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Published on: January 20, 2023
Prediction of fluid responsiveness following liver compression in pediatric patients with single ventricle physiology
Ji-Hyun Lee1, Hwan-Suk Jang1, Pyoyoon Kang1
1Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
Insights
Liver compression effectively predicts fluid responsiveness in children with single ventricle physiology. Blood pressure changes during this maneuver offer a reliable, non-invasive method for assessing fluid needs in these complex pediatric cardiac patients.
Area of Science:
- Pediatric Cardiology
- Hemodynamics
- Critical Care Medicine
Background:
- Assessing fluid responsiveness is crucial in children with single ventricle physiology undergoing cardiac surgery.
- Current methods for fluid responsiveness assessment can be invasive or less reliable in this population.
Purpose of the Study:
- To evaluate the efficacy of blood pressure changes during liver compression as a predictor of fluid responsiveness in children with single ventricle physiology.
- To compare the predictive value of liver compression between bidirectional cavopulmonary shunt (BCPS) and Fontan procedures.
Main Methods:
- Prospective, interventional study involving children aged 3 months to 5 years undergoing BCPS or extracardiac Fontan operation.
- Liver compression applied for 10 seconds at 30 mmHg, measuring blood pressure and hemodynamic parameters before and after fluid loading.
- Fluid responsiveness defined as >15% increase in stroke volume index.
Main Results:
- In BCPS patients, increased systolic, diastolic, and mean arterial pressure during liver compression significantly predicted fluid responsiveness (AUCs 0.928, 0.859, 0.874).
- In Fontan patients, only increased systolic arterial pressure during liver compression showed predictive value (AUC 0.786).
- Pleth variability index and respiratory variation in aortic blood flow peak velocity were not predictive in either group.
Conclusions:
- Blood pressure increase induced by liver compression is a valuable predictor of fluid responsiveness in children with single ventricle physiology.
- Liver compression may be more clinically useful in BCPS patients compared to Fontan patients due to differences in circulatory dynamics.
Introduction:
The role of liver compression in predicting fluid responsiveness in children with a single ventricle has never been evaluated. The purpose of this study was to assess whether blood pressure changes during liver compression predict fluid responsiveness in children with single ventricle physiology.
Methods:
This prospective, interventional study included children aged 3 months to 5 years who underwent surgery for bidirectional cavopulmonary shunt or extracardiac Fontan operation. Before fluid loading, the right upper abdomen was compressed at 30 mmHg for 10 s, and changes in the blood pressure waves were recorded before administering 10 ml kg-1 of crystalloid solution. Systolic arterial pressure, diastolic arterial pressure, central venous pressure, pleth variability index, respiratory variation in aortic blood flow peak velocity, and stroke volume were measured before and after fluid loading. A volume responder was defined as a patient with >15% increase in stroke volume index.
Results:
Thirty patients underwent bidirectional cavopulmonary shunt (15 responders and 15 non-responders), and 32 underwent Fontan surgery (17 responders and 15 non-responders). In children with bidirectional cavopulmonary shunt, Δsystolic arterial pressure > 8 mmHg (sensitivity 76.9% and specificity 93.3%), Δdiastolic arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 93.3%), and Δmean arterial pressure > 7 mmHg (sensitivity 69.2% and specificity 100%) during liver compression predicted fluid responsiveness. The areas under the receiver operating characteristic curves of Δsystolic arterial pressure, Δdiastolic arterial pressure, and Δmean arterial pressure were 0.928, 0.859, and 0.874 (all p < .001). In children who underwent Fontan surgery, only Δsystolic arterial pressure > 16 mmHg was predictive of fluid responsiveness (sensitivity of 41.2% and specificity of 100%), with the areas under the receiver operating characteristic curves curve of 0.786 (p < .001). Pleth variability index and respiratory variation in aortic blood flow peak velocity had no predictive value for fluid responsiveness after both types of surgeries.
Discussion:
In BCPS patients, liver compression increases the inferior vena cava flow which directly leads to an increase in preload. On the other hand, blood flow from the liver drains directly into the pulmonary arteries in Fontan circulation. Because of this characteristics for preload determination, the clinical application of liver compression to monitor hemodynamic changes might be more useful in patients with bidirectional cavopulmonary shunt than those with Fontan circulation.
Conclusion:
Increase in blood pressure induced by liver compression is predictive of fluid responsiveness in children with single ventricle physiology.
