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Predicting Fluid Responsiveness in Critically Ill Patients by Using Combined End-Expiratory and End-Inspiratory Occlusions With Echocardiography

Jozwiak, Mathieu MD1,2; Depret, François MD1,2; Teboul, Jean-Louis MD, PhD1,2; Alphonsine, Jean-Emmanuel MD1,2; Lai, Christopher MD1,2; Richard, Christian MD1,2; Monnet, Xavier MD, PhD1,2

doi: 10.1097/CCM.0000000000002704
Online Clinical Investigations

Objectives: First, we aimed at assessing whether fluid responsiveness is predicted by the effects of an end-expiratory occlusion on the velocity-time integral of the left ventricular outflow tract. Second, we investigated whether adding the effects of an end-inspiratory occlusion and of an end-expiratory occlusion on velocity-time integral can predict fluid responsiveness with similar reliability than end-expiratory occlusion alone but with a higher threshold, which might be more compatible with the precision of echocardiography.

Design: Diagnostic study.

Setting: Medical ICU.

Patients: Thirty mechanically ventilated patients in whom fluid administration was planned.

Interventions: A 15-second end-expiratory occlusion and end-inspiratory occlusion, separated by 1 minute, followed by a 500-mL saline administration.

Measurements and Main Results: Pulse contour analysis–derived cardiac index and velocity-time integral were measured during the last 5 seconds of 15-second end-inspiratory occlusion and end-expiratory occlusion and after fluid administration. End-expiratory occlusion increased velocity-time integral more in responders than in nonresponders to fluid administration (11% ± 5% vs 3% ± 1%, respectively; p < 0.0001), and end-inspiratory occlusion decreased velocity-time integral more in responders than in nonresponders (12% ± 5% vs 5% ± 2%, respectively; p = 0.0002). When adding the absolute values of changes in velocity-time integral observed during both occlusions, velocity-time integral changed by 23% ± 9% in responders and by 8% ± 3% in nonresponders. Fluid responsiveness was predicted by the end-expiratory occlusion–induced change in velocity-time integral with an area under the receiver operating characteristic curve of 0.938 (0.785–0.989) and a threshold value of 5%. Fluid responsiveness was predicted by the sum of absolute values of changes in velocity-time integral during both occlusions with a similar reliability (area under the receiver operating characteristic curve = 0.973 [0.838–1.000]) but with a threshold of 13%. Both sensitivity and specificity were 93% (68–100%).

Conclusions: If consecutive end-inspiratory occlusion and end-expiratory occlusion change velocity-time integral is greater than or equal to 13% in total, fluid responsiveness is accurately predicted. This threshold is more compatible with the precision of echocardiography than that obtained by end-expiratory occlusion alone.

Supplemental Digital Content is available in the text.

1Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.

2Inserm UMR S_999, Univ Paris-Sud, Le Kremlin-Bicêtre, France.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Drs. Teboul and Monnet received funding from Pulsion Medical System and are members of the medical advisory board for Pulsion Medical Systems. Dr. Monnet received support for article research from assistance publique hôpitaux de Paris. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: mathieu.jozwiak@aphp.fr

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