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Fluid Responsiveness Predictability in Immediate Postoperative Pediatric Cardiac Surgery. Is the Old Slandered
Eran Shostak1,2, Tzippy Shochat2, Orit Manor1,2
1Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
Insights
In pediatric cardiac surgery patients, common fluid responsiveness predictors like pressure variation and ultrasound failed. Dynamic central venous pressure changes showed modest predictability in this specific population.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular physiology
- Echocardiography and hemodynamic monitoring
Background:
- Acute low cardiac output (CO) is common in pediatric cardiac intensive care units (PCICUs).
- Predicting fluid responsiveness is crucial for managing these patients, yet data is limited for the immediate postoperative congenital heart surgery population.
- Existing fluid responsiveness assessment methods may not be reliable in this unique patient group.
Purpose of the Study:
- To evaluate the utility of various hemodynamic, bedside ultrasound, and Doppler parameters for predicting fluid responsiveness.
- To identify reliable indicators of fluid responsiveness in neonates and infants immediately after cardiac surgery.
- To address the scarcity of literature regarding fluid responsiveness prediction in this specific pediatric population.
Main Methods:
- A prospective observational study was conducted in a PCICU.
- Included were mechanically ventilated, immediate postoperative pediatric cardiac surgery patients with presumed hypovolemic low CO.
- Assessed clinical, arterial-derived, hemodynamic, sonographic, Doppler, and echocardiographic parameters before a fluid bolus (15-20 cc/kg crystalloid).
Main Results:
- Of 52 patients, 65% were fluid responsive (cardiac index >10% increase).
- Arterial systolic pressure variation, continuous-Doppler preload parameters, and inferior vena cava distensibility index (IVCDI) failed to predict fluid responsiveness.
- Dynamic central venous pressure (CVP) change demonstrated significant, albeit modest, predictability (AUC 0.654, P=0.0375).
Conclusions:
- Standard fluid responsiveness predictors (SPV, USCOM, IVC-based parameters) were ineffective in mechanically ventilated pediatric cardiac patients postoperatively.
- Dynamic CVP change over several hours emerged as the sole parameter with significant, modest predictive value.
- Further research is needed to establish optimal fluid management strategies in this vulnerable population.
Objective:
Acute low cardiac output (CO) is a frequent scenario in pediatric cardiac intensive care units (PCICU). While fluid responsiveness has been studied extensively, literature is scarce for the immediate postoperative congenital heart surgery population admitted to PCICUs. This study analyzed the utility of hemodynamic, bedside ultrasound, and Doppler parameters for prediction of fluid responsiveness in infants and neonates in the immediate postoperative cardiac surgery period.
Design:
A prospective observational study.
Setting:
University affiliated, tertiary care hospital, PCICU.
Participants:
Immediate postoperative pediatric patients displaying a presumed hypovolemic low CO state were included. A clinical, arterial derived, hemodynamic, sonographic, Doppler-based, and echocardiographic parameter assessment was performed, followed by a fluid bolus therapy.
Interventions:
Fifteen to 20 cc/kg crystalloid fluid bolus.
Main Outcome Measures:
Fluid responsiveness was defined as an increase in cardiac index >10% by echocardiography.
Results:
Of 52 patients, 34 (65%) were fluid responsive. Arterial systolic pressure variation, continuous-Doppler preload parameters, and inferior vena-cava distensibility index (IVCDI) by bedside ultrasound all failed to predict fluid responsiveness. Dynamic central venous pressure (CVP) change yielded a significant but modest fluid responsiveness predictability of area under the curve 0.654 (P = 0.0375).
Conclusions:
In a distinct population of mechanically ventilated, young, pediatric cardiac patients in the immediate postoperative period, SPV, USCOM preload parameters, as well as IVC-based parameters by bedside ultrasound failed to predict fluid responsiveness. Dynamic CVP change over several hours was the only parameter that yielded significant but modest fluid responsiveness predictability.
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