title: Limitations of global end-diastolic volume index as a parameter of cardiac preload in the early phase of severe sepsis: a subgroup analysis of a multicenter, prospective observational study.
abstract: BACKGROUND
  In patients with severe sepsis, depression of cardiac performance is common and is often associated with left ventricular (LV) dilatation to maintain stroke volume. Although it is essential to optimize cardiac preload to maintain tissue perfusion in patients with severe sepsis, the optimal preload remains unknown. This study aimed to evaluate the reliability of global end-diastolic volume index (GEDI) as a parameter of cardiac preload in the early phase of severe sepsis.
  
  
  METHODS
  Ninety-three mechanically ventilated patients with acute lung injury/acute respiratory distress syndrome secondary to sepsis were enrolled for subgroup analysis in a multicenter, prospective, observational study. Patients were divided into two groups-with sepsis-induced myocardial dysfunction (SIMD) and without SIMD (non-SIMD)-according to a threshold LV ejection fraction (LVEF) of 50% on the day of enrollment. Both groups were further subdivided according to a threshold stroke volume variation (SVV) of 13% as a parameter of fluid responsiveness.
  
  
  RESULTS
  On the day of enrollment, there was a positive correlation (r = 0.421, p = 0.045) between GEDI and SVV in the SIMD group, whereas this paradoxical correlation was not found in the non-SIMD group and both groups on day 2. To evaluate the relationship between attainment of cardiac preload optimization and GEDI value, GEDI with SVV ≤13% and SVV >13% was compared in both the SIMD and non-SIMD groups. SVV ≤13% implies the attainment of cardiac preload optimization. Among patients with SIMD, GEDI was higher in patients with SVV >13% than in patients with SVV ≤13% on the day of enrollment (872 [785-996] mL/m(2) vs. 640 [597-696] mL/m(2); p < 0.001); this finding differed from the generally recognized relationship between GEDI and SVV. However, GEDI was not significantly different between patients with SVV ≤13% and SVV >13% in the non-SIMD group on the day of enrollment and both groups on day 2.
  
  
  CONCLUSIONS
  In the early phase of severe sepsis in mechanically ventilated patients, there was no constant relationship between GEDI and fluid reserve responsiveness, irrespective of the presence of SIMD. GEDI should be used as a cardiac preload parameter with awareness of its limitations.
authors.affiliation: Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai, Miyagi, 980-8574 Japan.
authors.forename: Tomoyuki
authors.initials: T
authors.lastname: Endo
authors.affiliation: Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574 Japan.
authors.forename: Shigeki
authors.initials: S
authors.lastname: Kushimoto
authors.affiliation: Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574 Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Yamanouchi
authors.affiliation: Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Kurume-shi, Fukuoka, 830-0011 Japan.
authors.forename: Teruo
authors.initials: T
authors.lastname: Sakamoto
authors.affiliation: Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Fukuoka, 814-0180 Japan.
authors.forename: Hiroyasu
authors.initials: H
authors.lastname: Ishikura
authors.affiliation: Department of Emergency and Critical Care Medicine, Kansai Medical University, Moriguchi, Osaka, 570-8506 Japan.
authors.forename: Yasuhide
authors.initials: Y
authors.lastname: Kitazawa
authors.affiliation: Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, 216-8511 Japan.
authors.forename: Yasuhiko
authors.initials: Y
authors.lastname: Taira
authors.affiliation: Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, 634-8521 Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Okuchi
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Bunkyo-ku, Tokyo, 113-8603 Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Tagami
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Bunkyo-ku, Tokyo, 113-8603 Japan.
authors.forename: Akihiro
authors.initials: A
authors.lastname: Watanabe
authors.affiliation: Department of Emergency and Critical Care Medicine, Nihon University School of Medicine Itabashi Hospital, Itabashi-ku, Tokyo, 173-8610 Japan.
authors.forename: Junko
authors.initials: J
authors.lastname: Yamaguchi
authors.affiliation: Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Bunkyo-ku, Tokyo, 113-8519 Japan.
authors.forename: Kazuhide
authors.initials: K
authors.lastname: Yoshikawa
authors.affiliation: Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, 177-8521 Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Sugita
authors.affiliation: Department of Critical Care Medicine, Jikei University School of Medicine, Minato-ku, Tokyo, 105-8471 Japan.
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Kase
authors.affiliation: Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, Tachikawa-shi, Tokyo, 190-0014 Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Kanemura
authors.affiliation: Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Takahashi
authors.affiliation: Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, Nagoya, Aichi, 457-8510 Japan.
authors.forename: Yuuichi
authors.initials: Y
authors.lastname: Kuroki
authors.affiliation: Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, Moriguchi, Osaka, 570-8507 Japan.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Izumino
authors.affiliation: Emergency and Critical Care Medical Center, Osaka City General Hospital, Miyakojima, Osaka, 534-0021 Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Rinka
authors.affiliation: Intensive Care Unit, Kobe City Medical Center General Hospital, Kobe, Hyogo, 650-0046 Japan.
authors.forename: Ryutarou
authors.initials: R
authors.lastname: Seo
authors.affiliation: Department of Anesthesia and Intensive Care, Hiroshima City Hospital, Hiroshima-shi, Hiroshima, 730-8518 Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Takatori
authors.affiliation: Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Yamaguchi, 755-8505 Japan.
authors.forename: Tadashi
authors.initials: T
authors.lastname: Kaneko
authors.affiliation: Intensive Care Unit, Nagasaki University Hospital, Sakamoto, Nagasaki, 852-8501 Japan.
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tama-shi, Tokyo, 206-8512 Japan.
authors.forename: Takayuki
authors.initials: T
authors.lastname: Irahara
authors.affiliation: Department of Emergency and Critical Care Medicine, Nippon Medical School Chiba Hokusou Hospital, Inzai-shi, Chiba, 270-1694 Japan.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Saito
keywords: Diastolic dysfunction; Global end-diastolic volume index; Sepsis-induced myocardial dysfunction; Severe sepsis; Stroke volume variation