Comparação da acurácia diagnóstica de índices dinâmicos e estáticos de pré-carga para predição da fluido-responsividade em cães anestesiados com isoflurano, sob ventilação mecânica
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Data
2020-02-21
Autores
Celeita-Rodríguez, Nathalia
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Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Objetivo: Comparar a acurácia diagnóstica da variação da pressão de pulso (VPP), variação do volume sistólico mensurada através do análise de contorno de pulso (VVSACP), índice de variabilidade pletismográfica (IVP), pressão venosa central (PVC) e índice do volume diastólico final global mensurado pela técnica de termodiluição transpulmonar (GEDVITDTP) para predizer a fluido-responsividade em cães. Animais: Quarenta cadelas saudáveis (13,8–26,8 kg) submetidas a ovário-salpingo-histerectomia. Métodos: A anestesia foi mantida com isoflurano sob ventilação mecânica com volume controlado (volume corrente 12 mL/kg, pausa inspiratória 40%, relação inspiração/expiração: 1:1,5). O débito cardíaco e o volume sistólico foram obtidos pela técnica de termodiluição transpulmonar através de um cateter inserido na artéria femoral. A fluido-responsividade (FR) foi avaliada por uma prova de carga (solução de Ringer com lactato, 20 mL/kg durante 15 minutos), administrada uma vez (n = 21) ou duas vezes (n = 18) antes da cirurgia. Respondedores a volume foram definidos como indivíduos onde o VS mensurado pela técnica de termodiluição transpulmonar, elevou-se acima de 15% após a última prova de carga. Resultados: Dos 39 animais incluídos no estudo, 21 cães foram classificados como respondedores e 18 não respondedores ao último desafio volêmico. As áreas sob as curvas de características de operação do receptor (AUROC) foram de 0,976, 0,906, 0,868 e 0,821 para VPP, IVP, PVC e VVSACP, respectivamente (p <0,0001 versus AUROC = 0,5). O GEDVITDTP não apresentou valor preditivo (AUROC = 0,660, p = 0,078). Os melhores valores de corte para discriminar indivíduos respondedores e não respondedores e respectivas zonas de incerteza diagnóstica (“gray zone”) foram: VPP >16% (15–16%), IVP >11% (10–13%), VVSACP >10% (9–18%) e PVC ≤1 mmHg (0–3mmHg). A percentagem de animais dentro das zonas inconclusivas foi de 13% (VPP), 28% (IVP), 51% (VVSACP) e 67% (PVC). Conclusões e relevância clínica: A VPP apresentou a melhor acurácia diagnóstica para predição da fluido-respondividade (resultados conclusivos em quase 90% da população) quando comparado com os demais índices de pré-carga em cães saudáveis. Caso a pressão arterial direta não esteja disponível, o IVP pode ser empregado para predizer FR com acurácia diagnóstica razoável (resultados conclusivos em aproximadamente 70% da população). Os valores de VPP e IVP acima do limite superior da “gray zone” (>16% e >13%, respectivamente) permitem uma predição confiável à expansão de volume em cães.
Objective: To compare the diagnostic accuracy of pulse pressure variation (PPV), stroke volume variation from pulse contour analysis (SVVPCA), plethysmographic variability index (PVI), central venous pressure (CVP) and global end-diastolic volume index measured by transpulmonary thermodilution (GEDVITPTD) to predict fluid responsiveness (FR) in dogs. Animals: A group of 40 bitches (13.8–26.8 kg) undergoing ovariohysterectomy. Methods: Anesthesia was maintained with isoflurane under volume-controlled ventilation (tidal volume 12 mL/kg; inspiratory pause during 40% of inspiratory time; inspiration: expiration ratio 1:1.5). Transpulmonary thermodilution cardiac output was recorded through a femoral artery catheter. FR was evaluated by a fluid challenge (lactated Ringer's, 20 mL kg over 15 minutes) administered once (n = 21) or twice (n = 18) before surgery. Individuals were responders if stroke volume index measured by transpulmonary thermodilution increased >15% after the last fluid challenge. Results: Of the 39 animals studied, 21 were responders and 18 were nonresponders. Area under the receiver operating characteristics curve (AUROC) was 0.976, 0.906, 0.868 and 0.821 for PPV, PVI, CVP and SVVPCA, respectively (p < 0.0001 from AUROC = 0.5). GEDVITPTD failed to predict FR (AUROC: 0.660, p = 0.078). Best cut-off thresholds discriminating responders and nonresponders, with respective zones of diagnostic uncertainty (gray zones) were: PPV >16% (15–16%), PVI >11% (10–13%), SVVPCA >10% (9–18%) and CVP 1 mmHg (0–3 mmHg). Percentage of animals within gray zone limits was 13% (PPV), 28% (PVI), 51% (SVVPCA) and 67% (CVP). Conclusions and clinical relevance: PPV has better diagnostic accuracy to predict FR (conclusive results in nearly 90% of population) than other preload indexes in healthy dogs. When invasive blood pressure is unavailable, PVI will predict FR with reasonable accuracy (conclusive results in approximately 70% of the population). PPV and PVI values above gray zone limits (>16% and >13%, respectively) can reliably predict responders to volume expansion in dogs.
Objective: To compare the diagnostic accuracy of pulse pressure variation (PPV), stroke volume variation from pulse contour analysis (SVVPCA), plethysmographic variability index (PVI), central venous pressure (CVP) and global end-diastolic volume index measured by transpulmonary thermodilution (GEDVITPTD) to predict fluid responsiveness (FR) in dogs. Animals: A group of 40 bitches (13.8–26.8 kg) undergoing ovariohysterectomy. Methods: Anesthesia was maintained with isoflurane under volume-controlled ventilation (tidal volume 12 mL/kg; inspiratory pause during 40% of inspiratory time; inspiration: expiration ratio 1:1.5). Transpulmonary thermodilution cardiac output was recorded through a femoral artery catheter. FR was evaluated by a fluid challenge (lactated Ringer's, 20 mL kg over 15 minutes) administered once (n = 21) or twice (n = 18) before surgery. Individuals were responders if stroke volume index measured by transpulmonary thermodilution increased >15% after the last fluid challenge. Results: Of the 39 animals studied, 21 were responders and 18 were nonresponders. Area under the receiver operating characteristics curve (AUROC) was 0.976, 0.906, 0.868 and 0.821 for PPV, PVI, CVP and SVVPCA, respectively (p < 0.0001 from AUROC = 0.5). GEDVITPTD failed to predict FR (AUROC: 0.660, p = 0.078). Best cut-off thresholds discriminating responders and nonresponders, with respective zones of diagnostic uncertainty (gray zones) were: PPV >16% (15–16%), PVI >11% (10–13%), SVVPCA >10% (9–18%) and CVP 1 mmHg (0–3 mmHg). Percentage of animals within gray zone limits was 13% (PPV), 28% (PVI), 51% (SVVPCA) and 67% (CVP). Conclusions and clinical relevance: PPV has better diagnostic accuracy to predict FR (conclusive results in nearly 90% of population) than other preload indexes in healthy dogs. When invasive blood pressure is unavailable, PVI will predict FR with reasonable accuracy (conclusive results in approximately 70% of the population). PPV and PVI values above gray zone limits (>16% and >13%, respectively) can reliably predict responders to volume expansion in dogs.
Descrição
Palavras-chave
Análise da curva ROC, Expansão volêmica, Índices de pré-carga, Fluidoterapia guiada por metas, Goal-directed fluid therapy, Preload indexes, ROC curve analysis, Volume expansion