title: Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock.
abstract: Volume expansion is a mainstay of therapy in septic shock, although its effect is difficult to predict using conventional measurements. Dynamic parameters, which vary with respiratory changes, appear to predict hemodynamic response to fluid challenge in mechanically ventilated, paralyzed patients. Whether they predict response in patients who are free from mechanical ventilation is unknown. We hypothesized that dynamic parameters would be predictive in patients not receiving mechanical ventilation. This is a prospective, observational, pilot study. Patients with early septic shock and who were not receiving mechanical ventilation received 10-mL/kg volume expansion (VE) at their treating physician's discretion after initial resuscitation in the emergency department. We used transthoracic echocardiography to measure vena cava collapsibility index and aortic velocity variation before VE. We used a pulse contour analysis device to measure stroke volume variation (SVV). Cardiac index was measured immediately before and after VE using transthoracic echocardiography. Hemodynamic response was defined as an increase in cardiac index 15% or greater. Fourteen patients received VE, five of whom demonstrated a hemodynamic response. Vena cava collapsibility index and SVV were predictive (area under the curve = 0.83, 0.92, respectively). Optimal thresholds were calculated: vena cava collapsibility index, 15% or greater (positive predictive value, 62%; negative predictive value, 100%; P = 0.03); SVV, 17% or greater (positive predictive value 100%, negative predictive value 82%, P = 0.03). Aortic velocity variation was not predictive. Vena cava collapsibility index and SVV predict hemodynamic response to fluid challenge patients with septic shock who are not mechanically ventilated. Optimal thresholds differ from those described in mechanically ventilated patients.
authors: Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA. michael.lanspa@imail.org
authors: Michael J
authors: MJ
authors: Lanspa
authors: Colin K
authors: CK
authors: Grissom
authors: Eliotte L
authors: EL
authors: Hirshberg
authors: Jason P
authors: JP
authors: Jones
authors: Samuel M
authors: SM
authors: Brown
mesh_terms: D001021:Aortic Valve / Q000502:physiology; D001810:Blood Volume / Q000502:physiology; D003422:Critical Care / Q000379:methods; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D010952:Plasma Substitutes / Q000627:therapeutic use*; D011446:Prospective Studies; D012772:Shock, Septic / Q000628:therapy*; D013318:Stroke Volume / Q000502:physiology; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D010952:Plasma Substitutes; D014665:Vasodilator Agents