Should We Really Use Respiratory Stroke Volume Variation to Assess Fluid Responsiveness in Cardiac Surgical Patients?

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Improve the Quality of Reporting to Improve Scientific Knowledge in the Field of Extracorporeal Membrane Oxygenation

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Capillary refill time variation induced by passive leg raising predicts capillary refill time response to volume expansion

International audienceBACKGROUND:A peripheral perfusion-targeted resuscitation during early septic shock has shown encouraging results. Capillary refill time, which has a prognostic value, was used. Adding accuracy and predictability on capillary refill time (CRT) measurement, if feasible, would benefit to peripheral perfusion-targeted resuscitation. We assessed whether a reduction of capillary refill time during passive leg raising (ΔCRT-PLR) predicted volume-induced peripheral perfusion improvement defined as a significant decrease of capillary refill time following volume expansion.METHODS:Thirty-four patients with acute circulatory failure were selected. Haemodynamic variables, metabolic variables (PCO2gap), and four capillary refill time measurements were recorded before and during a passive leg raising test and after a 500-mL volume expansion over 20 min. Receiver operating characteristic curves were built, and areas under the curves were calculated (ROCAUC). Confidence intervals (CI) were performed using a bootstrap analysis. We recorded mortality at day 90.RESULTS:The least significant change in the capillary refill time was 25% [95% CI, 18-30]. We defined CRT responders as patients showing a reduction of at least 25% of capillary refill time after volume expansion. A decrease of 27% in ΔCRT-PLR predicted peripheral perfusion improvement with a sensitivity of 87% [95% CI, 73-100] and a specificity of 100% [95% CI, 74-100]. The ROCAUC of ΔCRT-PLR was 0.94 [95% CI, 0.87-1.0]. The ROCAUC of baseline capillary refill time was 0.73 [95% CI, 0.54-0.90] and of baseline PCO2gap was 0.79 [0.61-0.93]. Capillary refill time was significantly longer in non-survivors than in survivors at day 90.CONCLUSION:ΔCRT-PLR predicted peripheral perfusion response following volume expansion. This simple low-cost and non-invasive diagnostic method could be used in peripheral perfusion-targeted resuscitation protocols.TRIAL REGISTRATION:CPP Lyon Sud-Est II ANSM: 2014-A01034-43 Clinicaltrial.gov, NCT02248025 , registered 13th of September 2014

Microvascular effects of intravenous esmolol in patients with normal cardiac function undergoing postoperative atrial fibrillation: a prospective pilot study in cardiothoracic surgery

Abstract Background Postoperative atrial fibrillation (POAF) is commonplace after cardiothoracic surgery. A rate control strategy using short-acting beta blockers is recommended as a first-line therapy in patients without hemodynamic instability. Microcirculatory effects of POAF and esmolol have not yet been investigated. We hypothesized that POAF without hemodynamic instability would induce microvascular dysfunction which could be reversed by intravenous esmolol. Methods Twenty-five cardiothoracic surgical patients with POAF were included in the study. Microcirculation was assessed by peripheral near-infrared spectroscopy (NIRS) in association with a vascular occlusion test (VOT) before esmolol infusion, during incremental doses of esmolol (25, 50, 100, and 200 μg/kg/min), and after a return to sinus rhythm. Esmolol was given to control heart rate to between 60 and 90 beats/min. Regional tissue oxygen saturation variables (StO2, StO2 min, StO2 max, and ∆StO2) and desaturation/resaturation speeds during VOT were recorded to evaluate the microcirculation. Results StO2 and resaturation speed were significantly improved when POAF returned to sinus rhythm (StO2 64% ± 6 versus 67% ± 6, P < 0.01; resaturation speed 0.53%/s (0.42–0.97) versus 0.66%/s (0.51–1.04), P = 0.020). ∆StO2 was significantly decreased after a return to sinus rhythm (7.9% ± 4.8 versus 6.1% ± 4.7, P = 0.026). During esmolol infusion, we found a significant decrease in both heart rate (P < 0.001) and blood pressure (P < 0.001), and a non-significant dose-dependent increase in StO2 (P = 0.081) and resaturation speed (P = 0.087). Conclusion POAF without hemodynamic instability is associated with significant impairment in the microcirculation which could be partially reversed by intravenous esmolol

Preload Dependence Fails to Predict Hemodynamic Instability During a Fluid Removal Challenge in Children*

International audienceObjectifs : La surcharge liquidienne augmente la morbidité et la mortalité chez les patients en USIP. L'élimination active des fluides améliore le pronostic mais peut aggraver le dysfonctionnement des organes. La dépendance à la précharge chez les adultes prédit l'instabilité hémodynamique induite par un défi d'élimination des fluides (FRC). Nous avons cherché à étudier la précision diagnostique des marqueurs dynamiques et statiques de la précharge dans la prédiction de l'instabilité hémodynamique et de la réduction du volume d'éjection systolique lors d'une CRF chez les enfants. Nous avons suivi la déclaration des normes de déclaration de l'exactitude diagnostique pour concevoir, mener et rapporter cette étude.Conception : Étude de cohorte prospective non interventionnelle.Contexte : De juin 2017 à avril 2019 dans une unité de soins intensifs cardiaques pédiatriques d'un hôpital tertiaire.Patients : Des patients âgés de 8 ans ou moins, présentant des symptômes de surcharge hydrique après une chirurgie cardiaque, ont été étudiés.Interventions : Nous avons confirmé la dépendance à la précharge par échocardiographie avant et pendant un test de compression abdominale calibré. Nous avons ensuite effectué un défi pour éliminer 10 ml/kg de liquide en moins de 120 minutes avec une infusion de diurétiques. L'instabilité hémodynamique était définie comme une diminution de 10 % de la pression artérielle moyenne.Mesure et principaux résultats : Nous avons comparé des patients présentant une instabilité hémodynamique avec des patients restant stables, et nous avons construit des courbes de caractéristiques opératoires du récepteur (ROC). Parmi 58 patients étudiés, 10 présentaient une instabilité hémodynamique. L'aire sous la courbe ROC était de 0,55 pour le test de dépendance de précharge (IC à 95 %, 0,34-0,75). En utilisant un seuil d'augmentation de 10 % de l'indice de volume systolique (SVi) pendant la compression abdominale calibrée, la spécificité était de 0,30 (IC à 95 %, 0,00-0,60) et la sensibilité était de 0,77 (IC à 95 %, 0,65-0,88). La variation moyenne de la pression artérielle et la variation du SVi n'étaient pas corrélées lors de l'élimination du liquide ; r = 0,19 ; IC à 95 % -0,07 à 0,43 ; p = 0,139.Conclusions : La dépendance à la précharge n'est pas précise pour prédire l'instabilité hémodynamique au cours d'une CRF. Nos données ne supportent pas une réduction du volume intravasculaire étant principalement responsable de la réduction de la pression artérielle lors d'une CRF chez les enfants

De Novo Complement-Binding Anti-HLA Antibodies in Heart Transplanted Patients Is Associated with Severe Cardiac Allograft Vasculopathy and Poor Long-Term Survival

International audienceIntroduction: De novo anti-HLA donor specific antibodies (DSA) have been inconsistently associated with cardiac allograft vasculopathy (CAV) and long-term mortality. We tested whether C3d-binding de novo DSA were associated with CAV or long-term-survival. Methods: We included 282 consecutive patients without preformed DSA on coronary angiography between 2010 and 2012. Angiographies were classified according to CAV ISHLT grading. The primary outcome was a composite criterion of severe CAV or mortality. As the impact of de novo antibodies should be assessed only after appearance, we used a Cox regression with time-dependent covariables. Results: Of the 282 patients, 51(18%) developed de novo DSA during follow-up, 29 patients had DSA with C3d-binding ability (DSA+C3d+), and 22 were without C3d-binding ability (DSA+C3d-). Compared with patients without DSA, DSA+C3d+ patients had an increased risk for the primary outcome of severe CAV or mortality (adjusted HR = 4.31 (2.40–7.74) p < 0.001) and long-term mortality (adjusted HR = 3.48 (1.97–6.15) p < 0.001) whereas DSA+C3d- did not (adjusted HR = 1.04 (0.43–2.47) p = 0.937 for primary outcome and HR = 1.08 (0.45–2.61) p = 0.866 for mortality). Conclusion: According to this large monocentric study in heart transplant patients, donor specific antibodies were associated with worse clinical outcome when binding complement. DSA and their complement-binding ability should thus be screened for to optimize heart transplant patient follow-up