Critical care (London, England) · 2026
Assessing fluid responsiveness in mechanically ventilated patients with intra-abdominal hypertension: a two-center, prospective, observational study.
СтатьяНаблюдательное исследованиеМногоцентровое исследованиеНазвание и аннотация: Перевод в очереди
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Si Xiang, Song Wenliang, Cao Daiyin, Zhu Weining, Lu Yali, Peng Huiru, Yuan Hao, Liang Liqun, Jiang Jinlong, Yang Tao, Ma Xiaoxun, Guo Jiayan, Liu Zimeng, Liu Yongjun, Chen Minying, Chen Ronglin, Guan Xiangdong, Wu Jianfeng, Shi Rui, Monnet Xavier
Аннотация
BACKGROUND: Intra-abdominal hypertension (IAH) may reduce the diagnostic accuracy of the passive leg raising (PLR) test for predicting fluid responsiveness, with unclear mechanisms. The reliability of the end-expiratory occlusion (EEO) test and mini-fluid challenge in IAH remains unknown. This study explored the mechanisms underlying PLR impairment and assessed the accuracy of EEO and mini-fluid challenge in detecting fluid responsiveness in patients with and without IAH.
METHODS: In this prospective study in two intensive care units (ICUs), we included ventilated patients with IAH ("IAH + "; intra-abdominal pressure [IAP] ≥ 12 mmHg) and without ("IAH-"), all monitored via transpulmonary thermodilution and receiving a 500-mL fluid challenge. Patients consecutively underwent a 1‑minute PLR, a 15‑second EEO, and a 1‑minute mini-fluid challenge of 100 mL, with cardiac index (CI) changes recorded during each maneuver. Following the mini-fluid challenge, the remaining 400 mL were infused over 14 min, and a ≥ 15% increase in CI was used to define fluid responders. The transmural pressure of the inferior vena cava was estimated by the central venous pressure (CVP) - IAP gradient.
RESULTS: We included 88 patients, 44 IAH- (25 fluid responders and 19 non-responders) and 44 IAH + (22 responders and 22 non-responders). Baseline IAP was 9 ± 2 mmHg in IAH- and 17 ± 3 mmHg in IAH + (p < 0.001). In IAH- responders, CI increased by 19 ± 11% during PLR and 31 ± 17% after volume expansion, with PLR positive in 24/25 responders. In IAH + responders, CI increased by 6 ± 7% during PLR (p < 0.001 vs. IAH-) and 30 ± 18% after volume expansion (p = 0.907 vs. IAH-). The AUROC of the PLR for detecting fluid responsiveness was 0.96 (0.87-1.00) in IAH- and 0.71 (0.56-0.87) in IAH + (p = 0.009 vs. IAH-). Among IAH + , there were 16 false negatives and 6 true positives for PLR, both with negative baseline CVP-IAP gradients. During PLR, the gradient reversed in true-positives (from -2.4 ± 4.0 to + 2.2 ± 2.7 mmHg, p = 0.014), whereas it remained negative in false-negatives (from -6.3 ± 3.7 to -1.4 ± 3.4 mmHg, p < 0.001). AUROC between IAH- and IAH + was similar for either the EEO test (0.95 [0.87-1.00] vs. 0.89 [0.80-0.97], p = 0.332) or mini-fluid challenge (0.94 [0.87-1.00] vs. 0.90 [0.79-1.00], p = 0.514).
CONCLUSION: In patients with IAH, the limited diagnostic value of PLR for fluid responsiveness may be related to persistently negative CVP-IAP gradients in false-negative cases, whereas EEO and mini-fluid challenge remain reliable alternatives.
METHODS: In this prospective study in two intensive care units (ICUs), we included ventilated patients with IAH ("IAH + "; intra-abdominal pressure [IAP] ≥ 12 mmHg) and without ("IAH-"), all monitored via transpulmonary thermodilution and receiving a 500-mL fluid challenge. Patients consecutively underwent a 1‑minute PLR, a 15‑second EEO, and a 1‑minute mini-fluid challenge of 100 mL, with cardiac index (CI) changes recorded during each maneuver. Following the mini-fluid challenge, the remaining 400 mL were infused over 14 min, and a ≥ 15% increase in CI was used to define fluid responders. The transmural pressure of the inferior vena cava was estimated by the central venous pressure (CVP) - IAP gradient.
RESULTS: We included 88 patients, 44 IAH- (25 fluid responders and 19 non-responders) and 44 IAH + (22 responders and 22 non-responders). Baseline IAP was 9 ± 2 mmHg in IAH- and 17 ± 3 mmHg in IAH + (p < 0.001). In IAH- responders, CI increased by 19 ± 11% during PLR and 31 ± 17% after volume expansion, with PLR positive in 24/25 responders. In IAH + responders, CI increased by 6 ± 7% during PLR (p < 0.001 vs. IAH-) and 30 ± 18% after volume expansion (p = 0.907 vs. IAH-). The AUROC of the PLR for detecting fluid responsiveness was 0.96 (0.87-1.00) in IAH- and 0.71 (0.56-0.87) in IAH + (p = 0.009 vs. IAH-). Among IAH + , there were 16 false negatives and 6 true positives for PLR, both with negative baseline CVP-IAP gradients. During PLR, the gradient reversed in true-positives (from -2.4 ± 4.0 to + 2.2 ± 2.7 mmHg, p = 0.014), whereas it remained negative in false-negatives (from -6.3 ± 3.7 to -1.4 ± 3.4 mmHg, p < 0.001). AUROC between IAH- and IAH + was similar for either the EEO test (0.95 [0.87-1.00] vs. 0.89 [0.80-0.97], p = 0.332) or mini-fluid challenge (0.94 [0.87-1.00] vs. 0.90 [0.79-1.00], p = 0.514).
CONCLUSION: In patients with IAH, the limited diagnostic value of PLR for fluid responsiveness may be related to persistently negative CVP-IAP gradients in false-negative cases, whereas EEO and mini-fluid challenge remain reliable alternatives.