Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock
Fluid responsiveness, Passive leg raising, Sepsis, Transthoracic echocardiography, Velocity time integral
Citation Information :
Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021; 25 (3):310-316.
Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee\'s clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18–65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as “responders.” Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017;43:304–377. DOI: 10.1007/s00134-017-4683-6.
Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000-2012. JAMA 2014;311:1308–1316. DOI: 10.1001/jama.2014.2637.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign. Crit Care Med 2013;41:580–637. DOI: 10.1097/CCM.0b013e31827e83af.
Polderman KH, Varon J. Do not drown the patient: appropriate fluid management in critical illness. Am J Emerg Med. 2015;33:448–450. DOI: 10.1016/j.ajem.2015.01.051.
Richard J-C, Bayle F, Bourdin G, Leray V, Debord S, Delannoy B, et al. Preload dependence indices to titrate volume expansion during septic shock: a randomized controlled trial. Crit Care 2015;19:5. DOI: 10.1186/s13054-014-0734-3.
Benes J, Giglio M, Brienza N, Michard F. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care 2014;18:584. DOI: 10.1186/s13054-014-0584-z.
Mandeville JC, Colebourn CL. Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review. Crit Care Res Pract. 2012;2012:513480. DOI: 10.1155/2012/513480.
Wu Y, Zhou S, Zhou Z, Liu B. A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness. Crit Care 2014;18:R108. DOI: 10.1186/cc13891.
Cavallaro F, Sandroni C, Marano C, La TG, Mannocci A, De WC, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010;36:1475–1483. DOI: 10.1007/s00134-010-1929-y.
Sidor M, Premachandra L, Hanna B, Nair N, Misra A. Carotid flow as a surrogate for cardiac output measurement in Hemodynamically stable participants. J Intensive Care Med 2020;35:650–655. DOI: 10.1177/0885066618775694.
Miller A, Mandeville J. Predicting and measuring fluid responsiveness with echocardiography. Echo Res Pract 2016;3:G1–G12. DOI: 10.1530/ERP-16-0008.
Weber U, Glassford NJ, Eastwood GM, Bellomo R, Hilton AK. A pilot study of the relationship between Doppler-estimated carotid and brachial artery flow and cardiac index. Anaesthesia 2015;70:1140–1147. DOI: 10.1111/anae.13069.
Weber U, Glassford NJ, Eastwood GM, Bellomo R, Hilton AK. A pilot assessment of carotid and brachial artery blood flow estimation using ultrasound Doppler in cardiac surgery patients. J Cardiothorac Vasc Anesth. 2016;30:141–148. DOI: 10.1053/j.jvca.2015.06.025.
Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest 2013;143:364–370. DOI: 10.1378/chest.12-1274.
Kupersztych-Hagege E, Teboul JL, Artigas A, Talbot A, Sabatier C, Richard C, et al. Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients. Br J Anaesth. 2013;111:961–966. DOI: 10.1093/bja/aet282.
Tan C, Rubenson D, Srivastava A, Mohan R, Smith MR, et al. Left ventricular outflow tract velocity time integral outperforms ejection fraction and Doppler-derived cardiac output for predicting outcomes in a select advanced heart failure cohort. Cardiovasc Ultrasound 2017;15:18. DOI: 10.1186/s12947-017-0109-4.
Ibarra-estrada MÁ, López-pulgarín JA, Mijangos-méndez JC, Díaz-gómez JL. Respiratory variation in carotid peak systolic velocity predicts volume responsiveness in mechanically ventilated patients with septic shock: a prospective cohort study. Crit Ultrasound J 2015;7:29. DOI: 10.1186/s13089-015-0029-1.
Girotto V, Teboul JL, Beurton A, Galarza L, Guedj T, Richarfd C, et al. Carotid and femoral Doppler do not allow the assessment of passive leg raising effects. Ann. Intensive Care 2018;8:67. DOI: 10.1186/s13613-018-0413-7.
Ferlini, L, Su, F, Creteur J, Taccone FS, Gaspard N. Cerebral autoregulation and neurovascular coupling are progressively impaired during septic shock: an experimental study. Intensive Care Med Exp 2020;8:44. DOI: 10.1186/s40635-020-00332-0.
Schramm P, Klein K, Falkenberg L, Berres M, Closhen D, Werhahn KJ, et al. Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium. Crit Care 2012;16:R181. DOI: 10.1186/cc11665.
Crippa IA, Subirà C, Vincent J-L, Fernandez RF, Hernandez SC, Cavicchi FZ, et al. Impaired cerebral autoregulation is associated with brain dysfunction in patients with sepsis. Crit Care 2018;22:327. DOI: 10.1186/s13054-018-2258-8.
Berg RMG, Plovsing RR, Ronit A, Bailey DM, Holstein-Rathlou N-H, Møller K. Disassociation of static and dynamic cerebral autoregulatory performance in healthy volunteers after lipopolysaccharide infusion and in patients with sepsis. Am J Physiol Regul Integr Comp Physiol 2012;303:R1127–R1135. DOI: 10.1152/ajpregu.00242.2012.
Pfister D, Siegemund M, Dell-Kuster S, Smielewski P, Rüegg S, Strebel SP, et al. Cerebral perfusion in sepsis-associated delirium. Crit Care 2008;12:R63. DOI: 10.1186/cc6891.
Fillinger MF, Schwarz RA. Volumetric blood flow measurement with color Doppler ultrasonography: the importance of visual clues. J Ultrasound Med 1993;12:123–130. DOI: 10.7863/jum.1993.12. 3.123.
Préau S, Saulnier F, Dewavrin F, Durocher A, Chagnon J-L. Passive leg raising is predictive of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute pancreatitis. Crit Care Med 2010;38:819–825. DOI: 10.1097/CCM.0b013e3181c8fe7a.