The main reasons for fluid challenge were oliguria ( = 22) and hypotension ( = 10). After FC, CI significantly increased in 24 (58%) cases; a total of 19 (46%) FCs resulted in an increase in PPV. Both CI and PPV increased in 13 responders and neither in 11; the coefficient of agreement was only 0.21. We found no correlation between absolute changes in CI and PPV after fluid challenge.
The results of this heterogenous population of critically ill patients suggest incoherence in fluid responsiveness between systemic and microvascular hemodynamics; larger cohort prospective studies with adequate a priori sample size calculations are needed to confirm these findings.
本研究旨在评估重症患者对液体冲击（FC）的全身血流动力学和微循环反应之间的一致性。
我们前瞻性地收集了需要进行FC的患者的数据，同时监测心脏指数（CI）和微循环。使用入射暗场（IDF）CytoCam设备（荷兰惠曾市Braedius Medical公司）评估舌下微循环。计算小灌注血管比例（PPV）。液体反应者定义为FC期间CI至少增加10%。根据微循环变化定义的反应者为FC结束时PPV至少增加10%。测量Cohen's kappa系数以评估根据CI和PPV将患者分类为FC“反应者”的一致性。
38例患者共进行了41次FC，中位时间为入住ICU后1（0 - 1）天。大多数液体冲击（39/41，95%）使用晶体液，液体总量中位数为500（500 - 500）mL。液体冲击的主要原因是少尿（ = 22）和低血压（ = 10）。FC后，24例（58%）患者的CI显著增加；共19次（46%）FC导致PPV增加。13例反应者的CI和PPV均增加，11例均未增加；一致性系数仅为0.21。我们发现液体冲击后CI和PPV的绝对变化之间无相关性。
这一异质性重症患者群体的结果表明全身和微血管血流动力学之间的液体反应性不一致；需要进行更大队列的前瞻性研究，并进行充分的先验样本量计算以证实这些发现。
