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Non-invasieve Cardiac Output Monitoring (NICOM®) als voorspeller van de respons op volumetherapie bij septische patiënten

(2016) Dijkstra, J. (Jildou)

Background: Sepsis is a major public health problem with a high level of mortality. The initial treatment of sepsis is based on the admission of intravenous fluid which significantly decreases the sepsis-related morbidity and mortality. However, only 50% of the patients are volume responders. When fluid therapy does not increase cardiac output (CO) or stroke volume (SV) it is useless and this overuse could be harmful, resulting in an increase of complications and mortality. This shows the importance of accurate admission of intravenous fluids to enhance the treatment of septic patients and minimalize the risks of excessive – or insufficient volume therapy. A method for noninvasive continue CO measurement is NICOM®, which uses bioreactance.
Objective: The purpose of this study is to evaluate the ability of the CO measured by NICOM® in combination with several standard measured clinical parameters to predict fluid responsiveness in septic patients. The use of clinical parameters appears to be insufficiently reliable for predicting fluid responsiveness.
Methods: During a period of 14 weeks, all patients admitted to the emergency department with suspected infection will be screened. If included, the first NICOM® measurements will be recorded 10 minutes after arrival (T0). Simultaneously, several hemodynamic – and metabolic parameters are registered. This process repeats for each admission of 500 ml fluids until discharge. A response to fluid therapy is defined as an increase in SV of at least 10% after fluid admission.
Results: In total, 38 septic patients who received fluid therapy were included, of which 66% were fluid responsive after infusion of 500 ml NaCl. After infusion of 1000 ml NaCl 81% of the study population were responder. Baseline characteristics including parameters measured by NICOM® and the clinical shockscore showed no differences between responders and non-responders and were not reliable for predicting fluid responsiveness in the total study population. However, the clinical shockscore was significantly higher in responders compared to non-responders in the severe septic patients. If patients were divided into responders/non-responders after 1000 ml fluid infusion, none of the non-responders showed a response after infusion of 1500 ml NaCl (NPV=100%, 95% CI=19,7-100).
Conclusion: Although NICOM® is able to monitor fluid responsiveness, it seems difficult to predict the response based on patient characteristics on baseline. For certain patients, infusion of 500 ml fluid therapy does not seem sufficient to induce an increase in SV. For this reason, the classification into responders and non-responders should be made after infusion of 1000 ml fluid therapy. If patients have not responded to fluid therapy at that time, the continuation of fluid infusion seems useless. The use of NICOM® could be beneficial in guiding fluid therapy, nevertheless further research is required to confirm this.





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