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Prédiction de la réponse à l’expansion volémique : Nouvelles limites, nouvelles méthodes

Abstract : Volume expansion is the first-line treatment of acute circulatory failure in almost all cases. However, its inconsistent effectiveness and side effects encourage to predict its effects before undertaking it. Several tests have been developed to detect preload responsiveness and we have sought to improve some of them and describe their limits.The passive leg raising (PLR) test is based on the transfer of some venous blood from the venous compartment of the splanchnic compartment and the lower limbs toward the thorax. We have shown that, in case of intra-abdominal hypertension, the diagnostic value of the test was lower, with many cases false negatives cases. This limitation of the PLR test is of importance because of the prevalence of intra-abdominal hypertension in critically ill patients.The effects of this test should be evaluated on cardiac output, and several methods have already been described for this evaluation. First, we have shown that measuring the effects of the test on carotid and femoral arterial flows was unreliable, with a very poor correlation between changes in cardiac output and those in these two arterial flows. Second, we have described an original and reliable method for measuring the effects of the test, which consists in measuring the perfusion index (PI), the ratio between the pulsatile and non-pulsatile portions of the pulse oximetry signal. Although a stable signal could not be obtained in all patients, changes in this index during PLR allowed the measurement of its effects and the detection of preload responsiveness. These results open up the possibility of measuring the effects of the test with a non-invasive tool that can be used in all patients in the intensive care unit and the operating room.Finally, we applied the PI measurement to another test of preload responsiveness, the end-expiratory occlusion test. It consists in interrupting mechanical ventilation for a few seconds and observing simultaneous changes in cardiac output. Although the changes are smaller than those induced by PLR, these changes were well tracked by PI changes and reliably detected preload dependence.
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Alexandra Beurton. Prédiction de la réponse à l’expansion volémique : Nouvelles limites, nouvelles méthodes. Cardiologie et système cardiovasculaire. Université Paris Saclay (COmUE), 2019. Français. ⟨NNT : 2019SACLS468⟩. ⟨tel-02461301⟩

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