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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.





ID 3356
Moeder ID 3084
Volgorde Dijkstra, J.
Naam DijkstraJ
Publiceren yes
OAI-naam Student_thesis
Path root/geneeskunde/2016/DijkstraJ/
Gemaakt op: 2017-03-08 12:16:46
Gemodificeerd op: 2017-03-08 12:17:31
Digitaal ID 58bff62e18e3f
Afstudeerrichting opleiding/afstudeerrichting 1
Studierichting Studierichting 1
Titel Non-invasieve Cardiac Output Monitoring (NICOM®) als voorspeller van de respons op volumetherapie bij septische patiënten
Ruilverkeer mogelijk no
Printen in opdracht no
Aantal pagina's 52
Publicatiejaar 2016
Taal nl
Engelse samenvatting 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.
Nederlandse samenvatting Achtergrond: Sepsis vormt een groot gezondheidsprobleem met een hoge mortaliteit. De initiële behandeling bij sepsis bestaat onder andere uit het toedienen van intraveneus vocht waardoor de sepsis gerelateerde morbiditeit en mortaliteit significant afnemen. Toch blijkt slechts de helft van de patiënten een respons op volumetherapie te laten zien. Wanneer volumetherapie niet leidt tot een stijging van de cardiac output (CO) of slagvolume (SV) heeft deze behandeling geen zin en kan de overmatige volumetherapie leiden tot een toename van complicaties en mortaliteit. Hieruit blijkt dat voor een optimale behandeling van patiënten met sepsis de toediening van intraveneus vocht nauwkeurig getitreerd moet worden om de risico’s van onder- en overvulling te minimaliseren. Een methode voor de non-invasieve, continue monitoring van de CO is de NICOM® welke gebruik maakt van bioreactantie.
Doel: Het doel van deze studie is om te onderzoeken of de CO gemeten door de NICOM in combinatie met verscheidene standaard gemeten klinische parameters de respons op volumetherapie kan voorspellen bij septische patiënten. Klinische parameters alleen blijken onvoldoende betrouwbaar voor het voorspellen van de respons op volumetherapie.
Methode: Gedurende 14 weken werden alle patiënten aangemeld op de centrale spoedopvang (CSO) met verdenking op infectie gescreend. Bij inclusie werd na 10 minuten (T0) gestart met het meten van de CO en het SV via de NICOM®. Daarnaast werden verscheidene metabole en vitale parameters genoteerd. De metingen werden herhaald na elke halve liter volumetherapie, tot aan ontslag. Men spreekt van een respons op volumetherapie wanneer het SV na vochtinfusie met minimaal 10% toenam.
Resultaten: In totaal werden 38 septische patiënten geïncludeerd welke tevens volumetherapie ontvingen, van hen was na infusie van 500 ml NaCl 66% responder. Na infusie van 1000 ml NaCl was 81% van de studiepopulatie responder. De baselinekarakteristieken inclusief de door NICOM® gemeten parameters en de klinische shockscore verschilden niet tussen responders en non-responders en waren niet in staat de respons op volumetherapie te voorspellen in de totale populatie. De klinische shockscore was wel significant hoger bij responders ten opzichte van non-responders in de subgroep met ernstige sepsis. Wanneer na 1000 ml volume-infusie de indeling responder/non-responder gemaakt wordt blijkt geen van de non-responders alsnog te responderen na infusie van 1500 ml NaCl (NPV=100%, 95% CI=19,7-100).
Conclusie: Hoewel de NICOM® de respons op volumetherapie kan monitoren, is het voorspellen van de respons aan de hand van patiëntkarakteristieken bij binnenkomst lastig. Bij een deel van de septische patiënten blijkt 500 ml volumetherapie onvoldoende om te leiden tot een toename in slagvolume. Het indelen in responders en non-responders na 1000 ml volume-infusie heeft de voorkeur. Wanneer patiënten op dat moment geen respons hebben laten zien lijkt het continueren van vochtinfusie niet zinvol. De NICOM® kan hierbij van toegevoegde waarde zijn in het sturen van volumetherapie, maar groter opgezet vervolgonderzoek is nodig om dit te bevestigen.
Onderwijsinstelling Medical Sciences
Type embargo abstract openbaar, scriptie op aanvraag
Auteur(s) Dijkstra, J. (Jildou)
UMCG begeleider(s) Begeleider:; Olgers, T.J. Internist-acuut geneeskundige; Locatie: Centrale Spoedopvang, UMCG
Auteur(s) Dijkstra, J. (Jildou)
UMCG begeleider(s) Begeleider:; Olgers, T.J. Internist-acuut geneeskundige; Locatie: Centrale Spoedopvang, UMCG


 
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