1st Department of Cardiovascular Anesthesia and Intensive Care Medicine, Prof. Dr. C.C. Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania.
Unit of Cardiac Anesthesia and Intensive Care, Fondazione Toscana Gabriele Monasterio, Hospital of Massa, Pisa, Italy.
Crit Care. 2024 Oct 22;28(1):339. doi: 10.1186/s13054-024-05124-6.
Fluid administration has traditionally focused on preload responsiveness (PR). However, preventing fluid intolerance, particularly due to systemic venous congestion (VC), is equally important. This study evaluated the incidence and predictability of VC following a 7 ml/kg crystalloid infusion in fluid-tolerant preload-responders and its association with adverse outcomes.
This single-center, prospective, observational study (May 2023-July 2024) included 40 consecutive patients who were mechanically ventilated within 6 h of intensive care unit (ICU) admission after elective open-heart surgery and had acute circulatory failure. Patients were eligible if they were both fluid-tolerant and preload-responsive. PR was defined as a ≥ 12% increase in left-ventricular outflow tract velocity time integral (LVOT-VTI) 1 min after a passive leg raising (PLR) test. VC was defined by a portal vein pulsatility index (PVPI) ≥ 50%. Patients received a 7 ml/kg Ringer's Lactate infusion over 10 min. The primary outcome was the incidence of VC 2 min post-infusion (early-VC). Secondary outcomes included VC at 20 min, the incidence of acute kidney injury (AKI) and severe AKI at 7 days, and ICU length of stay (LOS).
45% of patients developed early-VC, with VC persisting in only 5% at 20 min. One-third of patients developed AKI, with 17.5% progressing to severe AKI. The median ICU LOS was 4 days. Patients with early-VC had significantly higher central venous pressure, lower mean perfusion pressure, worse baseline right ventricular function, and a higher incidence of severe AKI. While LVOT-VTI returned to baseline by 20 min in both groups, PVPI remained elevated in early-VC patients (p < 0.001). The LVOT-VTI versus PVPI regression line showed similar slopes (p = 0.755) but different intercepts (p < 0.001), indicating that, despite fluid tolerance and PR at baseline, early-VC patients had reduced right ventricular diastolic reserve (RVDR). Post-PLR PVPI predicted early-VC with an area under the curve of 0.998, using a threshold of 44.3% (p < 0.001).
Post-PLR PVPI effectively predicts fluid-induced early-VC in fluid-tolerant preload-responders, identifying those with poor RVDR. Its use can guide fluid management in cardiac surgery patients, helping to prevent unnecessary fluid administration and associated complications.
NCT06440772. Registered 30 May 2024. Retrospectively registered.
液体管理传统上侧重于前负荷反应性（PR）。然而，预防液体不耐受，特别是由于全身静脉充血（VC），同样重要。本研究评估了在接受 7ml/kg 晶体液输注后，在液体耐受且前负荷反应性的患者中，VC 的发生率和可预测性及其与不良结局的关系。
这是一项单中心、前瞻性、观察性研究（2023 年 5 月至 2024 年 7 月），纳入了 40 例在择期心脏手术后 6 小时内接受机械通气并出现急性循环衰竭的连续患者。患者入选标准为既液体耐受又前负荷反应性。PR 定义为被动抬腿（PLR）试验后 1 分钟左心室流出道速度时间积分（LVOT-VTI）增加≥12%。VC 定义为门静脉搏动指数（PVPI）≥50%。患者在 10 分钟内接受 7ml/kg 的林格乳酸盐输注。主要结局是输注后 2 分钟时 VC 的发生率（早期-VC）。次要结局包括 20 分钟时的 VC、7 天内急性肾损伤（AKI）和严重 AKI 的发生率以及 ICU 住院时间（LOS）。
45%的患者发生早期-VC，仅 5%的患者在 20 分钟时持续存在 VC。三分之一的患者发生 AKI，其中 17.5%进展为严重 AKI。ICU LOS 的中位数为 4 天。发生早期-VC 的患者中心静脉压显著升高，平均灌注压降低，右心室功能基线较差，严重 AKI 的发生率较高。尽管两组患者的 LVOT-VTI 在 20 分钟时均恢复到基线，但早期-VC 患者的 PVPI 仍升高（p<0.001）。LVOT-VTI 与 PVPI 回归线斜率相似（p=0.755），但截距不同（p<0.001），表明尽管基线时液体耐受和 PR，早期-VC 患者的右心室舒张储备（RVDR）降低。PLR 后 PVPI 预测早期-VC 的曲线下面积为 0.998，使用 44.3%的阈值（p<0.001）。
PLR 后 PVPI 可有效预测液体耐受且前负荷反应性患者的液体诱导性早期-VC，识别出那些 RVDR 较差的患者。它的使用可以指导心脏手术患者的液体管理，有助于预防不必要的液体给予和相关并发症。
NCT06440772。注册于 2024 年 5 月 30 日。回顾性注册。
