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Methods. Neonates and infants under general anaesthesia without myocardial dysfunction
were prospectively included when the attending anaesthetist, blinded to TED
measurements, decided to provide VE based on clinical appreciation and standard
monitoring data. Standard and TED-derived data were recorded before and after VE. After
VE, patients were classified as responders and non-responders, if their indexed stroke
volume (iSV) increased by more than 15% or not, respectively. The attending anaesthetist
assessment of VE responsiveness was recorded at the end of VE.
Results. Fifty patients aged 42 (4) post-conceptional weeks were included, among which 26
(52%) were responders. Baseline iSV was the only parameter associated with VE
responsiveness. Baseline iSV was fairly correlated with VE-induced changes in iSV (r 20.64)
and was associated with an area under the receiver operating characteristic curve of 0.90
(0.80, 0.99). Using a cut-off of 25 ml m22, baseline iSV predicted volume responsiveness with
a sensitivity of 92% and a specificity of 83%. Attending anaesthetists assessment of VE
effectiveness agreed only moderately with TED measurements of iSV changes.
Conclusions. TED-derived iSV measurement during volatile anaesthesia is useful to predict and
follow VE responsiveness in neonates and infants without myocardial dysfunction.
Keywords: Doppler ultrasonography, transoesophageal; infants; monitoring, intraoperative;
newborns
Accepted for publication: 16 August 2011
harmful as the immaturity of neonatal diastolic cardiac function increases the risk of congestive pulmonary oedema in
cases of undue fluid loading.2 As clinical appreciation of
the volaemic status is known to be unreliable in ventilated
children,3 minimally invasive tools that could predict
patient responsiveness to VE would be extremely useful. A
non-invasive, user-friendly monitor allowing for the
measurement of CO and effective management of haemodynamic instability in neonates and infants would be a
major advance in practice. Transoesophageal Doppler (TED)
has been shown to effectively measure CO in newborns
and children4 and, therefore, could allow for the assessment
of the efficacy of VE. Moreover, among many velocity TED
waveform-derived indices, corrected flow time (cFT) has
been shown to reflect LV filling.5 The aim of the study was
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
Transoesophageal
Doppler (TED) is useful to
guide intraoperative
volume expansion (VE) in
neonates and young
infants.
Background. Volume expansion (VE) in neonates or infants during volatile anaesthesia may
lead to fluid overload if inappropriate. Transoesophageal Doppler (TED), a non-invasive
cardiac output monitoring technique, can provide a comprehensive estimation of the
volaemic status. We evaluated whether intraoperative TED-derived parameters can
predict volume responsiveness.
BJA
Methods
Statistical analysis
Patients were initially classified as responders (R) if their iSV
increased by 15% after VE. Patients with ,15% change
in iSV were classified as non-responders (NR). Results are
expressed as mean (SD) or median (10th, 90th percentiles),
where appropriate. R/NR groups and baseline/post-VE
measurements were compared using Students, Wilcoxons,
x 2, or Fischers exact test, as appropriate. Covariables significantly associated with VE responsiveness in the univariate
analysis (P,0.05) were entered in a logistic regression analysis to explore the relative importance of each covariable on
VE responsiveness [step-by-step procedure based on the
maximum
likelihood
ratio
test
(a-to-enter0.10,
a-to-exit0.20)]. Interactions between covariables were
assessed if relevant. Adjusted odds ratios and 95% confidence intervals were calculated. Receiver operating characteristic (ROC) curves were fitted for variables significantly
associated with VE responsiveness in the multivariate analysis. The area under the ROC curve was calculated using the
trapezoid rule. For each variable, a cut-off value was determined to maximize both sensitivity and specificity. Linear
correlations were searched between variables associated
with VE responsiveness and VE-induced iSV changes, using
the Spearman rank method. k coefficient was calculated to
assess the concordance between R/NR classification and
anaesthetist perceived responsiveness to VE. Statistical significance threshold was set at 5%. Statistical analysis was
performed using SASTM version 9.0 (SAS InstituteTM , Cary,
NC, USA).
Results
Results are presented in Tables 1 and 2 for both R and NR at
baseline and post-VE and are expressed as mean (SD) or
median (10th, 90th percentiles), where appropriate. Fifty-six
patients were felt to be hypovolaemic and required VE. Six
patients were excluded from the study due to inability to
101
This prospective study was conducted at the Centre Hospitalier Universitaire de Montpellier after Research Ethics Board
approval (Comite de Protection des Personnes SudMediterranee III, Ref: 2009.12.01 bis) and the study was
registered with EudraCT (Ref: 2009-A01185-52). Informed
consent from patients caregivers was obtained before
inclusion in the study. Neonates and infants weighing
between 2.5 and 5.0 kg, aged ,6 months, undergoing a surgical procedure under volatile anaesthesia requiring tracheal
intubation and controlled ventilation were consented for the
possible entry into the study. Exclusion criteria were preoperative haemodynamic instability or catecholamine infusion, known congenital heart disease with haemodynamic
consequences, hypothermia (temperature ,358C), and oesophageal malformation. Patients were optimized before operation and deemed haemodynamically stable and clinically
euvolaemic before the induction of anaesthesia. Anaesthesia
was maintained using a volatile anaesthetic, but otherwise
was not strictly standardized. Ventilation was set to maintain
end-tidal CO2 between 25 and 35 mm Hg. Arterial pressure
was measured using a standard non-invasive cuff applied
to the upper limb. Patients were formally entered into the
study if the attending paediatric anaesthetist felt that it
was necessary to provide a fluid bolus during the maintenance of anaesthesia. The need for VE was based on traditional endpoints such as clinical history, type of surgery,
perioperative events, and standard monitoring data excluding TED measurements. Upon selection into the study, a
second anaesthesiologist was called to perform TED
measurements. TED-derived data and standard monitoring
data were registered immediately before and after VE. The
second anaesthetist inserted a 5 mm diameter, 4 MHz, flexible TED probe (Cardio QPTM, Deltex MedicalTM , Chichester, UK)
through the mouth of the patient in an attempt to place its
tip in the mid-oesophagus. The attending anaesthetist was
blinded to TED waveform- or TED-derived data. The optimal
position of the probe was suggested by an audible,
maximal pitch and a sharply defined velocity waveform
with minimal spectral dispersion. Five consecutive TED
measurements pre- and post-VE were completed and averaged. The probe was rotated to display the best aortic
blood flow signal before each measurement. Cardiac index
(CI), iSV, cFT (length of time of systolic blood flow adjusted
for HR, that is, divided by the square root of the heart cycle
time), PV (maximal velocity during systole), and MA (PV
divided by the acceleration time during systole) of the descending aorta velocity waveform were recorded. VE consisted
of an infusion of 10 30 ml kg21 of crystalloid (normal saline
0.9%) or colloid (albumin 4% or Voluvenw hydroxyethyl starch
130/0.4 6%) over a period of 2040 min. Patients were
excluded if: (i) a correct TED signal was impossible to
obtain, (ii) an anaesthetic or a surgical event with haemodynamic consequences occurred during VE, such as epidural
bolus, surgical incision, surgical bleeding, compression of
great vessels, or pneumoperitoneum inflation, or (iii) there
was concurrent use of a vasoactive agent. Volatile anaesthetic concentration and mechanical ventilation were kept
constant during the VE period. At the end of VE, the attending anaesthesiologist was asked to classify the VE as positive
(improved haemodynamic status) or negative (unchanged or
worsened haemodynamic status). Each patient could only be
included once in the study.
BJA
Raux et al.
Groups
R (n526)
NR (n524)
P-value
37 (4)
36 (4)
11 (1, 63)
Post-conceptional age
(weeks)
41 (3)
44 (5)
0.004
2.9 (1)
2.6 (0.9)
0.173
3.3 (0.8)
3.8 (1)
0.049
11.6 (2.7)
0.006
0.977
Diaphragmatic hernia
Oesogastric junction
surgery
11
13
Bladder surgery
Penis surgery
Sacrococcygeal teratoma
Peritoneal catheter
withdrawal
Discussion
Propofol (mg kg
6.5 (2.5)
7.5 (4.5)
0.648
0.9 (0.2)
1.1 (0.5)
0.282
0.1
0.2 (0.2)
0.182
83
0.243
102
69
31
As shown in Table 2, before VE, baseline HR, CI, iSV, cFT, and
PV differed significantly between R and NR. In the multivariate model, iSV was found to be the only parameter significantly associated with VE responsiveness [P0.0001,
adjusted odds ratio of 1.39 (1.13, 1.70)]. As seen in
Figure 1, baseline iSV correlated negatively with VE-induced
iSV changes (r 20.64; P,0.0001). Using a cut-off of 25 ml
m22, baseline iSV predicted volume responsiveness with a
sensitivity of 92% and a specificity of 83%. Figure 2 shows
that the area under the curve of iSV was found to be 0.90
(0.80, 0.99).
Pyloromyotomy
17
16.8 (9.4)
14.4 (3.5)
0.466
53 (48)
40 (25)
0.924
Duration of VE (min)
24 (10)
28 (9)
0.079
BJA
Table 2 Anaesthetic, respiratory, and haemodynamic parameters. R and NR, responders and non-responders to VE; VE, volume expansion; MAC,
minimum alveolar concentration: 3.3% and 9.16% were considered as MAC of sevoflurane and desflurane, respectively. Twenty per cent
potentiation by N2O was considered when associated; HR, heart rate; MAP, mean arterial pressure; CI, cardiac index; iSV, indexed stroke volume;
cFT, corrected flow time; PV, peak velocity; MA, mean acceleration; results are mean (SD); *P,0.05 baseline vs after VE; P, R vs NR at baseline
Groups
R (n526)
NR (n524)
Baseline
After VE
Baseline
P-value
After VE
0.8 (0.3)
0.7 (0.3)*
0.7 (0.2)
0.7 (0.2)
0.167
9.4 (2.2)
9.3 (2.6)
9.3 (1.6)
8.7 (2.2)
0.851
28 (4)
28 (4)
27 (3)
27 (3)
0.657
3 (1)
3 (1)
2 (1)
2 (1)
0.227
19 (3)
19 (3)
20 (4)
22 (5)
0.120
SpO2 (%)
98 (2)
98 (2)
99 (2)
99 (2)
0.077
36 (0.7)*
35.8 (0.8)
35.8 (0.8)
0.185
0.007
Haemodynamic parameters
HR (min21)
144 (19)
135 (16)*
129 (18)
127 (15)
32 (9)
37 (8)*
32 (7)
36 (7)*
2.9 (0.6)
3.8 (0.8)*
3.7 (0.8)
3.6 (0.8)
0.495
,0.001
20.7 (4.6)
28.4 (7)*
29.2 (6.5)
28.8 (6.3)
,0.001
cFT (ms)
320 (28)
353 (29)*
354 (32)
368 (25)*
,0.001
100 (23)
129 (38)*
127 (28)
120 (25)*
,0.001
MA (cm s22)
12.6 (2.4)
14.7 (3.6)*
13.7 (2.7)
13.1 (2.9)
0.158
140
1.0
120
0.9
100
0.8
80
0.7
Sensitivity
PV (cm s21)
60
40
20
0.6
0.5
0.4
0.3
20
0.2
40
10
0.1
15
30
35
20
25
Baseline iSV (ml m2)
40
45
0.0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
1-specificity
rapidly lead to pulmonary oedema.2 Furthermore, anaesthetists had difficulty distinguishing whether a patient had
responded positively or negatively to VE. In 28% of our
patients, the clinicians felt that NR had effectively
responded to VE. Inaccurate appraisal of volume status
after inaugural fluid challenge may expose patients to
further undue fluid loading.
Little research has focused on the assessment of preload
dependence and the paediatric hearts ability to convert an
augmentation of preload into an increase in CO. Static
indices such as central venous access (CVP) and pulmonary
arterial occlusive pressure (PAOP) are considered to be the
103
36.1 (0.7)
BJA
Raux et al.
R (n526)
25.5 (6)
+18.9 (28.4)
+31 (23.7)
NR (n524)
21.5 (7)
+14.3 (19.5)
P-value
0.035
0.639
21.7 (10)
,0.001
iSV (%)
+37.4 (21.8)
20.9 (11.4)
,0.001
cFT (%)
+10.6 (8.2)
21.5 (7)
,0.001
PV (%)
+29.2 (20.7)
24.4 (10.7)
,0.001
MA (%)
+18.4 (19.2)
21.9 (19.6)
,0.001
104
negative inotropic actions independent of changes in autonomic nervous system tone based on studies in denervated
animals.20 21 Desfluranes sympathoexcitation properties
can mask its direct negative inotropic effects.22 Patients
receiving desflurane, nitrous oxide, or both were equally distributed among the R and NR groups, suggesting a minimal
effect of these agents on cardiac contractility. Nevertheless,
this is a factor that may have led to a decreased iSV
threshold predicting VE responsiveness in our study. A
recent meta-analysis which included 29 studies examined
the performance of dynamic indices in the assessment of
volume responsiveness.1 In five of eight studies examining
SV measures before VE, SV was reduced in patients who
were found to be responders when compared with nonresponders.23 27 Among the three other studies, two
focused on patients treated with b-blockers15 28 and consequently may modify the relationship between preload and
CO. The last study used CO data derived from combined
TED aortic blood velocity and aortic diameter measurements,29 which has been found to increase the measurement error.30 Other studies included in this meta-analysis
did not stipulate SV values before VE, but did report
reduced CO before VE in patient responders compared with
non-responders.13 31 34 In a study which included mechanically ventilated postoperative cardiac surgery patients
without cardiac dysfunction, the area under the ROC curve
describing the value of CI in predicting responsiveness to
VE was 0.74 (0.07) vs 0.63 (0.07) and 0.58 (0.08) for PAOP
and CVP, respectively, and 0.98 (0.01) for respiratory-induced
changes in arterial pulse pressure.34 Among the data derived
from TED-based blood flow velocity waveform, cFT has been
proposed as a value of preload index.5 8 29 However, this parameter is also influenced by afterload and, therefore, may
lack specificity for predicting responsiveness to VE, which
seems to be the case in our study.8 35 PV and MA, two
indices derived from the shape of aortic blood velocity waveform and related to myocardial contractility, increased
significantly in the R group but not in the NR group
(Table 3). However, these indices are also known to be influenced by changes in preload and afterload changes.36 Alternatively, this may reflect known complex interactions
between cardiac loading conditions and contractility.
In daily practice, the decision of VE is based on multiple
factors including quantitative clinical endpoints, anaesthetic
depth, and the dynamic clinical and surgical context. There
were no predefined arterial pressure values used to prompt
VE in our study. However, MAP in both the R and NR groups
were low before VE (mean32 mm Hg), knowing that acceptable MAP can usually be grossly defined as equivalent to the
number of weeks of gestational age (i.e. 37 and 36 weeks in R
and NR, respectively).37 This observation supports the preoccupation with MAP values and its significant role in anaesthetic management.38 Systolic arterial hypotension
associated with a normal CI and iSV in the NR group [3.7
(0.8) litre min21 m22 and 29.2 (6.5) ml m22, respectively]
suggests a state of excessive arterial vasodilatation.39 The
hypotensive effect of sevoflurane is well described and is
BJA
Conclusion
Monitoring CO by TED in neonates and young infants without
cardiac dysfunction undergoing volatile anaesthesia can be
used to predict responsiveness to VE with a sensitivity of
92% and a specificity of 83%. In this study, TED showed
that VE based on standard clinical monitoring data may be
inappropriate in as much as 50% of patients in this age
group. Furthermore, the lack of responsiveness to VE was
not detected in over 25% of patients, possibly leading to
undue fluid loading. TED is a minimally invasive and quickly
learned monitoring technique that is useful to guide intraoperative VE and could be shown in the future to improve
postoperative outcomes in neonates and young infants.
Declaration of interest
None declared.
Funding
Departmental sources. Department of Anaesthesia and Critical Care Medicine, Montpellier University Hospital, France.
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