Clinical evaluation of the change of pressure gradient between mean systemic filling pressure and central venous pressure in fluid responsiveness for septic shock patients

doi:10.3877/cma.j.issn.2096-1537.2019.02.012

Abstract

Abstract:

Objective

To evaluate clinical value of the change of pressure gradient between mean systemic filling pressure (Pmsf) and central venous pressure (CVP) in fluid responsiveness for septic shock patients.

Methods

A prospective observational study was conducted. Twenty patients with septic shock undergoing mechanical ventilation who admitted to intensive care unit of Nanjing Drum-tower Hospital from January 2017 to September 2017 were enrolled. All patients underwent volume expansion (VE) (300 ml saline for 20 min, rapid intravenous infusion). The patients were divided into fluid responded group (ΔCI≥10%) and fluid unresponded group (ΔCI<10%), according to the change of cardiac output index (ΔCI) after VE. The hemodynamic parameters [heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), systemic vascular resistance index (SVRI), intrathoracic blood volume index (ITBVI), extravascularlung water index (EVLWI), stroke volume variation (SVV), Pmsf, Pmsf-CVP, the change of Pmsf (ΔPmsf), Δ(Pmsf-CVP)] before and after VE were recorded. The hemodynamic parameters were compared between two groups. Receiver operating characteristic (ROC) curve was plotted to analyze the value of hemodynamic parameters in fluid responsiveness.

Results

VE were performed in 26 instances in 20 patients, among which 17 instances were fluid responded. Pmsf and (Pmsf-CVP) before VE in responsive group were significantly lower than those of the non-responsive group [(19.06±3.03) mmHg vs (23.00±5.96) mmHg, (8.29±3.92) mmHg vs (14.78±6.12) mmHg, t=-2.26, -3.30, all P<0.05]. ΔPmsf and Δ(Pmsf-CVP) in responsive group were significantly higher than those of the non-responsive group [10.00(6.00, 14.00) mmHg vs 4.00 (1.00, 9.50)mmHg, 7.00(3.50, 11.50) mmHg vs -1.00(-2.00, 3.00) mmHg, z=-2.57, -2.75, all P<0.05]. ROC curve analysis showed that the area under ROC curve (AUC) of Pmsf before VE, (Pmsf-CVP) before VE, ΔPmsf and Δ(Pmsf-CVP) for evaluating fluid responsiveness was 0.739, 0.810, 0.810 and 0.902 respectively, which was significantly higher than that of ΔCVP (AUC=0.654). The optimal cut-off value of Pmsf before VE for evaluating fluid responsiveness was 21.98 mmHg with a sensitivity of 88.2%, and a specificity of 66.7%. The optimal cut-off value of (Pmsf-CVP) before VE for evaluating fluid responsiveness was 11.48 mmHg with a sensitivity of 88.2%, and a specificity of 77.8%. The optimal cut-off value of ΔPmsf for evaluating fluid responsiveness was 5.5 mmHg with a sensitivity of 82.4%, and a specificity of 66.7%. The optimal cut-off value of Δ(Pmsf-CVP) for evaluating fluid responsiveness was 3.5 mmHg with a sensitivity of 76.5%, and a specificity of 100.0%.

Conclusion

Pmsf before VE, (Pmsf-CVP) before VE, ΔPmsf and Δ(Pmsf-CVP) can evaluate fluid responsiveness in patients with septic shock and undergoing mechanical ventilation. Δ(Pmsf-CVP) has the highest value among these parameters.

Key words: Septic shock, Fluid responsiveness, Mean systemic filling pressure, Change of pressure gradient between mean systemic filling pressure and central venous pressure

Beiyuan Zhang, Hui Qi, Qin Gu. Clinical evaluation of the change of pressure gradient between mean systemic filling pressure and central venous pressure in fluid responsiveness for septic shock patients[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2019, 05(02): 145-150.

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References 21

1	Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis [J]. Crit Care, 2015, 19:251.
2	刘丽霞，胡振杰. 液体超负荷与急性肾损伤，孰因孰果?[J/OL]. 中华重症医学电子杂志, 2017, 3(1):73-77.
3	张宏民，刘大为，王小亭, 等. 每搏量变异评价顽固性感染性休克患者容量反应性 [J]. 中华内科杂志, 2010, 49(7):610-613.
4	Myatra SN, Prabu NR, Divatia JV, et al. The changes in pulse pressure variation or stroke volume variation after a ″tidal volume challenge″ reliably predict fluid responsiveness during low tidal volume ventilation [J]. Crit Care Med, 2017, 45(3):415-421.
5	Guyton AC. Determination of cardiac output by equating venous return curves with cardiac response curves [J]. Physiol Rev, 1955, 35(1):123-129.
6	Maas JJ, Geerts BF, van den Berg PC, et al. Assessment of venous return curve and mean systemic filling pressure in postoperative cardiac surgery patients [J]. Crit Care Med, 2009, 37(3):912-918.
7	Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 [J]. Crit Care Med, 2017, 45(3):486-552.
8	Lu N, Xi X, Jiang L, et al. Exploring the best predictors of fluid responsiveness in patients with septic shock [J]. Am J Emerg Med, 2017, 35(9):1258-1261.
9	Vignon P, Repesse X, Begot E, et al. Comparison of echocardiographic indices used to predict fluid responsiveness in ventilated patients [J]. Am J Respir Crit Care Med, 2017, 195(8):1022-1032.
10	吴敬医，张霞，王箴, 等. 超声心动图评价感染性休克患者液体反应性的临床研究 [J]. 中华危重病急救医学, 2014, 26(1):36-40.
11	Persichini R, Silva S, Teboul JL, et al. Effects of norepinephrine on mean systemic pressure and venous return in human septic shock [J]. Crit Care Med, 2012, 40(12):3146-3153.
12	Preau S, Saulnier F, Dewavrin F, et al. Passive leg raising is predictive of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute pancreatitis [J]. Crit Care Med, 2010, 38(3):819-825.
13	Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge [J]. Crit Care Med, 2007, 35(1):64-68.
14	汪志刚，张燕，朱丽红. 红细胞参数在危重病患者液体管理中的作用 [J]. 中华危重病急救医学, 2013, 25(5):277-280.
15	Magder S. Understanding central venous pressure: not a preload index? [J]. Curr Opin Crit Care, 2015, 21(5):369-375.
16	潘纯，邱海波. 静脉回流：重症医学医师值得关注的心功能之外的问题 [J/OL]. 中华重症医学电子杂志, 2016, 2(2):75-80.
17	Maas JJ, Geerts BF, Jansen JR. Evaluation of mean systemic filling pressure from pulse contour cardiac output and central venous pressure [J]. J Clin Monit Comput, 2011, 25(3):193-201.
18	Gupta K, Sondergaard S, Parkin G, et al. Applying mean systemic filling pressure to assess the response to fluid boluses in cardiac post-surgical patients [J]. Intensive Care Med, 2015, 41(2):265-272.
19	Guérin L, Teboul JL, Persichini R, et al. Effects of passive leg raising and volume expansion on mean systemic pressure and venous return in shock in humans [J]. Crit Care, 2015,19:411.
20	Aya HD, Cecconi M. Can (and should) the venous tone be monitored at the bedside? [J]. Curr Opin Crit Care, 2015, 21(3):240-244.
21	Aya HD, Rhodes A, Fletcher N, et al. Transient stop-flow arm arterial-venous equilibrium pressure measurement: determination of precision of the technique [J]. J Clin Monit Comput, 2016, 30(1):55-61.

组别	例次	HR（次/分）		MAP（mmHg）		CI［L/（min?m²）］		SVV（%）
组别	例次	VE前	VE后	VE前	VE后	VE前	VE后	VE前	VE后
无液体反应性组	17	97.78±19.87	90.89±18.16^b	69.67±10.93	74.78±13.21	3.05±0.72	3.23±0.79^b	13.00±3.39	10.89±3.48^b
有液体反应性组	9	103.47±22.40	108.06±22.80	69.59±9.80	81.12±12.77^b	2.57±0.66	3.59±1.00^b	15.35±3.71	13.47±4.19^b
组别	例次	ITBVI（ml/m²）		EVLWI（ml/kg）		SVRI（dyn?s/cm⁵）		CVP（mmHg）
组别	例次	VE前	VE后	VE前	VE后	VE前	VE后	VE前	VE后
无液体反应性组	17	855.89±218.44	915.56±234.40^b	8.21±2.68	9.18±3.42	1832.67±683.31	1869.78±695.40	8.22±4.32	12.89±4.68^b
有液体反应性组	9	757.29±194.37	892.18±246.81^b	10.78±6.94	10.82±7.62	1851±550.35	1712.24±688.81	10.76±3.54	14.18±4.23^b
组别	例次	Pmsf（mmHg）		Pmsf-CVP（mmHg）		△Pmsf_VE后-VE前（mmHg）	△（Pmsf-CVP）_VE后-VE前（mmHg）
组别	例次	VE前	VE后	VE前	VE后	△Pmsf_VE后-VE前（mmHg）	△（Pmsf-CVP）_VE后-VE前（mmHg）
无液体反应性组	17	23.00±5.96	26.00±3.84	14.78±6.12	13.11±3.98	4.00（1.00，9.50）	-1.00（-2.00，3.00）
有液体反应性组	9	19.06±3.03^a	29.35±3.84^b	8.29±3.92^a	15.59±4.98^b	10.00（6.00，14.00）^a	7.00（3.50，11.50）^a

组别	例次	HR（次/分）		MAP（mmHg）		CI［L/（min?m²）］		SVV（%）
组别	例次	VE前	VE后	VE前	VE后	VE前	VE后	VE前	VE后
无液体反应性组	17	97.78±19.87	90.89±18.16^b	69.67±10.93	74.78±13.21	3.05±0.72	3.23±0.79^b	13.00±3.39	10.89±3.48^b
有液体反应性组	9	103.47±22.40	108.06±22.80	69.59±9.80	81.12±12.77^b	2.57±0.66	3.59±1.00^b	15.35±3.71	13.47±4.19^b
组别	例次	ITBVI（ml/m²）		EVLWI（ml/kg）		SVRI（dyn?s/cm⁵）		CVP（mmHg）
组别	例次	VE前	VE后	VE前	VE后	VE前	VE后	VE前	VE后
无液体反应性组	17	855.89±218.44	915.56±234.40^b	8.21±2.68	9.18±3.42	1832.67±683.31	1869.78±695.40	8.22±4.32	12.89±4.68^b
有液体反应性组	9	757.29±194.37	892.18±246.81^b	10.78±6.94	10.82±7.62	1851±550.35	1712.24±688.81	10.76±3.54	14.18±4.23^b
组别	例次	Pmsf（mmHg）		Pmsf-CVP（mmHg）		△Pmsf_VE后-VE前（mmHg）	△（Pmsf-CVP）_VE后-VE前（mmHg）
组别	例次	VE前	VE后	VE前	VE后	△Pmsf_VE后-VE前（mmHg）	△（Pmsf-CVP）_VE后-VE前（mmHg）
无液体反应性组	17	23.00±5.96	26.00±3.84	14.78±6.12	13.11±3.98	4.00（1.00，9.50）	-1.00（-2.00，3.00）
有液体反应性组	9	19.06±3.03^a	29.35±3.84^b	8.29±3.92^a	15.59±4.98^b	10.00（6.00，14.00）^a	7.00（3.50，11.50）^a

指标	AUC	95%CI	P值	最佳临界值	敏感度（%）	特异度（%）
Pmsf	0.739	0.496~0.981	0.049	22.0	88.2	66.7
Pmsf-CVP	0.810	0.616~1.000	0.010	11.5	88.2	77.8
△CVP	0.654	0.431~0.876	0.205	2.4	41.2	88.9
△Pmsf	0.810	0.637~0.984	0.010	5.5	82.4	66.7
△（Pmsf-CVP）	0.902	0~1.000	0.001	3.5	76.5	100.0

指标	AUC	95%CI	P值	最佳临界值	敏感度（%）	特异度（%）
Pmsf	0.739	0.496~0.981	0.049	22.0	88.2	66.7
Pmsf-CVP	0.810	0.616~1.000	0.010	11.5	88.2	77.8
△CVP	0.654	0.431~0.876	0.205	2.4	41.2	88.9
△Pmsf	0.810	0.637~0.984	0.010	5.5	82.4	66.7
△（Pmsf-CVP）	0.902	0~1.000	0.001	3.5	76.5	100.0

[1]	Zhengmin Jin, Qin Zhu, Yunxia Long. Logistic regression analysis of the pathogens infection and prognosis in patients with severe sepsis/septic shock [J]. Chinese Journal of Lung Diseases(Electronic Edition), 2020, 13(05): 607-611.
[2]	Guangqing Cui, Lingyu Ge. PiCCO guided precise treatment in septic shock patients with cardiac insufficiency [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2023, 09(02): 185-190.
[3]	Xing Cai, Wenjuan Zhang, Jiangquan Yu, Ruiqiang Zheng. Study on the prognostic value of plasma heparin-binding protein in the early diagnosis and prognosis of sepsis [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2023, 09(02): 168-177.
[4]	Danbin Xu, Longxiang Su, Bayinchahan·Boranyi, Lu Wang, Mutalifu·Maihemuti, Jingjing Wang, Caihong Wang, Genan Wang, Yun Long. Potential clinical value of P(cv-a)CO₂/C(a-v)O₂ ratio in early goal-directed resuscitation of septic shock [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2022, 08(01): 23-30.
[5]	Yun Huang, Jing Ming, Chenchen Gong, Xu Liu, Jianyu Fu, Hongying Bi, Hui Fang, Yan Tang, Yuanyi Liu, Difen Wang. Severe myelosuppression causescatheter related severe cavitary Staphylococcus aureus pneumonia [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2021, 07(03): 282-284.
[6]	Lu Zhang, Xiang Li, Shihong Xia, Qi Tong, Yingjie Sun, Xueli. Ma. Development and clinical application of the diagnosis and treatment of septic shock in the era of precision medicine [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2021, 07(02): 169-173.
[7]	Zhiwei Gao, Jianfeng Xie, Ling Liu, Hui Chen, Cong Li, Yi Yang. Clinical research progress of diastolic blood pressure in predicting the progression and guiding the treatment of septic shock [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2021, 07(02): 159-163.
[8]	He Sun, Chunfeng He, Xiaodong Wu, Huize Han, Yi Shi, Qiang Li. Efficacy and safety analysis of Ceftazidime-Avibatam in carbapene-resistant Klebsiella pneumoniae infected patients with septic shock [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2021, 07(01): 76-80.
[9]	Xuezhong Xing, Yong Gao, Haijun Wang, Shining Qu, Chulin Huang, Hao Zhang. Value of pulse-indicator continuous cardiac output monitoring in management guiding of septic shock: a Meta-analysis [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2021, 07(01): 43-47.
[10]	Yuan Yu, Hong Liu. Acute myocardial infarction complicated with septic shock during extracorporeal cardiopulmonary resuscitation support: a case report [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2020, 06(03): 353-356.
[11]	Weizhu Ding, Qihong Chen. Effect of 1-hour bundle on prognosis of patients with septic shock [J]. Chinese Journal of Clinicians(Electronic Edition), 2020, 14(10): 826-829.
[12]	Fen Liu, Tianqing Huang, Yilin Yang, Huishu Liu. Analysis of the maternal septic shock: 98 case reports [J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2020, 09(03): 175-179.
[13]	Yishi He, Zhuoqiang Wu, Jiaming Wu, Hanwei Chen, Xin Yang. Clinical analysis of bedside ultrasound intervention combined with antibiotics in the treatment of acute and severe bacterial liver abscess [J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2022, 10(04): 418-421.
[14]	Ningyang Ding, Sisen Zhang. Correlation between cytokine levels and immune function in patients with sepsis [J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2022, 08(02): 77-80.
[15]	Jisong Zhang, Yuming Wang, Yanjun Zheng, Xing Qi, Peili Chen, Wen Shi, Ying Chen, Zhitao Yang, Enqiang Mao, Erzhen Chen. Predictive effect of neutrophil gelatinase-associated apolipoprotein (NGAL) on prognosis in patients with sepsis/septic shock [J]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2020, 06(04): 202-208.

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