Online Supplement. Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography

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1 Online Supplement Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography A Comparative Study Philippe Vignon, MD, PhD; Emmanuelle Begot, MD; Arnaud Mari, MD; Stein Silva, MD; Loïc Chimot, MD; Pierre Delour, MD; Frédéric Vargas, MD, PhD; Bruno Filloux, MD; David Vandroux, MD; Julien Jabot, MD; Bruno François, MD; Nicolas Pichon, MD; Marc Clavel, MD; Bruno Levy, MD, PhD; Michel Slama, MD, PhD; and Béatrice Riu-Poulenc, MD CHEST 2018; 153(1): AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: /j.chest

2 e-appendix 1. Hemodynamic assessment For each hemodynamic assessment with transpulmonary thermodilution (TPT), aliquots of 15 ml of iced saline were injected as a bolus through a dedicated lumen of the internal jugular catheter for calibration and to obtain at least three measurements of cardiac index with less than 10% variability 1. Derived hemodynamic indices included stroke index, global end-diastolic volume index, cardiac function index, stroke volume variations, and extravascular lung water 2. The following critical care echocardiographic (CCE) parameters were measured in triplicate and averaged: respiratory variations of superior vena cava diameter 3, of inferior vena cava diameter 4, and of left ventricular outflow tract maximal Doppler velocity 5, left ventricular ejection fraction using the monoplane Simpson s rule 6, left ventricular outflow tract velocity-time integral used as a surrogate of stroke volume 7, right and left ventricular end-diastolic area ratio in the long axis view of the heart 8, mitral Doppler E and A wave maximal velocity, and lateral mitral annulus tissue Doppler E maximal velocity 9. When a passive leg raise was performed, cardiac index (TPT) and left ventricular outflow tract velocity-time integral (CCE) were measured when they reached their highest value, usually within 60 to 90 sec 10. Diagnostic algorithm and proposed therapeutic changes Respiratory variations of superior vena cava, inferior vena cava and LV outflow tract maximal Doppler velocity 36% 3, 18% 4, and 12% 5 indicated fluid responsiveness, respectively. An increase of TPT-derived cardiac index 10% 11 and of outflow tract Doppler velocity-time integral 10% 12 during passive leg raise had similar significance. Cardiac dysfunction was defined as a cardiac function index 4.1 L/min using TPT 2 and a left ventricular (LV) ejection fraction < 50% 6. Acute cor pulmonale was echocardiographically defined as the conjunction of a dilated right ventricular (RV) cavity (end-diastolic RV and LV areas measured in the long axis view of the heart greater than 0.6) and a paradoxical septal motion in the short-axis view of the heart 8. Additional fluid resuscitation was proposed in the presence of signs of fluid responsiveness, inotropes were suggested in the presence of acute heart failure, inotropes (increase of RV contractility) or vasopressors (increase of perfusion pressure of right coronary artery) associated with changes in ventilator settings (protective ventilation to decrease RV afterloading) 13, prone positioning 14 (to decrease hypercapnia which is associated with increased pulmonary artery pressure, and to reduce pulmonary vascular resistance as a result of improved functional residual capacity due to alveolar recruitment in dorsal dependent regions) and inhaled NO (to reduce RV loading conditions including pulmonary vascular resistance, hence RV afterload) 15 were

3 recommended in the presence of acute cor pulmonale, and increasing doses of vasopressors were proposed in the presence of symptomatic vasoplegia. In the absence of hypotension, fluid responsiveness, acute heart failure, or any other identifiable source of circulatory failure under vasopressor support, the initial therapeutic management was considered as adequate and no therapeutic change or tapering ongoing catecholamines administration was proposed (Figure 1). References 1. Monnet X, Persichini R, Ktari M, Jozwiak M, Richard C, Teboul JL. Precision of the transpulmonary thermodilution measurements. Crit Care. 2011;15(4):R Sakka SG, Reuter DA, Perel A. The transpulmonary thermodilution technique. J Clin Monit Comput. 2012;26(5): Vieillard-Baron A, Chergui K, Rabiller A, et al. Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med. 2004;30(9): Barbier C, Loubières Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med.javascript:AL_get(this, 'jour', 'Intensive Care Med.'); 2004;30(9): Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119(3): Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1): Zoghbi WA, Quinones MA. Determination of cardiac output by Doppler echocardiography: a critical appraisal. Herz. 1986;11(5): Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest. 1997;111(11): Vignon P, Allot V, Lesage J, et al. Diagnosis of left ventricular diastolic dysfunction in the setting of acute changes in loading conditions Crit Care. 2007;11(2):R Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34(5): Bentzer P, Griesdale DE, Boyd J, McLean K, Sirounis D, Ayas NT. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA 2016;316(12): Vignon P, Repessé X, Bégot E, et al. Comparison of echocardiographic indices used to predict fluid responsiveness in ventilated patients. Am J Respir Crit Care Med. 2017;195(8): Vieillard-Baron A, Price LC, Matthay MA. Acute cor pulmonale in ARDS. Intensive Care Med. 2013;39(10): Vieillard-Baron A, Charron C, Caille V, Belliard G, Page B, Jardin F. Prone positioning unloads the right ventricle in severe ARDS. Chest. 2007;132(5): Fierobe L, Brunet F, Dhainaut JF, Monchi M, Belghith M, Mira JP, Dall ava-santucci J, Dinh-Xuan AT. Effect of inhaled nitric oxide on right ventricular function in adult respiratory distress syndrome. Am J Respir Crit Care Med. 1995;151(5):

4 e-table 1: Hemodynamic parameters measured using transpulmonary thermodilution in patients with septic shock according to the proposed treatment after off-line adjudication by independent experts Transpulmonary thermodilution parameters Study population (n=137) Fluid loading (n=50) Inotropes (n=18) Increasing dose of vasopressors (n=6) No change / tapering catecholamines (n=26) CI (L/min/m²) 3.25± ± ± ± ±1.62 SI (ml/m²) 31±12 27±9 24±7 35±6 42±12 CFI (L/min) 18±6 18±6 14±6 19±1 22±6 GEDVi (ml/m²) 723± ± ± ±94 822±179 SVV (%) 12±7 17±7 11±7 9±5 9±5 EVLWi (ml/kg) 12±5 11±6 12±4 12±4 13±7 Increase of CI induced by PLR (%) 8±10 14±12-9±10 5±5 Abbreviations: CI, cardiac index; SI, stroke index; CFI, cardiac function index; GEDVi, global enddiastolic volume index; SVV, stroke volume variation; EVLW, extravascular lung water. PLR, passive leg raise.

5 e-table 2: Hemodynamic parameters measured using critical care echocardiography in patients with septic shock according to the proposed treatment after off-line adjudication by independent experts Critical care echocardiographic parameters Study population (n=137) Fluid loading (n=50) Inotropes (n=18) Increasing dose of vasopressors (n=6) No change / tapering catecholamines (n=26) LVOT VTI (cm) 15±6 15±6 12±5 16±3 19±5 LVEF (%) 50±17 53±17 28±8 56±17 56±13 ΔVmaxAo (%) 14±9 19±9 9±5 12±5 9±4 ΔSVC (%) 20±16 32±18 11±9 7±6 12±7 ΔIVC (%) 12±13 18±14 8±4 2±1 7±7 RVEDA / LVEDA 0.7± ± ± ± ±0.2 Mitral E/A (cm/s) 1.3± ± ± ± ±0.9 Lateral E (cm/s) 11.7± ± ± ± ±6.6 Increase of LVOT VTI induced by PLR (%) 11±15 18±18-3±4 1±4 Abbreviations: LVOT, left ventricular outflow tract velocity-time integral used as a surrogate of stroke volume; LVEF, left ventricular ejection fraction; ΔVmaxAo, respiratory variations of left ventricular outflow tract maximal Doppler velocity; ΔSVC, superior vena cava collapsibility index; ΔIVC, inferior vena cava distensibility index; RVEDA/LVEDA, right ventricular and left ventricular end-diastolic areas ratio when measured in the long axis view of the heart; E/A, mitral pulse-wave Doppler E and A wave maximal velocity ratio; Lateral E, lateral mitral tissue Doppler E maximal velocity; PLR, passive leg raise