Authors: Mingwang Jia ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Jialin Yang ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Fang Peng ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Yinling Wang ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Guangyuan Liao ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Yuanmei Gao ( Department of Intensive Care Unit, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. )
Objective: To investigate volume management by comparing between critical care ultrasound examination and pulse indicator cardiac output (PICCO) in patient with septic shock.
Method: Patients with septic shock during July 2017 and June 2018 were included. Inferior Vena Cava (IVC), total end-diastolic volume index (GEDI), central venous pressure (CVP), lactic acid and oxygenation index were measured by ultrasound. First, the accuracy difference of IVC, GEDI and CVP estimation capacity was compared. According to the changes of IVCmin, IVCmax, and GEDI, they were divided into 5 groups to compare the differences of lactic acid and oxygenation index between the groups and the correlation of lactate and Oxygenation index (PaO2/FiO2) between IVC and GEDI was analyzed. The correlation of lactate and PaO2/FiO2 between B lines and extravascular pulmonary water index (ELWI) was noted.
Results: The accuracy of IVC and GEDI in volume estimation was greater than 75%, significantly higher than that of CVP (53.3%) (P<0.05). The correlation results showed that GEDI was significantly correlated with IVCmax and IVCmin (P<0.05), while there was a significant correlation between b-line area and oxygenation index, ELWI and lactic acid, ELWI and oxygenation index (P<0.05). IVCmin, IVCmax and GEDI were respectively divided into 5 groups for comparing the difference between lactic acid and oxygenation. It was found that there were significant differences between the two indicators of IVCmin in different groups (P>0.05). The oxygenation index of the group ≤IVCmax was significantly lower than that of the group 0.5 ≤IVCmax < 1.0cm (P<0.05). The oxgenation indexes of groups 500≤GEDI < 600mL/m2; 600≤GEDI < 700mL/m2. 700≤GEDI < 800mL/m2 were significantly higher than that of group 0 < GEDI < 500mL/m2 (P<0.05).
Conclusion: Critical care ultrasound examination and PICCO are better methods than in volume management, but PICCO is more individualized, and PICCO in patients with valvular heart disease is not recommended.
Keywords: Critical care ultrasound, PICCO, Septic shock. (JPMA 70: 51 [Special Issue]; 2020)
Infectious shock is one of the most common diseases in ICU1 with fluid resuscitation being is the most important treatment strategy.2,3 However, the shock guidelines of 2016 point out that conservative fluid therapy strategy is recommended in the absence of evidence of tissue hypo-perfusion.4 Therefore, the evaluation and adjustment of the volume load is of great significance for the development and prognosis of septic shock patients. Pulse Indicator Continuous Cardiac Output (PICCO) is an invasive haemodynamic monitoring measure, which can accurately reflect body volume load and guide fluid therapy.5 But it is expensive, and there are some limitations in the condition of intracardiac shunt. Critical care ultrasound has the advantages of fast, non-invasive, simple and reproducible in volume assessment.6 The purpose of this study is to compare the advantages and disadvantages of critical care ultrasound and PICCO in volume management of septic shock patients, and to explore more suitable methods for volume assessment of septic shock patients. Thus the objective of this research was to investigate volume management by comparing between critical care ultrasound examination and PICCO in patients with septic shock.
Patients and Methods
A comparative study was conducted on patients transferred to ICU due to septic shock from July 2017 to June 2018. Inclusion criteria: were age >18 years, consistent with "The diagnostic criteria for septic shock based on the 2016 guidelines for SSC".7 Exclusion criteria were those having contraindications for PICCO catheterization. All patients in whom inferior vena cava (IVC) could not be measured by critical care ultrasound and whose treatment time in ICU was less than 3 days.
The maximum and minimum diameters of inferior vena cava vessels were measured by critical care ultrasound. Under the xiphoid process, the point of indication was pointed to the head, and the inferior vena cava (IVC) section was obtained. Under M mode, the sampling line was placed at 2cm from IVC into the right atrium. The maximum and minimum internal diameters of the inferior vena cava vessels (IVCmax and IVCmin) were measured respectively. In supine position, the ultrasound probe was perpendicular to the chest wall and the indication point was facing the head. The B-line area of the lung was detected according to the standardized checkpoint in the BLUE process, and the number of B-line areas was recorded.
IVC, PICCO and central venous pressure (CVP) were measured at 7:00 a.m. on the 1st, 2nd and 3rd day after patients were transferred to ICU, and lactic acid and oxygenation index were recorded at the same time. IVC, PICCO and CVP were measured again at 16:00 on the first day.
The accuracy of IVC, PICCO and CVP in evaluating the volume was calculated by the volume change from 7:00 to 16:00 on the first day, and the similarities and differences of the accuracy were compared. According to the size of IVCmax, patients were divided into five groups: 0.5
The correlation among the three groups and the similarities and differences of lactic acid and oxygenation index were compared. This gave the correlation between the number of B-line areas and Extravascular Lung Water Index (ELWI) and the correlation between them and lactic acid and oxygenation index.
The statistical analysis software package SPSS 21.0 was used for statistical analysis. The experimental data were expressed by mean ± standard deviation (x±s), t-test and correlation test. The counting data were expressed by rate (%) and c2 test was used. P<0.05 indicated that the difference was statistically significant.
A total of 30 patients were enrolled, including 12 males, with an average age of 38.87±7.66 years.
As shown in Table-1, the accuracy of CVP, IVCmax and IVCmin were 53.3%, 83.33% and 90.0% respectively. Accuracy of GEDI was 76.7%, and accuracy of GEDI* was 84.0%. The results of comparing the accuracy of estimated capacity showed that the accuracy of IVCmax and GEDI* was significantly higher than that of CVP (P<0.05). The estimation accuracy of IVCmin was significantly higher than that of CVP (P<0.01). In the correlation analysis of GEDI and IVC, there was no significant correlation between GEDI and IVCmax (r = 0.048, P = 0.653), and no significant correlation between GEDI and IVCmin (r = 0.033, P = 0.755); after excluding patients with valvular heart disease, there was a significant correlation between GEDI and IVCmax (r = 0.311, P = 0.007), and there was a significant correlation between GEDI and IVCmin (r = 0.308, P = 0.007).
After comparing the different groups of IVCmin, IVCmax and GEDI in difference between lactic acid and oxgenation index, it was found that in Figure-1A, lactic acid indexes of 0.5 IVCmin < 1.0 cm, 1.0 or less IVCmin < 1.5 cm, 1.5 or less IVCmin < 2.0 cm and 2.0 or less IVCmin groups were 3.97, 3.45 + / - 3.27, 2.59 4.93 mm + / - 1.12 and 2.77 + / - 0.33, and there was no significant difference of lactic acid index for each group (p > 0.05).
As seen from figure 1B, the oxgenation indices of IVCmin in different groups were 302.01±123.11, 298.61±122.7, 273.99±108.25 and 238.08±126.86, respectively, and there was no significant difference of the oxygenation index of each group (p>0.05). According to Figure-2A, lactic acid indexes of 0.5 IVCmax < 1.0 cm, 1.0 or less or less IVCmax < 1.5 cm, 1.5 or less IVCmax < 2.0 cm, 2.0 or less IVCmax < 2.5 cm, 2.5 or less IVCmax groups were 2.39, 3.69 + / - 3.94, 3.44 0.2 mm + / - 3.63, 2.71 and 2.8 0.41 mm 1.04 mm and there was no significant difference of lactic acid index between groups (p > 0.05).
As seen from figure 2B, the oxgenation index of IVCmax in different groups was 471.98±43.16, 301.09±106.92, 283.79±112.04, 288.3±104.74 and 151.79±123.85, respectively. The oxygenation index of group 2.5 0.05).
According to Figure-3B, the oxygenation index of groups of 500
In the correlation analysis between the number of B-line areas and ELWI, there was a significant correlation between the number of B-line areas and ELWI (r=0.737, P<0.001), the number of B-line areas and lactic acid (r=0.606, p<0.001), the number of B-line areas and oxygenation index (r=-0.590, p<0.001), ELWI and lactic acid (r=0.886, p<0.001), and ELWI and oxygenation index (r=-0.553, p < 0.001).
Septic shock, also known as septic or toxic shock, is a medical condition caused by severe infection and sepsis. Early detection, timely diagnosis and effective treatment are the key to prevention. Fluid resuscitation is an indispensable treatment for patients with septic shock, but the control of fluid volume is constantly changing with the update of research. Current guidelines recommend the use of conservative fluid therapy strategy which brings more stringent requirements for the control of fluid volume. At present, there are many commonly used monitoring methods in the clinic, the most common one is the measurement of CVP, but CVP as an indicator of capacity load still has obvious shortcomings. Whether it is appropriate to use CVP as an indicator of capacity regulation is still controversial.8,9
Haemodynamic monitoring is very important in patients with severe shock or acute respiratory distress syndrome (ARDS). PICCO (pulse index contour cardiac output, pulse medical systems, Germany) system has been developed and used in critical care environment for several years. PICCO is an invasive haemodynamic monitoring measure, which can accurately reflect the body volume load and guide fluid therapy. Under the monitoring and guidance of PICCO technology, patients with septic shock were treated with EGDT combined with early fluid resuscitation and positive inotropic drugs, rather than using vasoconstrictor drugs alone, resulting in high blood pressure. Using PICCO haemodynamics to monitor the patients with severe septic shock can obtain more comprehensive indices such as blood volume, systemic vascular resistance, cardiac function, etc., and guide the selection of fluid resuscitation, antidiuretic drugs and inotropic drugs.
GEDI is a direct reflection of the state of cardiac capacity, which can more accurately reflect the true situation of cardiac capacity. Many experiments show that GEDI reflects cardiac preload better than CVP and other related indicators.10,11 However, the procedure is complicated and expensive, and catheter-related complications may occur with invasive catheterization. The catheter-related blood flow infection will increase the mortality of critically ill patients.12 GEDI targeted fluid resuscitation is better than central venous pressure in the treatment of septic shock, but it cannot reduce the mortality.
As one of the last stations for blood to flow into the heart, IVC's inner diameter and collapse degree have been used to evaluate the volume status of severe patients. Some studies suggest that the IVC diameter of patients with hypovolaemia is smaller than that of patients with normal blood volume while dilated and fixed IVC usually indicates that patients are in a state of volume overload.13-15 Because IVC changes with blood flow and has a good correlation with blood volume, more and more clinicians use bedside ultrasound to assess volume load. The index of inferior vena cava collapse is one of the dynamic indexes for diagnosing hypovolemia in patients with septic shock, which is related to delta cardiac output after leg raising test. We believe that, based on the experience of clinicians, observing one of these two parameters is enough to determine the hypovolaemia of patients with septic shock.
Subsequently, the consistency between GEDI and IVC further proves this view. In the analysis of IVC and lactic acid and oxygenation index, it can be seen that the ideal range of IVC min control is 1.516-19 Both GEDI and IVC are more accurate than CVP and can be used as guidance for volume assessment. However, the evaluation of GEDI is also affected by specific diseases of patients. The accuracy of GEDI in patients with valvular heart disease is also lower, which cannot be used as a basis for volume assessment.20-24
Fluid resuscitation needs to be guided by volume assessment in patients with septic shock. Critical care ultrasound and PICCO are both more ideal methods for volume assessment, but PICCO needs more individualized assessment, and PICCO is not recommended for patients with heart valve disease.
Disclaimer: I hereby declare that this research paper is my own and autonomous work. All sources and aids used have been indicated as such. All texts either quoted directly or paraphrased have been indicated by in-text citations. Full bibliographic details are given in the reference list which also contains internet sources. This work has not been submitted to any other journal for consideration.
Conflict of Interest: We declare that all contributing authors of this paper have no conflict of interest and all have contributed equally for this research work.
Funding Disclosure: This work was supported by Guangdong Natural Science Foundation by grant number (2017A030313857)
1. Blanco P, Volpicelli G. Common pitfalls in point-of-care ultrasound: a practical guide for emergency and critical care physicians. Crit Ultrasound J 2016;8:15. doi: 10.1186/s13089-016-0052-x.
2. Alvi MA, Hassan A, Tanveer Q, Saleem A, Qamar W. Peste Des Petitis Ruminants: An overview and a case report from Pakistan. Matrix Sci Medica 2017;1:20-2. DOI: 10.26480/msm.02.2017.20.22
3. Ebrahim GJ. Sepsis, septic shock and the systemic inflammatory response syndrome. J Trop Pediatr 2011;57:77-9. doi: 10.1093/tropej/fmr022.
4. Razzak MA, Islam MA, Rahman MH, Sathi MA, Atikuzzamman M. Screening Of Lentil Germplasm Against Stemphylium Blight By Observing Disease Reaction In Three Different Stages. Malays J Halal Res 2018;1:15-8. DOI: 10.26480/mjhr.02.2018.15.18
5. Torgersen C, Dünser MW, Schmittinger CA, Pettilä V, Ruokonen E, Wenzel V, et al. Current approach to the haemodynamic management of septic shock patients in European intensive care units: a cross-sectional, self-reported questionnaire-based survey. Eur J Anaesthesiol 2011;28:284-90. doi: 10.1097/EJA.0b013e3283405062.
6. Mohammed GE. Productivity of pure stands and intercropped Forage sorghum and hyacinth bean. Malays J Sustain Agric 2018;2:5-6. DOI: 10.26480/mjsa.01.2018.05.06
7. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43:304-77. doi: 10.1007/s00134-017-4683-6.
8. Gu J, Zhang D. Analysis on influencing factors of industrial pollution taking Zhejiang Province as an example. Acta Sci Malays 2018;2:14-6. DOI: 10.26480/asm.01.2018.14.16
9. Fagley RE, Haney MF, Beraud AS, Comfere T, Kohl BA, Merkel MJ, et al. Critical Care Basic Ultrasound Learning Goals for American Anesthesiology Critical Care Trainees: Recommendations from an Expert Group. Anesth Analg 2015;120:1041-53. doi: 10.1213/ANE.0000000000000652.
10. Wahab WA, Adzmi AN. The investigation of cytotoxic effect of Cinnamomum zeylanicum extracts on human breast cancer cell line (Mcf-7). Sci Herit J 2017;1:23-8. DOI: 10.26480/gws.02.2017.23.28
11. Kanji HD, McCallum JL, Bhagirath KM, Neitzel AS. Curriculum Development and Evaluation of a Hemodynamic Critical Care Ultrasound: A Systematic Review of the Literature. Crit Care Med 2016;44:e742-50. doi: 10.1097/CCM.0000000000001661.
12. Rashid H, Arslan C, Khan SN. Wastewater Irrigation, Its Impact On Environment And Health Risk Assessment In Peri Urban Areas Of Punjab Pakistan-A Review. Environ Contam Rev 2018;1:30-5. DOI: 10.26480/ecr.01.2018.30.35
13. Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, et al. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). J Intensive Care 2018;6:7. doi: 10.1186/s40560-017-0270-8.
14. Al-Malah KI, Al Mansoori HS, Al Mansoori ARM, Al Hamadi MAA, Al Mansoori GM. Production Of Ammonia At Relatively Low P, T: Aspen Process Economic Analysis. Acta Chem Malay 2018;2:1-5. DOI: 10.26480/acmy.01.2018.01.05
15. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259-65. doi: 10.1097/CCM.0b013e3181feeb15.
16. Leizou, KE, Ashraf MA. Status Of Heavy Metals In Water, Sediments And Clam (Galatea Paradoxa, Born 1778) Of The Diebu Creek, Bayelsa State, Niger Delta Region, Nigeria. Acta Chem Malay 2018;2:6-10. DOI: 10.26480/acmy.01.2018.06.10
17. Michard F, Alaya S, Zarka V, Bahloul M, Richard C, Teboul JL. Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest 2003;124:1900-8. doi: 10.1378/chest.124.5.1900.
18. Ashraf MA, Hanfiah MM. Recent advances in assessment on clear water, soil and air. Environ Sci Pollut Res Int 2017;24:22753-4. doi: 10.1007/s11356-017-9267-z.
19. Schuster DP. The evaluation of pulmonary edema by measuring lung water. In: Tobin MJ, eds. Principles and Practice of Intensive Care Monitoring. New York, USA: McGraw-Hill, 1998; pp 693-705.
20. Ashraf MA. Persistent organic pollutants (POPs): a global issue, a global challenge. Environ Sci Pollut Res Int 2017;24:4223-7. doi: 10.1007/s11356-015-5225-9.
21. Lichtwarck-Aschoff M, Zeravik J, Pfeiffer UJ. Intrathoracic blood volume accurately reflects circulatory volume status in critically ill patients with mechanical ventilation. Intensive Care Med 1992;18:142-7. doi: 10.1007/BF01709237.
22. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32. doi: 10.1056/NEJMoa061115.
23. Dipti A, Soucy Z, Surana A, Chandra S. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. Am J Emerg Med 2012;30:1414-9.e1. doi: 10.1016/j.ajem.2011.10.017.
24. Zengin S, Al B, Genc S, Yildirim C, Ercan S, Dogan M, et al. Role of inferior vena cava and right ventricular diameter in assessment of volume status: a comparative study: ultrasound and hypovolemia. Am J Emerg Med 2013;31:763-7. doi: 10.1016/j.ajem.2012.10.013.