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Accuracy of cumulative volumes of fluid challenge to assess fluid responsiveness in critically ill patients with acute circulatory failure: a pharmacodynamic approach
British Journal of Anaesthesia ( IF 9.8 ) Pub Date : 2021-12-08 , DOI: 10.1016/j.bja.2021.10.049
Romain Barthélémy 1 , Manuel Kindermans 1 , Paul Delval 1 , Magalie Collet 1 , Samuel Gaugain 1 , Maurizio Cecconi 2 , Alexandre Mebazaa 3 , Benjamin G Chousterman 3
Affiliation  

Background

The relationship between the dose (volume of fluid) and the effect (increase of stroke volume [SV]) has been poorly described. We hypothesised that the analysis of the dynamic response of SV during fluid challenge (FC) helps to determine the optimal volume of FC, along with its diagnostic accuracy parameters for fluid responsiveness.

Methods

A prospective observational study was conducted in critically ill patients with circulatory failure. Patients monitored with oesophageal Doppler and assigned to an FC of 500 ml of crystalloid were included. The areas under the curve (AUC) and 95% confidence intervals (CI95) of the receiver operating characteristic curves for cumulative volumes from 50 to 450 ml were determined for fluid responsiveness (SV increase ≥15% from baseline) along with other parameters of diagnostic accuracy. In the pharmacodynamic analysis, dose–effect and dose–response models were constructed, with determination of median and 90% effective dose (ED50 and ED90).

Results

Forty-five patients were included. The AUC increased with cumulative volumes of FC up to 250 ml (AUC250 0.93 [CI95: 0.85–1.00]), followed by a plateau above 0.95 of AUC. The optimal volume was 250 ml, associated with a specificity of 0.89 [CI95: 0.78–1.00], a sensitivity of 0.92 [CI95: 0.69–1.00], and a threshold of 9.6% increase in SV. The ED50 was 156 [CI95: 136–177] ml and the ED90 was 312 [CI95: 269–352] ml.

Conclusions

A volume of FC of 250 ml with a threshold of 9.6% increase in SV showed the highest accuracy in detecting fluid responsiveness in critically ill patients with shock.

Clinical trial registration

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中文翻译:

累积液体挑战量以评估急性循环衰竭危重患者液体反应性的准确性:一种药效学方法

背景

剂量(液体量)和效果(每搏输出量 [SV] 的增加)之间的关系描述得很少。我们假设对液体挑战 (FC) 期间 SV 的动态响应的分析有助于确定 FC 的最佳体积,以及液体反应性的诊断准确性参数。

方法

在循环衰竭的危重患者中进行了一项前瞻性观察研究。包括使用食管多普勒监测并分配到 500 ml 晶体液 FC 的患者。确定从 50 到 450 ml 的累积体积的受试者工作特征曲线的曲线下面积 (AUC) 和 95% 置信区间 (CI 95 ) 的液体反应性(SV 从基线增加≥15%)以及其他参数诊断准确性。在药效学分析中,构建了剂量-效应和剂量-反应模型,确定了中位数和 90% 有效剂量(ED 50和 ED 90)。

结果

包括 45 名患者。AUC 随着 FC 的累积体积增加到 250 ml (AUC 250 0.93 [CI 95 : 0.85–1.00]) 增加,随后达到 AUC 0.95 以上的平台期。最佳体积为 250 ml,特异性为 0.89 [CI 95:0.78–1.00],灵敏度为 0.92 [CI 95:0.69–1.00],SV 增加 9.6% 的阈值。ED 50为 156 [CI 95 : 136–177] ml,ED 90为 312 [CI 95 : 269–352] ml。

结论

FC 体积为 250 ml,SV 增加 9.6% 的阈值,在检测危重休克患者的液体反应性方面表现出最高的准确性。

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更新日期:2022-01-12
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