Bruna Mario, Alfaro Sebastian, Muñoz Felipe, Cisternas Liliana, Gonzalez Cecilia, Conlledo Rodrigo, Ulloa-Morrison Rodrigo, Huilcaman Marcos, Retamal Jaime, Castro Ricardo, Rola Philippe, Wong Adrian, Argaiz Eduardo R, Contreras Roberto, Hernandez Glenn, Kattan Eduardo
Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile.
Facultad de Medicina, Escuela de Medicina, Universidad Andrés Bello, Viña del Mar, Chile.
Intensive Care Med Exp. 2024 May 8;12(1):46. doi: 10.1186/s40635-024-00631-w.
Assessment of dynamic parameters to guide fluid administration is one of the mainstays of current resuscitation strategies. Each test has its own limitations, but passive leg raising (PLR) has emerged as one of the most versatile preload responsiveness tests. However, it requires real-time cardiac output (CO) measurement either through advanced monitoring devices, which are not routinely available, or echocardiography, which is not always feasible. Analysis of the hepatic vein Doppler waveform change, a simpler ultrasound-based assessment, during a dynamic test such as PLR could be useful in predicting preload responsiveness. The objective of this study was to assess the diagnostic accuracy of hepatic vein Doppler S and D-wave velocities during PLR as a predictor of preload responsiveness.
Prospective observational study conducted in two medical-surgical ICUs in Chile. Patients in circulatory failure and connected to controlled mechanical ventilation were included from August to December 2023. A baseline ultrasound assessment of cardiac function was performed. Then, simultaneously, ultrasound measurements of hepatic vein Doppler S and D waves and cardiac output by continuous pulse contour analysis device were performed during a PLR maneuver.
Thirty-seven patients were analyzed. 63% of the patients were preload responsive defined by a 10% increase in CO after passive leg raising. A 20% increase in the maximum S wave velocity after PLR showed the best diagnostic accuracy with a sensitivity of 69.6% (49.1-84.4) and specificity of 92.8 (68.5-99.6) to detect preload responsiveness, with an area under curve of receiving operator characteristic (AUC-ROC) of 0.82 ± 0.07 (p = 0.001 vs. AUC-ROC of 0.5). D-wave velocities showed worse diagnostic accuracy.
Hepatic vein Doppler assessment emerges as a novel complementary technique with adequate predictive capacity to identify preload responsiveness in patients in mechanical ventilation and circulatory failure. This technique could become valuable in scenarios of basic hemodynamic monitoring and when echocardiography is not feasible. Future studies should confirm these results.
评估动态参数以指导液体管理是当前复苏策略的主要支柱之一。每种测试都有其自身的局限性，但被动抬腿试验（PLR）已成为最通用的前负荷反应性测试之一。然而，它需要通过先进的监测设备（这些设备并非常规可用）或超声心动图（这并不总是可行的）来实时测量心输出量（CO）。在诸如PLR这样的动态测试期间，分析肝静脉多普勒波形变化（一种基于超声的更简单评估方法）可能有助于预测前负荷反应性。本研究的目的是评估PLR期间肝静脉多普勒S波和D波速度作为前负荷反应性预测指标的诊断准确性。
在智利的两个内科-外科重症监护病房进行前瞻性观察研究。纳入2023年8月至12月循环衰竭且接受控制性机械通气的患者。进行了心脏功能的基线超声评估。然后，在PLR操作期间，同时通过连续脉搏轮廓分析装置进行肝静脉多普勒S波和D波的超声测量以及心输出量测量。
分析了37例患者。63%的患者为前负荷反应性，定义为被动抬腿后CO增加10%。PLR后最大S波速度增加20%显示出最佳诊断准确性，检测前负荷反应性的敏感性为69.6%（49.1-84.4），特异性为92.8（68.5-99.6），受试者工作特征曲线下面积（AUC-ROC）为0.82±0.07（与AUC-ROC为0.5相比，p=0.001）。D波速度显示出较差的诊断准确性。
肝静脉多普勒评估作为一种新型辅助技术出现，具有足够的预测能力，可识别机械通气和循环衰竭患者的前负荷反应性。该技术在基础血流动力学监测场景以及超声心动图不可行时可能变得有价值。未来的研究应证实这些结果。
