Neither dynamic, static, nor volumetric variables can accurately predict fluid responsiveness early after abdominothoracic esophagectomy

Abstract

BackgroundHypotension is common in the early postoperative stages after abdominothoracic esophagectomy for esophageal cancer. We examined the ability of stroke volume variation (SVV), pulse pressure variation (PPV), central venous pressure (CVP), intrathoracic blood volume (ITBV), and initial distribution volume of glucose (IDVG) to predict fluid responsiveness soon after esophagectomy under mechanical ventilation (tidal volume >8 mL/kg) without spontaneous respiratory activity.MethodsForty-three consecutive non-arrhythmic patients undergoing abdominothoracic esophagectomy were studied. SVV, PPV, cardiac index (CI), and indexed ITBV (ITBVI) were postoperatively measured by single transpulmonary thermodilution (PiCCO system) after patient admission to the intensive care unit (ICU) on the operative day. Indexed IDVG (IDVGI) was then determined using the incremental plasma glucose concentration 3 min after the intravenous administration of 5 g glucose. Fluid responsiveness was defined by an increase in CI >15% compared with pre-loading CI following fluid volume loading with 250 mL of 10% low molecular weight dextran.ResultsTwenty-three patients were responsive to fluids while 20 were not. The area under the receiver-operating characteristic (ROC) curve was the highest for CVP (0.690) and the lowest for ITBVI (0.584), but there was no statistical difference between tested variables. Pre-loading IDVGI (r = −0.523, P <0.001), SVV (r = 0.348, P = 0.026) and CVP (r = −0.307, P = 0.046), but not PPV or ITBVI, were correlated with a percentage increase in CI after fluid volume loading.ConclusionsThese results suggest that none of the tested variables can accurately predict fluid responsiveness early after abdominothoracic esophagectomy.

Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis

“…As a result, meta-regression analysis with the objective to explore the effects of potential covariates on the diagnostic performance of PPV was not performed. Four outliers were identified by means of a Galbraith plot (Figure 4 ) [ 30 , 41 - 43 ]. Heterogeneity became nonsignificant (Cochrane Q statistic = 0.146, P = 0.465) after removal of these four outliers, while the SROC AUC slightly improved (0.95, 95% CI = 0.93 to 0.97).…”

“…Similar to Fischer and colleagues’ study, Biais and colleagues evaluated right ventricular function using echocardiography and excluded patients with right ventricular dysfunction from their study [ 34 ]. Ishihara and colleagues examined the predictive value of PPV in patients after open-chest abdominothoracic esophagectomy with extensive resection of lymph nodes [ 43 ]. They postulated that extensive alteration of thoracic structure might change the cyclic variation of intrathoracic pressure, leading to a modified heart–lung interaction.…”

ZVD – adé? Bitte nicht!

“…Weiterhin ergab sich bei Patienten mit septischem Schock und/oder "acute respiratory distress syndrome" (ARDS) im Rahmen einer randomisierten kontrollierten Studie kein Vorteil einer auf dem "pulse contour cardiac output" (PiCCO) basierten gegenüber einer ZVD-basierten Flüs-sigkeitstherapie [39]. Insgesamt bleibt zu bedenken, dass nach großen Eingriffen, wie beispielsweise einer thorakoabdominellen Ösophagusresektion, aufgrund der stark veränderten Anatomie weder statische noch dynamische Vorlastparameter Aussagen zur Volumenreagibilität ermöglichen [15] …”