End-of-Procedure Volume Responsiveness Defined by the Passive Leg Raise Test Is Not Associated With Acute Kidney Injury After Cardiopulmonary Bypass.

OBJECTIVES: Renal hypoperfusion is a common mechanism of cardiac surgery-related acute kidney injury (CS-AKI). However, the optimal amount of volume resuscitation to correct systemic hypoperfusion and prevent the postoperative development of CS-AKI has been a subject of debate. The goal of this study was to assess the association of volume responsiveness determined by stroke volume variation using the passive leg raise test (PLRT) at chest closure, with the development of CS-AKI according to the Kidney Disease Improving Global Outcomes criteria. DESIGN: Single-center, prospective observational study. SETTING: Tertiary hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 131 patients were studied from January 2015 until May 2017. All patients underwent cardiac surgery that required cardiopulmonary bypass. Volume responsiveness was assessed at chest closure using the PRLT. Stroke volume variation from the sitting to the recumbent positions was measured by transesophageal echocardiography. Fluid responsiveness was defined as an increase of >12% of stroke volume from sitting to recumbent positions. A total of 82 (68.3%) patients were fluid-responsive versus 38 (31.6%) who were fluid-unresponsive. CS-AKI occurred in 30% of patients. There was no difference in CS-AKI between fluid-responsive and fluid-nonresponsive groups. However, CS-AKI was associated independently with an increases in body mass index and preoperative diastolic blood pressure. CS-AKI also was associated with prolonged intensive care unit length of stay. CONCLUSION: End-of-procedure volume responsiveness is not associated with a high risk for postoperative CS-AKI.

Feasibility of Fluid Responsiveness Assessment in Patients at Risk for Increased Intracranial Pressure.

Background: Effective fluid management is important for patients at risk of increased intracranial pressure (ICP). Maintaining constant cerebral perfusion represents a challenge, as both hypovolemia and fluid overload can severely impact patient outcomes. Fluid responsiveness tests, commonly used in critical care settings, are often deemed potentially hazardous for these patients due to the risk of disrupting cerebral perfusion. Methods: This single-center, prospective, clinical observational study enrolled 40 patients at risk for increased ICP, including those with acute brain injury. Informed consent was obtained from each participant or their legal guardians before inclusion. The study focused on the dynamics of ICP and cerebral perfusion pressure (CPP) changes during the Passive Leg Raise Test (PLRT) and the End-Expiratory Occlusion Test (EEOT). Results: The results demonstrated that PLRT and EEOT caused minor and transient increases in ICP, while consistently maintaining stable CPP. EEOT induced significantly lower ICP elevations, making it particularly suitable for use in high-risk situations. Conclusions: PLRT and EEOT can be considered feasible and safe for assessing fluid responsiveness in patients at risk for increased ICP. Notably, EEOT stands out as a preferred method for high-risk patients, offering a dependable strategy for fluid management without compromising cerebral hemodynamics.

Principles of Resuscitation.

Shock from all causes carries a high mortality. Rapid and intentional intervention to resuscitate can reduce mortality and organ injury. Approaches to fluid resuscitation, vasopressor use as well as commonly assessed laboratory values are reviewed in this paper.

Inspiratory collapse of the inferior vena cava and the kissing ventricle sign: markers of poor prognosis in emergency gastrointestinal bleeding. / El colapso inspiratorio de la vena cava inferior y la obliteración sistólica (kissing) ventricular izquierda: marcadores de mal pronóstico en la hemorragia gastrointestinal en urgencias.

OBJECTIVES: Gastrointestinal bleeding, one of the main reasons for emergency department visits, is associated with significant mortality, complications, and high health care spending. Studies have shown the usefulness of hemodynamic monitoring by ultrasound of the inferior vena cava (IVC), imaging of systolic obstruction of the left ventricle (the kissing sign), changes in cardiac output, or surrogates for cardiac output such as the left ventricular velocity time integral before and after a passive leg raise. There is currently no evidence for applying this approach to evaluating hypovolemia due to gastrointestinal bleeding. MATERIAL AND METHODS: We prospectively recruited 203 emergency department patients with gastrointestinal bleeding between August 2015 and April 2017; this sample size provided a 95% CI for a proportion of 5%, with a precision of 3% and expected losses of 15%. Recorded data were as follows: medical histories, observations during physical examinations, laboratory results, diagnostic variables, treatment details, clinical course, and ultrasound findings related to hemodynamics. RESULTS: Clinical course was worse in patients with evidence of hypovolemia such as a small (<1 cm) end-expiratory IVC diameter (IVCEE) or the kissing sign. Complications were more prevalent at 24 hours and 30 days, a finding that was not associated with the other clinical or laboratory variables commonly monitored. We also saw that both a small IVCEE and persistent inspiratory collapse of the IVC of more than 50% after a passive leg raise test might prove useful for identifying patients at risk for anemia at 24 hours, allowing time to start preventive measures. CONCLUSION: The analysis of IVCEE, inspiratory collapse of the IVC, or the kissing sign in combination with clinical and laboratory findings can facilitate the use of clinical practice algorithms that can encourage the efficient risk-based assignment of resources and improve prognosis.

OBJETIVO: La hemorragia digestiva (HD) constituye un problema médico con significativa morbimortalidad y elevado consumo de recursos sanitarios, y es uno de los motivos principales de consulta en los servicios de urgencias. Varios estudios han destacado la utilidad de la ecografía clínica en la monitorización hemodinámica, a partir del análisis de la vena cava inferior (VCI), visualizando la obliteración sistólica del ventrículo izquierdo ("kissing del VI") así como cambios en el gasto cardíaco (GC) o marcadores subrogados al GC como la integral velocidad tiempo (IVT) en el tracto de salida del VI, antes y después de la prueba de elevación pasiva de miembros inferiores (EPMI). En la actualidad, no hay evidencia directa relacionada con la aplicabilidad de este enfoque en la hipovolemia por HD. METODO: Entre agosto de 2015 y abril de 2017, se reclutaron prospectivamente 203 pacientes (nivel de confianza del 95%, precisión 3%, proporción 5%, pérdidas estimadas 15%), que consultaron en el servicio de urgencias por HD. Se recogieron los antecedentes médicos, la exploración física, los hallazgos analíticos, variables relacionadas con el diagnóstico, con el tratamiento, con la evolución clínica y variables ecográficas relacionadas con la situación hemodinámica. RESULTADOS: Los pacientes con datos de hipovolemia como un diámetro de VCI espiratorio (CAVAesp) < 1 cm o un "kissing del VI" presentaron peor evolución, con mayor presencia de complicaciones a las 24 horas y 30 días, hallazgo que no se observó con otros parámetros clínicos o analíticos comúnmente empleados. Además se observó que tanto la CAVAesp < 1 cm, como la persistencia del colapso inspiratorio de la VCI (CICAVA) > 50% tras la PLR podrían ser de utilidad para identificar a los pacientes en los que es esperable una anemización a las 24 horas. CONCLUSIONES: El análisis de marcadores ecográficos como la CAVAesp, CIVACA o el "kissing del VI", combinados con variables clínicas y de laboratorio, permitiría implementar algoritmos de actuación más eficientes y asignar mejor los recursos en función del perfil de riesgo, lo cual podría conducir a una mejora en el pronóstico.

Passive leg raise testing effectively reduces fluid administration in septic shock after correction of non-compliance to test results.

BACKGROUND: Fluid resuscitation is considered a cornerstone of shock treatment, but recent data have underlined the potential hazards of fluid overload. The passive leg raise (PLR) test has been introduced as one of many strategies to predict 'fluid responsiveness.' The use of PLR testing is applicable to a wide range of clinical situations and has the potential to reduce fluid administration, since PLR testing is based upon (reversible) autotransfusion. Despite these theoretical advantages, data on the net effect on fluid balance as a result of PLR testing remain scarce. METHODS: We performed a prospective single-center multi-step interventional study in patients with septic shock to evaluate the effect of implementation of PLR testing on the fluid balance (FB) 48 hours after ICU admission. All patients were equipped with a PiCCO® device for pulse contour analysis to guide fluid administration. An increase in stroke volume (SV) ≥ 10% was considered a positive test result. RESULTS: Before introduction of PLR testing, 21 patients were prospectively included in period 1 with a median FB of 4.8 [3.3-7.8]L. After an extensive training program, PLR testing was introduced and 20 patients were included in period 2. Median FB was 4.4 [3.3-7.5]L and did not differ from period 1 (p = 0.72). Further analysis revealed that non-compliance to the PLR test result was 44%. These findings were discussed with all ICU doctors and nurses. By consensus, non-compliance to the PLR test result was identified as the main reason for unsuccessful implementation of PLR testing. After this evaluation, 19 patients were included in period 3 under equal conditions as in period 2. In this period, median FB was 3.1 [1.5-4.9]L and significantly reduced in comparison with periods 1 and 2 (p = 0.016 and p = 0.023, respectively). Non-compliance was 9% and significantly lower than in period 2 (p = 0.009). CONCLUSION: Implementation of PLR testing in patients with septic shock reduced fluid administration in the first 48 hours of ICU admission significantly and substantially. To achieve this endpoint, substantial non-compliance of ICU team members had to be addressed. Fluid administration despite a negative PLR test was the most common form of non-compliance.