Cardiac Preload Responsiveness in Children With Cardiovascular Dysfunction or Dilated Cardiomyopathy. Issue 1 (January 2015)

• Record Type: Journal Article
• Authors: de la Oliva, Pedro; Menéndez-Suso, Juan J.; Iglesias-Bouzas, Mabel; Álvarez-Rojas, Elena; González-Gómez, José M.; Roselló, Patricia; Sánchez-Díaz, Juan I.; Jaraba, Susana
• Is Part Of: Pediatric critical care medicine. Volume 16:Issue 1(2015)
• Publication Date: 2015-01
• Subjects: Pediatric intensive care -- Periodicals; Pediatric emergencies -- Periodicals; 618.05
• DOI: 10.1097/PCC.0000000000000286
• Languages: English
• ISSNs: 1529-7535

Abstract

<abstract> <title> <x xml:space="preserve">Abstract</x> </title> <sec> <title>Objectives:</title> <p>To characterize cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy using global end-diastolic volume index, stroke volume index, cardiac index, and extravascular lung water index.</p> </sec> <sec> <title>Design:</title> <p>Prospective multicenter observational study.</p> </sec> <sec> <title>Setting:</title> <p>Medical/surgical PICUs of seven Spanish University Medical Centers.</p> </sec> <sec> <title>Patients:</title> <p>Seventy-five pediatric patients (42 male, 33 female), median age 36 months (range, 1–207 mo), were divided into three groups: normal cardiovascular status, cardiovascular dysfunction, and dilated cardiomyopathy.</p> </sec> <sec> <title>Interventions:</title> <p>All patients received hemodynamic monitoring with PiCCO<sub>2</sub> (Pulsion Medical System SE, Munich, Germany). We evaluated 598 transpulmonary thermodilution sets of measurements. In 40 patients, stroke volume index, cardiac index, and global end-diastolic volume index were measured before and after 66 fluid challenges and loadings to test fluid responsiveness at different preload levels.</p> </sec> <sec> <title>Measurements and Main Results:</title> <p>Global end-diastolic volume versus predicted body surface area exhibits a power-law relationship: Global end-diastolic volume = 488.8·predicted body surface area<sup>1.388</sup> (<italic>r</italic><sup>2</sup> = 0.93). Four levels of cardiac preload were established from the resulting "normal" global end-diastolic volume index (= 488.8·predicted body surface area<sup>0.388</sup>). Stroke volume index and cardiac index versus global end-diastolic volume index/normal global end-diastolic volume index built using a linear mixed model analysis emulated Frank-Starling curves: in cardiovascular dysfunction group, stroke volume index (geometric mean [95% CI]) was 27 mL/m<sup>2</sup> (24–31 mL/m<sup>2</sup>) at "⩽ 0.67 times normal global end-diastolic volume index, " 37 mL/m<sup>2</sup> (35–40 mL/m<sup>2</sup>) at "> 0.67 ⩽ 1.33 times normal global end-diastolic volume index" (Δ stroke volume index = 35%; <italic>p</italic> < 0.0001; area under the receiver-operating characteristic curve = 75%), 45 mL/ m<sup>2</sup> (41–49 mL/m<sup>2</sup>) at "> 1.33 ⩽ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 21%; <italic>p</italic> < 0.0001; area under the receiver-operating characteristic curve = 73%), and 47 mL/m<sup>2</sup> (43–51 mL/m<sup>2</sup>) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 4%; <italic>p</italic> = 1; area under the receiver-operating characteristic curve = 54%). In dilated cardiomyopathy group, stroke volume index was 21 mL/m<sup>2</sup> (17–26 mL/m<sup>2</sup>) at "> 0.67 ⩽ 1.33 times normal global end-diastolic volume index, " 27 mL/m<sup>2</sup> (21–34 mL/ m<sup>2</sup>) at "> 1.33 ⩽ 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = 29%; <italic>p</italic> = 0.005; area under the receiver-operating characteristic curve = 64%), and 25 mL/m<sup>2</sup> (20–32 mL/m<sup>2</sup>) at "> 1.51 times normal global end-diastolic volume index" (Δ stroke volume index = –8%; <italic>p</italic> = 1; area under the receiver-operating characteristic curve = 54%).</p> </sec> <sec> <title>Conclusions:</title> <p>This study provides "normal" values for global end-diastolic volume index and limits of cardiac preload responsiveness in pediatric patients with cardiovascular dysfunction and dilated cardiomyopathy: 1.33 times normal global end-diastolic volume index represents the upper limit of patent cardiac preload responsiveness, with the highest expected responsiveness being below 0.67 times normal global end-diastolic volume index. The maximum response of the Frank-Starling relationship and therefore the level of no additional preload reserve is 1.33 to 1.51 times normal global end-diastolic volume index. Above 1.51 times normal global end-diastolic volume index preload responsiveness is unlikely, and the risk of pulmonary edema is maximal.</p> </sec> </abstract>