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

Jacquet-Lagrèze, Matthias; Acker, Amélie; Hentzen, Julie; Didier, Capucine; Lamer, Sabine De; Chardonnal, Laurent; Bouhamri, Noureddine; Portran, Philippe; Schweizer, Rémi; Lilot, Marc

doi:10.1097/pcc.0000000000002906

Cited by 4 publications

(3 citation statements)

References 33 publications

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“…We previously found that passive leg raising does not accurately predict cardiac index decrease nor hypotension following a fluid removal challenge of 500 mL UFnet over one hour in patients undergoing CRRT [ 10 ]. We observed the same results with calibrated abdominal compression to test preload responsiveness in children before a diuretics-induced fluid removal of 5 mL/kg over 2 h [ 11 ]. In our opinion, preload unresponsiveness better predicts the delay between the initiation of a UFnet at a higher rate rather than that of vascular refilling and the occurrence of hypovolemia.…”

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confidence: 75%

Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate?

2023

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Section: Commentmentioning

confidence: 75%

Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate?

2023

Self Cite

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“…The latest article from the Pediatric Cardiac Critical Care Consortium (PC4) registry describing potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue in the cardiac ICU (11). An article (12) and editorial (13) on fluid overload, intravascular volume, and fluid removal in the perioperative pediatric cardiac surgery population. A mixed-methods, single-center PC4-registry dataset of outcomes in 364 patients discharged to home directly from the cardiac ICU (14).…”

Section: “Pccm Connections” For Readersmentioning

confidence: 99%

Editor’s Choice Articles for April

Tasker¹

2022

Pediatric Critical Care Medicine

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W elcome to April 2022. Again, lots of content in this issue of Pediatric Critical Care Medicine (PCCM). Yes-everything is worthy of your attention and as usual my highlights are the three Editor's Choice articles. That said, there is more that I want to tell you about in the PCCM Connections for Readers section, where you can learn from a much-anticipated PCCM Concise Clinical Science Review, a PCCM Narrative, as well as more clinical cardiac critical care research articles.

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“…In this issue of Pediatric Critical Care Medicine , Jacquet-Lagrèze et al (4) conducted a prospective observational study to assess the ability to predict hemodynamic instability with active fluid removal following pediatric cardiac surgery. The study included children 8 years old or younger ( n = 58) who were deemed to be fluid overloaded based on the presence of peripheral edema or a greater than 10% increase in body weight following surgery.…”

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When Volume and Pressure Are Not Equal*

Loomba

Flores

Bronicki

2022

Pediatric Critical Care Medicine

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F luid overload and the removal of intravascular volume are a common challenge following cardiac surgery. This is of particular importance because fluid overload has been demonstrated to increase morbidity and mortality following pediatric cardiac surgery (1, 2). However, fluid removal in preload-dependent patients decreases stroke volume (SV), and cardiac output may contribute to organ injury and dysfunction (3).In this issue of Pediatric Critical Care Medicine, Jacquet-Lagrèze et al (4) conducted a prospective observational study to assess the ability to predict hemodynamic instability with active fluid removal following pediatric cardiac surgery. The study included children 8 years old or younger (n = 58) who were deemed to be fluid overloaded based on the presence of peripheral edema or a greater than 10% increase in body weight following surgery. The primary aim of the study was to determine if preload dependence predicted hemodynamic instability (decrease in blood pressure [BP] of 10% or greater) following the active removal (diuretics) of 10 cc/kg of fluid over 2 hours. Preload dependence was determined by a 10% or greater calibrated abdominal compression (CAC)induced increase in SV index (SVi).The study concluded that changes in SVi with CAC were not predictive of hemodynamic instability following fluid removal (area under the curve of 0.55). The study also found that other markers used to assess preload such as inferior cava vein collapsibility and central venous pressure (CVP) also failed to predict hemodynamic stability after fluid removal.No single marker had good positive predictive and negative predictive values. They found that preload dependence was most accurately predicted by inferior cava vein diameter (area under the curve of 0.72). This represents good accuracy to predict hemodynamic stability and provided a positive predictive value of 1 but a negative predictive value of 0.3. In the clinical setting, this would mean that inferior cava vein diameter of less than 0.72 cm/m 2 would predict a decrease in mean BP 100% of the time after fluid removal, whereas a diameter of greater than 0.72 cm/m 2 would predict the absence of a decrease in mean BP only 30% of the time. Thus, if this metric is used, it is still very possible that there may be a decrease in BP even if the inferior cava vein diameter is greater than the provided cutoff.We applaud the authors for exploring the hemodynamic effects of active fluid removal and attempting to identify "hemodynamic" parameters that may be useful in predicting who will not tolerate such a strategy. It is difficult to objectively determine what constitutes fluid overload and similarly what constitutes adequate intravascular volume. The use of a CVP to guide fluid management may be useful. However, this parameter has significant limitations for guiding such strategies (5). The indicator of ventricular

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

Cited by 4 publications

References 33 publications

Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate?

Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate?

Editor’s Choice Articles for April

When Volume and Pressure Are Not Equal*

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