Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients?
OBJECTIVE
To investigate whether the respiratory changes in arterial pulse (DeltaPP) and in systolic pressure (DeltaSP) could predict fluid responsiveness in spontaneously breathing (SB) patients. Because changes in intrathoracic pressure during spontaneous breathing (SB) might be insufficient to modify loading conditions of the ventricles, performances of indicators were also assessed during a forced respiratory maneuver.


METHODS
Prospective interventional study.


METHODS
A 34-bed university hospital medico-surgical ICU.


METHODS
Thirty-two SB patients with clinical signs of hemodynamic instability.


METHODS
A 500-ml volume expansion (VE).


RESULTS
Cardiac index, assessed using transthoracic echocardiography, increased by at least 15% after VE in 19 patients (responders). At baseline, only dynamic indicators were higher in responders than in nonresponders (13+/-5% vs. 7+/-3%, p=0.003 for DeltaPP and 10+/-4% vs. 6+/-2%, p=0.002 for DeltaSP). Moreover, they significantly decreased after VE (11+/-5% to 6+/-4%, p<0.001 for DeltaPP and 8+/-4% to 6+/-3%, p<0.001 for DeltaSP). DeltaPP and DeltaSP areas under the ROC curve were high (0.81+/-0.08 and 0.82+/-0.08; p=0.888, respectively). A DeltaPP>or=12% predicted fluid responsiveness with high specificity (92%) but poor sensitivity (63%). The forced respiratory maneuver reproducing a dyspneic state decreased the predictive power.


CONCLUSIONS
Due to their lack of sensitivity and their dependence to respiratory status, DeltaPP and DeltaSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.
Soubrier
Stéphane
S
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France. ssoubrier@nordnet.fr.|EA 3614, Lille II University, 59000, Lille, France. ssoubrier@nordnet.fr.
Saulnier
Fabienne
F
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.|EA 3614, Lille II University, 59000, Lille, France.
Hubert
Hervé
H
EA 3614, Lille II University, 59000, Lille, France.
Delour
Pierre
P
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.
Lenci
Hélène
H
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.
Onimus
Thierry
T
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.|EA 3614, Lille II University, 59000, Lille, France.
Nseir
Saad
S
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.|EA 3614, Lille II University, 59000, Lille, France.
Durocher
Alain
A
Service de Réanimation Médicale, Hôpital Calmette, CHRU, boulevard du Pr Leclercq, 59037, Lille cedex, France.|EA 3614, Lille II University, 59000, Lille, France.
D001794:Blood Pressure; D016638:Critical Illness; D004452:Echocardiography; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012143:Respiratory Physiological Phenomena; D012680:Sensitivity and Specificity