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Published on: May 2, 2017
Fluid responsiveness and changes in venous congestion and lung water during volume expansion in critically ill
Xiang Si1,2,3, Daiyin Cao4,5, Rui Shi6,7
1Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. sixiang@mail.sysu.edu.cn.
Background:
The relationship between fluid responsiveness and right-and left-sided congestion remains underexplored. This study aimed to delineate the dynamic behaviour of venous congestion and extravascular lung water index (EVLWI) during a fluid challenge depending on the concomitant changes in cardiac index (CI).
Methods:
In patients from three intensive care units, for whom a 500-mL fluid challenge was administered, we retrospectively analysed CI, central venous pressure (CVP), venous excess ultrasound (VExUS), and EVLWI, which had been prospectively recorded. A VExUS congestion point was calculated from 0 to 7 by assigning 1 point to each degree of abnormality for the 4 investigated veins. A subgroup analysis was planned in patients with acute respiratory distress syndrome (ARDS).
Results:
We analysed 64 patients, of whom 42 (66%) were fluid responders (FR+) defined by a CI increase ≥ 15% with fluid infusion. Before the fluid challenge, CVP was lower in FR + than in fluid non-responders (FR-) (7.3 [2.9-10.3] vs. 10.6 [8.2-13.0] mmHg,respectively, p = 0.002). VExUS grades and congestion points were not different between FR + and FR- (Grade 0: 62% vs. 55%, respectively, p = 0.601; congestion points: 1.0 [0.0-2.3] vs. 2.0 [1.0-3.0], respectively, p = 0.053). EVLWI was also similar between groups. Following fluid administration, VExUS grade deterioration occurred in 5% of FR + versus 73% of FR- (p < 0.001). After the fluid challenge, abnormal VExUS grades were more prevalent in FR - than in FR+ (91% vs. 43%, respectively, p < 0.001), and congestion points were higher (4.0 [3.0-5.0] vs. 1.5 [1.0-3.0], respectively, p < 0.001). CVP increased by 1.4 [0.4-2.4] mmHg in FR + and 2.0 [1.1-3.5] mmHg in FR- (p = 0.064). Among 25 patients with ARDS, EVLWI increased more than in patients without ARDS, in both FR- (by 1.7 [0.9-3.3] vs. 0.7 [0-1.4] mL/kg, respectively, p = 0.046) and FR+ (by 1.0 [-0.6-2.5] vs. 0 [-0.7-0.4] mL/kg, respectively, p = 0.009).
Conclusion:
A fluid challenge worsened venous congestion, assessed by VExUS as well as CVP, in fluid non-responders, while it was not in fluid responders.
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