The role of clinical examination, chest X-ray and central venous pressure in volume assessment in critically ill patients: a comparison with PiCCO-derived data
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Abstract
Background
Assessment of preload and goal-directed resuscitation are crucial parts of ICU therapy.
To assess preload, clinical parameters such as filling of the jugular veins, edema
and pleural effusions as well as X-ray are used. In addition, haemodynamic parameters
such as the central venous pressure (CVP), pulmonary arterial wedge pressure and PiCCO-derived
global end-diastolic volume index (GEDVI) are determined. The GEDVI has been shown
to be superior to pressure-based parameters with regard to volume responsiveness in
several studies. However, PiCCO data are not available in all patients, and frequently
clinical examination, CVP and chest X-ray are the first tools for preload assessment.
It was the aim of our study to evaluate clinical assessment, X-ray and CVP with regard
to the GEDVI and extravascular lung water index (ELWI).
Methods
In 86 patients of an internal ICU, clinical examination was independently determined
by a physician and investigator not working in the ICU. Subsequently, chest X-ray
(analysed by an experienced radiologist), CVP and PiCCO (Pulsion Company, Munich,
Germany) measurements were performed and these data were correlated to clinical findings.
Results
Patients (n = 86; 34 females, 52 males) included 25 patients with cirrhosis, 18 patients
with pancreatitis, 19 patients with sepsis; age 63.0 ± 15.5 years; APACHE II score
23.3 ± 8.4. Leg edema significantly correlated to CVP (r = 0.247; P = 0.038) and (negatively)
to GEDVI (r = -0.258; P = 0.032). CVP and GEDVI were not associated: r = 0.035; P
= 0.784. The ELWI significantly correlated to the degree of rales (r = 0.258; P =
0.016) and GEDVI (r = 0.557; P < 0.001). The ELWI and CVP did not correlate (r = 0.030;
P = 0.785). Global clinical preload assessment (scale 1–10) was not predictive for
GEDVI. Radiological assessment significantly overestimated the GEDVI (901.41 ± 139.76
vs 782.56 ± 183.80 ml/m2; P < 0.001) and underestimated the ELWI (7.22 ± 1.38 vs 9.77
± 4.51 ml/kg; P < 0.001).
Conclusion
(1) Leg edema and increased CVP do not exclude preload deficiency determined by the
GEDVI, which was overestimated by X-ray. (2) CVP and leg edema are poor predictors
of the ELWI, which was significantly associated with audible rales but underestimated
by X-ray.