Assessment of fluid volume in critically ill patients with extravascular lung water index / 中华危重病急救医学

Objective To examine the effect of rapid infusion test guided by extravascular lung water index (EVLWI) on hemodynamics in critically ill patients at different states in order to guide volume resuscitation.Methods A prospective observation was conducted.Forty critically ill patients admitted to Department of Critical Care Medicine of Tianjin Third Central Hospital from June 2012 to April 2014 were enrolled.Based on the levels of EVLWI and pulmonary vascular permeability index (PVPI) and the cardiac function,the patients were divided into four groups:septic patients with normal EVLWI and PVPI (n =17),septic patients with increased EVLWI and PVPI (n =3),septic patients with increased EVLWI and normal PVPI (n =4),and coronary heart disease and heart failure patients with normal EVLWI and PVPI (n =16).The rapid infusion test was conducted in all patients using lactated Ringer solution 250 mL,followed by infusion of crystalloid with rate of 150 mL/h.The conditions of mechanical ventilation and vasoactive drugs were not changed during study.The changes in EVLWI,intrathoracic blood volume index (ITBVI),and cardiac index (CI) before capacity load,at immediate capacity load,and 15,45,105 minutes after load were determined by pulse indicator continuous cardiac output (PiCCO).On the base of volume status before and after the liquid infusion,the standard for the changes were:stroke volume (SV) increased by 12％-15％,central venous pressure (CVP) greater ≥ 2 mmHg (1 mmHg =0.133 kPa),CI ＞ 15％,and ITBVI change greater than 10％.Results There were no statistically significant differences in the observed indicators at the each time point before and after rapid infusion test among the four groups (all P ＞ 0.05).In septic patients with normal EVLWI and PVPI group,ITBVI was slightly increased by 5.4％-9.7％ from 15 minutes to 45 minutes after rapid infusion test.In coronary heart disease and heart failure patients with normal EVLWI and PVPI group,the EVLWI was increased by 11.9％,5.9％,and 14.7％ respectirely at 15,45,and 105 minutes,ITBVI was slightly increased by 6.4％ at 45 minutes,CI was increased by 29.5％ immediately after rapid infusion.In septic patients with increased EVLWI and PVPI group,CVP was increased by 8 mmHg immediately,EVLWI was increased significantly by 15.8％ at 45 minutes,ITBVI was slightly decreased by 10.0％ at 45 minutes,CI was increased by 24.7％ immediately,and increased by 17.0％ at 105 minutes,and PVPI was increased by 15.6％-28.1％ at 15-105 minutes after rapid infusion.In septic patients with increased EVLWI and normal PVPI group,CVP was increased by 1.5 mmHg at 15 minutes,EVLWI was increased immediately,which was increased by 17.4％,24.0％,and 31.4％ respectively at 15,45,and 105 minutes,ITBVI was increased by 13.9％ at 15 minutes,CI was increased by 16.1％ at 15 minutes after rapid fluid infusion.Conclusions Rapid fluid replacement in critically ill patients with crystalloid,regardless of whether the EVLWI was normal or increased,the short-term response was affected by the volume and cardiac function of patients.Different status of patients showed different volume effect curve:no significant changes in hemodynamic parameters were found in patients with normal EVLWI and volume parameters.In patients with potential cardiac dysfunction,CI and EVLWI increased significantly; regardless of PVPI increased or normal,EVLWI and CI were increased in patients with elevated EVLWI; two different changes could be found in the two types of pulmonary edema while ITBVI was increased.

Clinical study of volume resuscitation in children with septic shock / 中华危重病急救医学

Objective To compare the effect of crystalloid and crystalloid plus albumin in the treatment of pediatric septic shock.Methods Data of 63 pediatric patients with septic shock admitted to Department of Critical Care Medicine of Hebei Provincial Children's Hospital were collected and retrospectively analyzed.The patients were divided into two groups according to whether they received albumin for volume resuscitation within 1 day after admission or not.The patients in observation group (crystalloid + albumin group,n =33) received normal saline (20 mL/kg) followed by 1 g/kg albumin 30 minutes after admission,and those in control group (crystalloid group,n =30) received only normal saline (20 mL/kg) 30 minutes after admission,and normal saline resuscitation was continued according to the effect of fluid therapy.Anti-infection and vasoactive drugs strategies were the same in both groups.The first-hour infusion volume,time showing stable hemodynamics,the incidence of pulmonary edema,and blood lactate levels at 0,6,12 hours after achieving the goals were compared,and blood lactate clearance rates were calculated.Results The first-hour infusion volume time in the observation group was lower than that in control group (mL:41.56 ± 10.50 vs.57.24 ± 7.54,t=4.596,P=0.000),and time showing stable hemodynamics was shorter than that in control group but without statistically significant difference (minutes:219.87 ±70.23 vs.287.10 ± 67.00,t=2.047,P=0.360).The incidence of pulmonary edema in observation group was slightly lower than that in control group [6.1％ (2/33) vs.10.0％ (3/30),x2±2.272,P=0.259].The lactic acid levels were decreased gradually along with rehabilitation time,while lactate clearance rate was increased in both groups.At 0 hour and 6 hours after resuscitation,the lactate level (mmol/L) in the observation group was significantly lower than that in control group [0 hour:3.65 ± 2.84 vs.5.72 ± 2.11,t＝ 1.940,P=0.046; 6 hours:2.12 ± 1.21 vs.4.09 ± 1.45,t=2.892,P=0.005],while the lactate clearance rate was significantly increased compared with control group [0 hour:(0.38 ± 0.15)％ vs.(0.18 ± 0.09)％,t=1.447,P=0.018; 6 hours:(0.62 ± 0.14)％ vs.(0.51 ± 0.11)％,t=1.920,P=0.047].However,at 12 hours after resuscitation,there were no statistically significant differences in the lactic acid level (mmol/L:1.46 ± 0.39 vs.1.54 ± 1.90,t=0.450,P=0.072) and the lactate clearance rate [(0.78 ± 0.19) ％ vs.(0.77 ± 0.18) ％,t =0.091,P=0.928] between observation group and control group.Conclusion Albumin resuscitation in children with septic shock can stabilize hemodynamics earlier,reduce the incidence of pulmonary edema,and improve the successful rescue rate of refractory septic shock.

Passive leg raising as an indicator of fluid responsiveness in patients with severe sepsis / 世界急诊医学杂志（英文）

@#BACKGROUND: In the management of critically ill patients, the assessment of volume responsiveness and the decision to administer a fluid bolus constitute a common dilemma for physicians. Static indices of cardiac preload are poor predictors of volume responsiveness. Passive leg raising (PLR) mimics an endogenous volume expansion (VE) that can be used to predict fluid responsiveness. This study was to assess the changes in stroke volume index (SVI) induced by PLR as an indicator of fluid responsiveness in mechanically ventilated patients with severe sepsis. METHODS: This was a prospective study. Thirty-two mechanically ventilated patients with severe sepsis were admitted for VE in ICU of the First Affiliated Hospital, Zhejiang University School of Medicine and Ningbo Medical Treatment Center Lihuili Hospital from May 2010 to December 2011. Patients with non-sinus rhythm or arrhythmia, parturients, and amputation of the lower limbs were excluded. Measurements of SVI were obtained in a semi-recumbent position (baseline) and during PLR by the technique of pulse indicator continuous cardiac output (PiCCO) system prior to VE. Measurements were repeated after VE (500 mL 6％ hydroxyethyl starch infusion within 30 minutes) to classify patients as either volume responders or non-responders based on their changes in stroke volume index (ΔSVI) over 15％. Heart rate (HR), systolic artery blood pressure (ABPs), diastolic artery blood pressure (ABPd), mean arterial blood pressure (ABPm), mean central venous pressure (CVPm) and cardiac index (CI) were compared between the two groups. The changes of ABPs, ABPm, CVPm, and SVI after PLR and VE were compared with the indices at the baseline. The ROC curve was drawn to evaluate the value of ΔSVI and the change of CVPm (ΔCVPm) in predicting volume responsiveness. SPSS 17.0 software was used for statistical analysis. RESULTS: Among the 32 patients, 22 were responders and 10 were non-responders. After PLR among the responders, some hemodynamic variables (including ABPs, ABPd, ABPm and CVPm) were significantly elevated (101.2±17.6 vs.118.6±23.7,P=0.03; 52.8±10.7 vs. 64.8±10.7,P=0.006; 68.3±11.7 vs. 81.9±14.4,P=0.008; 6.8±3.2 vs. 11.9±4.0,P=0.001). After PLR, the area under curve (AUC) and the ROC curve of ΔSVI and ΔCVPm for predicting the responsiveness after VE were 0.882±0.061 (95％CI 0.759–1.000) and 0.805±0.079 (95％CI 0.650–0.959) when the cut-off levels of ΔSVI and ΔCVPm were 8.8％ and 12.7％, the sensitivities were 72.7％ and 72.7％, and the specificities were 80％ and 80％. CONCLUSION: Changes in ΔSVI and ΔCVPm induced by PLR are accurate indices for predicting fluid responsiveness in mechanically ventilated patients with severe sepsis.

Effects of Small Volume Resuscitation with Different Fluids on Lung of Rats Undergoing Endotoxic Shock / 中山大学学报(医学科学版)

[Objective]This study was designed to investigate the effects of small volume resuscitation with different fluids on the lung of endotoxie rats.[Methods]Thirty SD rats weighting 180-250 g were divided randomly into 5 groups(n=6):Group C[lipopolysaccharide(LPS)negative control group],Group E(LPS+4 mL/kg physiologic saline),Group HSS(LPS+4 mL/kg 75 g/L hypertonic saline solution),Group HES(LPS+4 mL/kg hydroxyethyl starch 130/0.4),Group HSH(LPS+4 mL/kg 75 g/L hypertonic sodium chloride hydroxyethyl starch 40).Resuscitation was administrated 30 min after LPS injected.Pathological examination and score were made under optical microscope.Dry/wet ratios were observed.Levels of total protein of bronchoalveolar lavage fluid(BALF)were measured.Thibabituric acid(TBA)was used to measure tissue malonaldehyde(MDA)levels.Xanthine oxidase(XO)was employed to measure the tissue activity of superoxide dismutase(SOD).[Results]Compared with group C,in the other 4 groups,pathological changes were server.Levels of total protein of BALF were higher(P＜0.05).Pathological score of group E was significantly higher(P＜0.01).Dry/wet ratio of group E was lower(P＜0.05).Tissue activity of SOD of group E was lower(P＜0.01).Levels of tissue MDA in group E and HSS were significantly higher.Compared with group E,in group HSS,HES and HSH,pathological changes were slighter(P＜0.01).Pathological scores and tissue MDA levels were lower(P＜0.01).Dry/wet ratios were higher(P＜0.05).Tissue activity of SOD were higher(P＜0.01),levels of total protein of BALF were lower(P＜0.05,P＜0.01).[Conclusion]Small volume resuscitation with HSS,HES,and HSH had protective effects on the lung of endotoxie rats.HES and HSH had better effect on decreasing the capillary permeability of the lung of endotoxic rats lung compared with HSS.

Blood loss and transcapillary refill in uncontrolled treated hemorrhage in dogs

Objetive: This study evaluated retroperitoneal hematomas produced by bilateral injury of iliac arteries (uncontrolled hemorrhage), blood volume loss, transcapillary refill, the effects of volume replacement on retroperitoneal bleeding and the hemodynamic changes with and without treatment. Methods: Initial blood volume was determined with Tc99m-labelled red cells, and bleeding was evaluated by means of a portable scintillation camera positioned over the abdomen. Previously splenectomized mongrel dogs (16.8 ± 2.2 kg) were submitted to hemorrhage for 30 minutes and randomized into three groups: I - no treatment (n=7); II - treatment with 32 mL/kg of Lactated Ringer's for three to five minutes (n=7); and III - treatment with 4 mL/kg of 7.5 percent NaCl plus 6.0 percent dextran 70 for three to five minutes (n=7). They were studied for an additional 45 minutes. Results: Volume replacement produced transitory recovery in hemodynamic variables, including mean pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac index, with significant increase in dogs treated with 32 mL/kg of Lactated Ringer's and 7.5 percent NaCl plus 6.0 percent dextran 70 (p<0.001, against no treatment), along with a decrease (p<0.001) in the systemic vascular resistance index. Groups II and III had significant initial decreases in hematocrit and hemoglobin. The treated dogs (groups II and III) presented rebleeding, which was greater during treatment with 32 mL/kg of Lactated Ringer's (group II). Conclusions: Despite the rebleeding observed in treated groups, the utilization of hypertonic saline solution with dextran proved to be effective in the initial reanimation, producing evident transcapillary refill, while the Lactated Ringer's solution produced capillary extravasation and was ineffective in the initial volume replacement in this model of uncontrolled hemorrhage.

The effect of volume resuscitation in opration on the early function of grafted kidney / 中国基层医药

Objective To observe the effect of volume resuscitation on the early grafted kidney function in opration.Methods 909 cases were divided into five groups according to the volume resuscitation in opration:group A: