Efectos del reto de líquidos sobre el acople ventrículo arterial en un biomodelo porcino de choque endotóxico

The effect of fluid challenge on ventriculo-arterial coupling in an endotoxic shock swine bio-model

Introducción: el reto de líquidos es una prueba que consiste en administrarlos y medir la respuesta hemodinámica mediante el cambio del gasto cardíaco (GC), aunque solo medir el GC resulta insuficiente. El acople ventrículo-arterial (AVA) (elastancia arterial efectiva/ elastancia telesistólica: Eae/Ets) aparece como una variable que evalúa el estado cardiocirculatorio en forma integral. Objetivo: evaluar el AVA en un biomodelo de choque endotóxico y durante retos de líquidos. Materiales y métodos: biomodelo de choque endotóxico (9 porcinos). Se midieron variables hemodinámicas cada hora desde un tiempo 0 (T0) hasta T6. Se realizaron 5 retos de líquidos entre T0 y T4. El tiempo de hipotensión se denominó TH0. Se calcularon diferencias de medianas de variables entre T0-T4. Se clasificaron los retos en dos grupos según el delta del AVA (AVA posreto-AVA prerreto), en ΔAVA≤0 o >0, se midieron variables antes y después de cada reto.  Se determinó la relación lactato/piruvato (L/P) en T0, T3 y T6, se establecieron correlaciones entre la diferencia LP T6-T0 y de variables hemodinámicas. Resultados: el AVA aumentó (1.58 a 2,02, p=0.042) por incremento en la Eae (1.74 a 2,55; p=0.017). El grupo ΔAVA≤0 elevó el GC (4.32 a 5,46, p=0.032) y el poder cardíaco (PC) (0.61 a 0,77, p=0,028). El Δ L/P se correlacionó con el Δ del índice de choque sistólico y diastólico (r=0.73), pero no con el del AVA. Conclusión: durante el choque endotóxico el AVA aumentó de manera significativa. Durante el reto de líquidos el grupo Δ AVA≤0, elevó el GC y PC. El Δ L/P no se correlacionó con variables del AVA.

1. Kattan E, Castro R, Vera M, Hernández G. Optimal target in septic shock resuscitation. Ann Transl Med. 2020;8(12):789. https://doi.org/10.21037/atm-20-1120.
2. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. https://doi.org/10.1007/s00134-021-06506-y.
3. Bakker J, Kattan E, Annane D, Castro R, Cecconi M, De Backer D, et al. Current practice and evolving concepts in septic shock resuscitation. Intensive Care Med. 2022;48(2):148-163. https://doi.org/10.1007/s00134-021-06595-9.
4. Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care. 2018;8(1):66. https://doi.org/10.1186/s13613-018-0402-x.
5. Vincent JL, Cecconi M, De Backer D. The fluid challenge. Crit Care. 2020;24(1):703. https://doi.org/10.1186/s13054-020-03443-y.
6. Monnet X, Julien F, Ait-Hamou N, Lequoy M, Gosset C, Jozwiak M, et al. Lactate and venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio, but not central venous oxygen saturation, predict increase in oxygen consumption in fluid responders. Crit Care Med. 2013;41(6):1412-1420. https://doi.org/10.1097/CCM.0b013e318275cece.
7. Monnet X, Teboul JL. My patient has received fluid. How to assess its efficacy and side effects?. Ann Intensive Care. 2018;8(1):54. https://doi.org/10.1186/s13613-018-0400-z.
8. Vincent JL, Singer M, Einav S, Moreno R, Wendon J, Teboul JL, et al. Equilibrating SSC guidelines with individualized care. Crit Care. 2021;25(1):397. https://doi.org/10.1186/s13054-021-03813-0.
9. Monge García MI, Santos A. Understanding ventriculo-arterial coupling. Ann Transl Med. 2020;8(12):795. https://doi.org/10.21037/atm.2020.04.10.
10. Pinsky MR, Guarracino F. How to assess ventriculoarterial coupling in sepsis. Curr Opin Crit Care. 2020;26(3):313-318. https://doi.org/10.1097/MCC.0000000000000721.
11. Guarracino F, Bertini P, Pinsky MR. Cardiovascular determinants of resuscitation from sepsis and septic shock. Crit Care. 2019;23(1):118. https://doi.org/10.1186/s13054-019-2414-9.
12. Li S, Wan X, Laudanski K, He P, Yang L. Left-Sided Ventricular-arterial Coupling and Volume Responsiveness in Septic Shock Patients. Shock. 2019;52(6):577-582. https://doi.org/10.1097/SHK.0000000000001327.
13. Zhou X, Pan J, Wang Y, Wang H, Xu Z, Zhuo W. Left ventricular-arterial coupling as a predictor of stroke volume response to norepinephrine in septic shock - a prospective cohort study. BMC Anesthesiol. 2021;21(1):56. https://doi.org/10.1186/s12871-021-01276-y.
14. Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ, Ospina Tascon GA, Monge García MI, Ruiz Narváez GA, Cruz Martínez LE. Changes of operative performance of pulse pressure variation as a predictor of fluid responsiveness in endotoxin shock. Sci Rep. 2022;12(1):2590. https://doi.org/10.1038/s41598-022-06488-x.
15. Hatib F, Jansen JR, Pinsky MR. Peripheral vascular decoupling in porcine endotoxic shock. J Appl Physiol (1985). 2011;111(3):853-860. https://doi.org/10.1152/japplphysiol.00066.2011.
16. Sunagawa K, Maughan WL, Burkhoff D, Sagawa K. Left ventricular interaction with arterial load studied in isolated canine ventricle. Am J Physiol 1983;245:H773-780. https://doi.org/10.1152/ajpheart.1983.245.5.H773.
17. Kelly RP, Ting CT, Yang TM, Liu CP, Maughan WL, et al. Effective arterial elastance as index of arterial vascular load in humans. Circulation. 1992;86(2):513-521. https://doi.org/10.1161/01.cir.86.2.513.
18. Chen CH, Fetics B, Nevo E, Rochitte CE, Chiou KR, et al. Noninvasive single-beat determination of left ventricular end-systolic elastance in humans. J Am Coll Cardiol 2001;38(7):2028-2034. https://doi.org/10.1016/s0735-1097(01)01651-5.
19. Monge García MI, Santos A, Diez Del Corral B, Guijo González P, et al. Noradrenaline modifies arterial reflection phenomena and left ventricular efficiency in septic shock patients: A prospective observational study. J Crit Care 2018;47:280-286. https://doi.org/10.1016/j.jcrc.2018.07.027.
20. Ikonomidis I, Aboyans V, Blacher J, Brodmann M, Brutsaert DL, Chirinos JA, De Carlo M, Delgado V, Lancellotti P, Lekakis J, Mohty D, Nihoyannopoulos P, Parissis J, Rizzoni D, Ruschitzka F, Seferovic P, Stabile E, Tousoulis D, Vinereanu D, Vlachopoulos C, Vlastos D, Xaplanteris P, Zimlichman R, Metra M. The role of ventricular-arterial coupling in cardiac disease and heart failure: assessment, clinical implications and therapeutic interventions. A consensus document of the European Society of Cardiology Working Group on Aorta & Peripheral Vascular Diseases, European Association of Cardiovascular Imaging, and Heart Failure Association. Eur J Heart Fail. 2019;21(4):402-424. https://doi.org/10.1002/ejhf.1436.
21. Huette P, Abou-Arab O, Longrois D, Guinot PG. Fluid expansion improve ventriculo-arterial coupling in preload-dependent patients: a prospective observational study. BMC Anesthesiol. 2020;20(1):171. https://doi.org/10.1186/s12871-020-01087-7.
22. Guarracino F, Ferro B, Morelli A, Bertini P, et al. Ventriculoarterial decoupling in human septic shock. Crit Care. 2014;18(2):R80. https://doi.org/10.1186/cc13842.
23. Claude M, Medam S, Antonini F, Alingrin J, Haddam M, Hammad E, Meyssignac B, Vigne C, Zieleskiewicz L, Leone M. Norepinephrine: Not too much, too long. Shock. 2015;44(4):305-309. https://doi.org/10.1097/SHK.0000000000000426.
24. Roberts RJ, Miano TA, Hammond DA, Patel GP, Chen JT, Phillips KM, Lopez N, Kashani K, Qadir N, Cairns CB, Mathews K, Park P, Khan A, Gilmore JF, Brown ART, Tsuei B, Handzel M, Chang AL, Duggal A, Lanspa M, Herbert JT, Martinez A, Tonna J, et al. Evaluation of Vasopressor Exposure and Mortality in Patients With Septic Shock. Crit Care Med. 2020;48(10):1445-1453. https://doi.org/10.1097/CCM.0000000000004476.
25. Chowdhury SM, Butts RJ, Taylor CL, Bandisode VM, Chessa KS, Hlavacek AM, Shirali GS, Baker GH. Validation of Noninvasive Measures of Left Ventricular Mechanics in Children: A Simultaneous Echocardiographic and Conductance Catheterization Study. J Am Soc Echocardiogr. 2016;29(7):640-647. https://doi.org/10.1016/j.echo.2016.02.016.