Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
권호 표지

Assessment of Parameters Measured with Volumetric Pulmonary Artery Catheter as Predictors of Fluid Responsiveness in Patients with Coronary Artery Occlusive Disease

관상동맥 질환을 가진 환자에서 폐동맥카테터로 측정한 전부하 지표들은 수액부하 반응을 예상할 수 있는가?

  • Lee, Ji-Yeon (Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine) ;
  • Lee, Jong-Hwa (Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine) ;
  • Shim, Jae-Kwang (Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine) ;
  • Yoo, Kyung-Jong (Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine) ;
  • Hong, Seung-Bum (Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine) ;
  • Kwak, Young-Lan (Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine)
  • 이지연 (연세대학교 의과대학 마취통증의학교실) ;
  • 이종화 (연세대학교 의과대학 마취통증의학교실) ;
  • 심재광 (연세대학교 의과대학 마취통증의학교실) ;
  • 유경종 (연세대학교 의과대학 세브란스병원 흉부외과학교실) ;
  • 홍승범 (연세대학교 의과대학 마취통증의학교실) ;
  • 곽영란 (연세대학교 의과대학 마취통증의학교실)
  • Published : 2008.02.05
Download PDF
⟨ Previous Next ⟩

Abstract

Background: Accurate assessment of the preload and the fluid responsiveness is of great importance for optimizing cardiac output, especially in those patients with coronary artery occlusive disease (CAOD). In this study, we evaluated the relationship between the parameters of preload with the changes in the stroke volume index (SVI) after fluid loading in patients who were undergoing coronary artery bypass grafting (CABG). The purpose of this study was to find the predictors of fluid responsiveness in order to assess the feasibility of using. certain parameters of preload as a guide to fluid therapy. Material and Method: We studied 96 patients who were undergoing CABG. After induction of anesthesia, the hemodynamic parameters were measured before (T1) and 10 min after volume replacement (T2) by an infusion of 6% hydroxyethyl starch 130/0.4 (10 mL/kg) over 20 min. Result: The right ventricular end-diastolic volume index (RVEDVI), as well as the central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP), failed to demonstrate significant correlation with the changes in the SVI (%). Only the right ventricular ejection fraction (RVEF) measured at T1 showed significant correlation. with the changes of the SVI by linear regression (r=0.272, p=0.017). However, when the area under the curve of receiver operating characteristics (ROC) was evaluated, none of the parameters were over 0.7. The volume-induced increase in the SVI was 10% or greater in 31 patients (responders) and under 10% in 65 patients (non-responders). None of the parameters of preload measured at T1 showed a significant difference between the responders and non-responders, except for the RVEF. Conclusion: The conventional parameters measured with a volumetric pulmonary artery catheter failed to predict the response of SVI following fluid administration in patients suffering with CAOD.

배경: 전부하의 정확한 평가와 수액요법을 통한 적절한 유지는 관상동맥질환자의 심박출량을 최적화하는데 있어서 매우 중요하다. 본 연구는 수액부하에 따른 일회 박출량지수의 변화와 전부하 지표들간의 상관관계를 살펴봄으로써, 이러한 전부하 지표들이 수액부하 반응을 예측할 수 있으며 수액요법의 지침으로 유용한가를 평가하였다. 대상 및 방법: 관상동맥우회술을 시행 받은 환자 96명을 대상으로 연구를 진행하였다. 마취유도 10분 후(T1)에 혈역학 변수들을 기록하고, 6% hydroethylstarch 130/0.4를 체중 kg당 10 mL를 20분에 걸쳐 정주하였으며, 이후 10분 후(T2)에 혈역학 변수를 다시 기록하였다. 결과: 수액부하에 따른 일회박출량지수 변화량(%)과 수액부하 전(T1)의 우심실박출계수가 통계적으로 유의한 상관관계를 보였으며(r=0.272, p=0.017), 중심정맥압, 폐모세혈관쐐기압, 이완기말우심실용적지수는 유의한 상관관계를 보이지 않았다. 이들 중 어떠한 지표도 ROC (receiver operating characteristics) 곡선아래 영역이 0.7을 넘지 않았다. 수액부하에 따라 일회박출량지수가 10% 이상 증가한 반응군으로, 증가하지 않은 군을 비반응군으로 정의하였을 때, 반응군은 31명, 비반응군은 65명이었으며, 우심실박출계수를 제외한 수액부하 전 지표들은 두 군간 차이를 보이지 않았다. 결론: 관상동맥 질환 환자에서 폐동맥카테터로 얻을 수 있는 전부하 지표들을 이용하여 수액부하에 따르는 일회박출량지수의 반응을 예측할 수는 없었다.

Keywords

References

  1. Reich D, Mittnacht A, London M, Kaplan J. Monitoring of the heart and vascular system: In: Kaplan J, Reich D, Lake C, Konstadt S. Kaplan's cardiac anesthesia. 5th ed. Philadelphia: Saunders. 2006;412-3
  2. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007;35:64-8 https://doi.org/10.1097/01.CCM.0000249851.94101.4F
  3. Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 2004;32:691-9 https://doi.org/10.1097/01.CCM.0000114996.68110.C9
  4. Wagner JG, Leatherman JW. Right ventricular end- diastolic volume as a predictor of the hemodynamic response to a fluid challenge. Chest 1998;113:1048-54 https://doi.org/10.1378/chest.113.4.1048
  5. Cheatham ML, Nelson LD, Chang MC, Safcsak K. Right ventricular end-diastolic volume index as a predictor of preload status in patients on positive end-expiratory pressure. Crit Care Med 1998;26:1801-6 https://doi.org/10.1097/00003246-199811000-00017
  6. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest 2001;119:867-73 https://doi.org/10.1378/chest.119.3.867
  7. Tousignant CP, Walsh F, Mazer CD. The use of transesophageal echocardiography for preload assessment in critically ill patients. Anesth Analg 2000;90:351-5 https://doi.org/10.1097/00000539-200002000-00021
  8. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29-36 https://doi.org/10.1148/radiology.143.1.7063747
  9. Calvin JE, Driedger AA, Sibbald WJ. The hemodynamic effect of rapid fluid infusion in critically ill patients. Surgery 1981;90:61-76
  10. Reuse C, Vincent JL, Pinsky MR. Measurements of right ventricular volumes during fluid challenge. Chest 1990;98: 1450-4 https://doi.org/10.1378/chest.98.6.1450
  11. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002;121:2000-8 https://doi.org/10.1378/chest.121.6.2000
  12. Diebel L, Wilson RF, Heins J, Larky H, Warsow K, Wilson S. End-diastolic volume versus pulmonary artery wedge pressure in evaluating cardiac preload in trauma patients. J Trauma 1994;37:950-5 https://doi.org/10.1097/00005373-199412000-00014
  13. Baek SM, Makabali GG, Bryan-Brown CW, Kusek JM, Shoemaker WC. Plasma expansion in surgical patients with high central venous pressure (CVP); the relationship of blood volume to hematocrit, CVP, pulmonary wedge pressure, and cardiorespiratory changes. Surgery 1975;78:304-15
  14. Wiesenack C, Fiegl C, Keyser A, Laule S, Prasser C, Keyl C. Continuously assessed right ventricular end-diastolic volume as a marker of cardiac preload and fluid responsiveness in mechanically ventilated cardiac surgical patients. Crit Care 2005;9:R226-33 https://doi.org/10.1186/cc3486
  15. Diebel LN, Wilson RF, Tagett MG, Kline RA. End-diastolic volume: a better indicator of preload in the critically ill. Arch Surg 1992;127:817-22 https://doi.org/10.1001/archsurg.1992.01420070081015
  16. Chassot PG, van der Linden P, Zaugg M, Mueller XM, Spahn DR. Off-pump coronary artery bypass surgery: physiology and anaesthetic management. Br J Anaesth 2004; 92:400-13 https://doi.org/10.1093/bja/aeh064
  17. Na SW, Nam SB, Kim DH, Shim HK, Yang HG, Kwak YL. Effect of preoperative volume loading with new hydroxyethyl starch (6% HES 130/0.4) in patients undergoing off-pump coronary artery bypass graft surgery. Korean J Anesthesiology 2006;51:669-74 https://doi.org/10.4097/kjae.2006.51.6.669
  18. Hofer CK, Muller SM, Furrer L, Klaghofer R, Genoni M, Zollinger A. Stroke volume and pulse pressure variation for prediction of fluid responsiveness in patients undergoing off-pump coronary artery bypass grafting. Chest 2005;128: 848-54 https://doi.org/10.1378/chest.128.2.848
  19. Jacquet L, Hanique G, Glorieux D, Matte P, Goenen M. Analysis of the accuracy of continuous thermodilution cardiac output measurement. Comparison with intermittent thermodilution and Fick cardiac output measurement. Intensive Care Med 1996;22:1125-9 https://doi.org/10.1007/BF01699240
  20. Zink W, Noll J, Rauch H, et al. Continuous assessment of right ventricular ejection fraction: new pulmonary artery catheter versus transoesophageal echocardiography. Anaesthesia 2004;59:1126-32 https://doi.org/10.1111/j.1365-2044.2004.03876.x