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LETTER TO THE EDITOR

Differentiating "Volumetric Preload Monitoring" and Assessing "Fluid Responsiveness"

Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, dreuter{at}uke.uni-hamburg.de

To the Editor:

With great interest we read the concise review article by Grocott et al. (1). However, the authors did not differentiate between assessing "static" preload parameters considered to be indicative for cardiac filling volumes and assessing "fluid responsiveness," the latter predicting the hemodynamic response to fluid loading (2). Measuring "static preload" allows quantifying a patient’s intravascular volume status and its changes over time. Numerous studies in different groups of patients demonstrated that volumetric parameters, such as the left ventricular end-diastolic area by transesophageal echocardiography (3) or the global end-diastolic volume by transcardiopulmonary thermodilution (4), are much more useful to answer that clinical question than measuring cardiac filling pressures. The more important question to answer in a hemodynamically instable patient is: will this patient benefit from fluid loading by an increase in cardiac output? Specifically, in patients with compromised cardiac function, this question has to be answered before fluid loading to prevent potentially deleterious fluid overload. This "prediction of fluid responsiveness" is the ratio behind the so-called "functional preload parameters," such as the systolic pressure variation and stroke volume variation. First systolic pressure variation, and later stroke volume variation, as continuous "on-line parameters" have been shown to predict fluid responsiveness in a wide range of surgical and septic patients (5-10). Thus, those parameters seem to represent useful clinical tools for more rational perioperative fluid management in mechanically ventilated patients.

References

1. Grocott MPW, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg 2005;100:1093-106.[Abstract/Free Full Text]
2. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of evidence: Chest 2002;121:2000-8.[Abstract/Free Full Text]
3. Cheung AT, Savino JS, Weiss SJ, et al. Echocardiographic and hemodynamic indexes of left ventricular preload in patients with normal and abnormal ventricular function. Anesthesiology 1994;81:376-87.[Web of Science][Medline]
4. Della Rocca G, Costa MG, Coccia C, et al. Preload index: pulmonary artery occlusion pressure versus intrathoracic blood volume monitoring during lung transplantation. Anesth Analg 2002;95:835-43.[Abstract/Free Full Text]
5. Coriat P, Vrillon M, Perel A, et al. Correlation of systolic pressure variations and echocardiographic estimates of end-diastolic left ventricular size in patients after aortic surgery. Anesth Analg 1994;78:46-53.[Abstract/Free Full Text]
6. Berkenstadt H, Margalit N, Hadani M, et al. Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg 2001;92:984-9.[Abstract/Free Full Text]
7. Reuter DA, Felbinger TW, Kilger E, et al. Optimising fluid therapy in mechanically ventilated patients after cardiac surgery by on-line monitoring of left ventricular stroke volume variations - a comparison to aortic systolic pressure variations. Br J Anaesth 2002;88:124-6.[Abstract/Free Full Text]
8. Reuter DA, Kirchner A, Felbinger TW, et al. Usefulness of left ventricular stroke volume variations to assess fluid responsiveness in patients with reduced left ventricular function. Crit Care Med 2003;31:1399-404.[Web of Science][Medline]
9. Tavernier B, Makhotine O, Lebuffe G, et al. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology 1998;89:1313-21.[Web of Science][Medline]
10. Marx G, Cope T, McCrossan L, et al. Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis. Eur J Anaesth 2004;21:132-8.[Web of Science][Medline]

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