Αρχειοθήκη ιστολογίου

Αλέξανδρος Γ. Σφακιανάκης
ΩτοΡινοΛαρυγγολόγος
Αναπαύσεως 5
Άγιος Νικόλαος Κρήτη 72100
2841026182
6032607174

Παρασκευή 10 Φεβρουαρίου 2017

Change in end-tidal carbon dioxide outperforms other surrogates for change in cardiac output during fluid challenge

<span class="paragraphSection"><strong>Background.</strong> During fluid challenge, volume expansion (VE)-induced increase in cardiac output (Δ<sub>VE</sub>CO) is seldom measured.<strong>Methods.</strong> In patients with shock undergoing strictly controlled mechanical ventilation and receiving VE, we assessed minimally invasive surrogates for Δ<sub>VE</sub>CO (by transthoracic echocardiography): fluid-induced increases in end-tidal carbon dioxide (Δ<sub>VE</sub>E′CO2); pulse (Δ<sub>VE</sub>PP), systolic (Δ<sub>VE</sub>SBP), and mean systemic blood pressure (Δ<sub>VE</sub>MBP); and femoral artery Doppler flow (Δ<sub>VE</sub>FemFlow). In the absence of arrhythmia, fluid-induced decrease in heart rate (Δ<sub>VE</sub>HR) and in pulse pressure respiratory variation (Δ<sub>VE</sub>PPV) were also evaluated. Areas under the receiver operating characteristic curves (AUC<sub>ROC</sub>s) reflect the ability to identify a response to VE (Δ<sub>VE</sub>CO ≥15%).<strong>Results.</strong> In 86 patients, Δ<sub>VE</sub>E′CO2 had an AUC<sub>ROC</sub>=0.82 [interquartile range 0.73–0.90], significantly higher than the AUC<sub>ROC</sub> for Δ<sub>VE</sub>PP, Δ<sub>VE</sub>SBP, Δ<sub>VE</sub>MBP, and Δ<sub>VE</sub>FemFlow (AUC<sub>ROC</sub>=0.61–0.65, all <span style="font-style:italic;">P</span> <0.05). A value of Δ<sub>VE</sub>E′CO2 >1 mm Hg (>0.13 kPa) had good positive (5.0 [2.6–9.8]) and fair negative (0.29 [0.2–0.5]) likelihood ratios. The 16 patients with arrhythmia had similar relationships between Δ<sub>VE</sub>E′CO2 and Δ<sub>VE</sub>CO to patients with regular rhythm (<span style="font-style:italic;">r</span><sup>2</sup>=0.23 in both subgroups). In 60 patients with no arrhythmia, Δ<sub>VE</sub>E′CO2 (AUC<sub>ROC</sub>=0.84 [0.72–0.92]) outperformed Δ<sub>VE</sub>HR (AUC<sub>ROC</sub>=0.52 [0.39–0.66], <span style="font-style:italic;">P</span><0.05) and tended to outperform Δ<sub>VE</sub>PPV (AUC<sub>ROC</sub>=0.73 [0.60–0.84], <span style="font-style:italic;">P</span>=0.21). In the 45 patients with no arrhythmia and receiving ventilation with tidal volume <8 ml kg<sup>−1</sup>, Δ<sub>VE</sub>E′CO2 performed better than Δ<sub>VE</sub>PPV, with AUC<sub>ROC</sub>=0.86 [0.72–0.95] <span style="font-style:italic;">vs</span> 0.66 [0.49–0.80], <span style="font-style:italic;">P</span>=0.02.<strong>Conclusions.</strong> Δ<sub>VE</sub>E′CO2 outperformed Δ<sub>VE</sub>PP, Δ<sub>VE</sub>SBP, Δ<sub>VE</sub>MBP, Δ<sub>VE</sub>FemFlow, and Δ<sub>VE</sub>HR and, during protective ventilation, arrhythmia, or both, it also outperformed Δ<sub>VE</sub>PPV. A value of Δ<sub>VE</sub>E′CO2 >1 mm Hg (>0.13 kPa) indicated a likely response to VE.</span>

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