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Predicting fluid responsiveness in 100 critically ill children: the effect of baseline contractility

  • Pediatric Original
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Abstract

Purpose

Fluid overload is a risk factor for poor outcome in intensive care; thus volume loading should be tailored towards patients who are likely to increase stroke volume. We aimed to evaluate the paediatric predictive ability (stroke volume increase of at least 15 % after fluid bolus) of novel and established volumetric and dynamic haemodynamic variables, and assess the influence of baseline contractility on response.

Methods

We assessed 142 volume loading episodes (10 ml/kg crystalloid) in 100 critically ill ventilated children, median (interquartile) weight 10 (5.6–15) kg. Eight advanced haemodynamic variables were assessed using two commercially available devices. Systemic ventricular contractility was measured as the maximum rate of systolic arterial pressure rise.

Results

Overall, predictive ability was poor, with volumetric variables performing better than dynamic (area under receiver operating characteristic curves ranged from 0.53 to 0.67). The best predictor was total end-diastolic volume index; however, this did not increase in a consistent way with volume loading, with change post volume being weakly related to baseline values (r = −0.19, p = 0.02). A multivariable model quantified the importance of contractility in stroke volume response. Children with high baseline contractility (≥75th centile) typically achieved a positive stroke volume response when end-diastolic volume values changed by 10–15 ml/m2.6, whereas patients with low contractility (≤25th centile) typically required end-diastolic volume increases of 35–40 ml/m2.6.

Conclusions

Current paediatric predictors of volume response perform poorly; prediction may be improved if baseline contractility is taken into account.

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Notes

  1. Calculated using pooled, weighted data from relevant studies within Gan [5].

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Acknowledgments

The manufacturers of the advanced haemodynamic monitors used in this study (Transonic Systems, Ithaca, New York and Vytech, Padova, Italy) provided hardware and consumables free of charge. Rohit Saxena received an educational grant from Transonic Systems, Ithaca, NY to partially cover his student fees with Kings College London. The current work forms part of his submission for the research degree MDres (Doctor of Medicine: Research).

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Authors and Affiliations

  1. Paediatric Intensive Care Unit, Evelina Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK

    Rohit Saxena, Andrew Durward, Sarah Steeley, Ian A. Murdoch & Shane M. Tibby

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  1. Rohit Saxena
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  2. Andrew Durward
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  3. Sarah Steeley
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  4. Ian A. Murdoch
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  5. Shane M. Tibby
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Correspondence to Shane M. Tibby.

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Additional information

Take-home message: The majority of advanced haemodynamic variables (volumetric and dynamic) have poor to moderate predictive ability in children in terms of the stroke volume response to fluid boluses. Baseline contractility is an important factor influencing patients’ response to fluid volume loading, such that a patient with poor baseline contractility will need to increase their end-diastolic volume by an increment that is 3–4 times greater than that of a patient with good contractility to be able to increase stroke volume by more than 15 %.

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Saxena, R., Durward, A., Steeley, S. et al. Predicting fluid responsiveness in 100 critically ill children: the effect of baseline contractility. Intensive Care Med 41, 2161–2169 (2015). https://doi.org/10.1007/s00134-015-4075-8

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  • DOI: https://doi.org/10.1007/s00134-015-4075-8

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