The increase in cardiac output induced by a decrease in positive end-expiratory pressure reliably detects volume responsiveness: the PEEP-test study
Christopher Lai,
Rui Shi,
Alexandra Beurton,
Francesca Moretto,
Soufia Ayed,
Nicolas Fage,
Francesco Gavelli,
Arthur Pavot,
Martin Dres,
Jean-Louis Teboul,
Xavier Monnet
Affiliations
Christopher Lai
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Rui Shi
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Alexandra Beurton
Service de Médecine intensive - Réanimation, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière
Francesca Moretto
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Soufia Ayed
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Nicolas Fage
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Francesco Gavelli
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Arthur Pavot
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Martin Dres
Service de Médecine intensive - Réanimation, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière
Jean-Louis Teboul
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Xavier Monnet
AP-HP, Service de médecine intensive-réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay
Abstract Background In patients on mechanical ventilation, positive end-expiratory pressure (PEEP) can decrease cardiac output through a decrease in cardiac preload and/or an increase in right ventricular afterload. Increase in central blood volume by fluid administration or passive leg raising (PLR) may reverse these phenomena through an increase in cardiac preload and/or a reopening of closed lung microvessels. We hypothesized that a transient decrease in PEEP (PEEP-test) may be used as a test to detect volume responsiveness. Methods Mechanically ventilated patients with PEEP ≥ 10 cmH2O (“high level”) and without spontaneous breathing were prospectively included. Volume responsiveness was assessed by a positive PLR-test, defined as an increase in pulse-contour-derived cardiac index (CI) during PLR ≥ 10%. The PEEP-test consisted in reducing PEEP from the high level to 5 cmH2O for one minute. Pulse-contour-derived CI (PiCCO2) was monitored during PLR and the PEEP-test. Results We enrolled 64 patients among whom 31 were volume responsive. The median increase in CI during PLR was 14% (11–16%). The median PEEP at baseline was 12 (10–15) cmH2O and the PEEP-test resulted in a median decrease in PEEP of 7 (5–10) cmH2O, without difference between volume responsive and unresponsive patients. Among volume responsive patients, the PEEP-test induced a significant increase in CI of 16% (12–20%) (from 2.4 ± 0.7 to 2.9 ± 0.9 L/min/m2, p 8.6% during the PEEP-test with a sensitivity of 96.8% (95% confidence interval (95%CI): 83.3–99.9%) and a specificity of 84.9% (95%CI 68.1–94.9%). The area under the receiver operating characteristic curve of the PEEP-test for detecting volume responsiveness was 0.94 (95%CI 0.85–0.98) (p 8.6% during a PEEP-test, which consists in reducing PEEP to 5 cmH2O, reliably detects volume responsiveness in mechanically ventilated patients with a PEEP ≥ 10 cmH2O. Trial registration ClinicalTrial.gov (NCT 04,023,786). Registered July 18, 2019. Ethics Committee approval CPP Est III (N° 2018-A01599-46).
