The Clinical Study About Fluid Management Through Vigileo With Passive Leg Raising Test In ALI/ARDS Patients

Objective: The acute lung injury （ALI）acute respiratory distresssyndrome（ARDS） is due to the severe shock, infection, trauma and burns andother noncardiogenic disease pathophysiology process. The injury of thepulmonary capillary endothelial cells and alveolar epithelial cells whichcaused by pulmonary interstitial and alveolar diffuse edema, directly leadingto acute hypoxemic respiratory failure and respiratory failure. As a result, thepulmonary endothelial permeability （PPI） is increased. Excessiveinflammatory reaction caused by alveolar epithelial and endothelial cell injurylead to pulmonary capillary permeability increase significantly. So theprotein-rich edema fluid will flow into the pulmonary interstitium and alveoli,which contribute to the formation of pulmonary edema.The severity of pulmonary edema plays an important role in theoccurrence, development and prognosis of ALI/ARDS. So the ALI/ARDSpatients will be more sophisticated and the volume management will be veryimportant. The optimal volume management for ALI/ARDS is not clear. Butthe present research suggests that when given positive fluid balance in theALI/ARDS patients leaded to trauma, the fatality rate significantly increased.But the negative fluid balance were significantly decreased the mortality rateof septic shock patients with ALI/ARDS. Thus currently recommendedvolume management is objectived to ensure the cardiac output based ontheminimalpulmonary artery wedge pressure （PAWP）. However, the currentclinical studies have confirmed that the method of pressure （CVP and PAWP）reflected the volume state were not very accurate. Pulmonary edema resultingfrom increased capillary permeability is a hallmark of acute lung injury, and inthis condition the intravascular hydrostatic pressure will be raise and oncoticpressure will be fall. Although the lung failure alone can be treated, the mortality of patients with ALI/ARDS is usually due to the failure ofnonpulmonary organs. The optimal fluid management of ALI/ARDS isunknown. The usual practice is wider-ranging, and many studies had evaluatedthe risks and benefits of the strategies of conservative as compared with liberalfluid management. In the conservative approach, fluid intake is restricted andurinary output is increased in an attempt to decrease lung edema, shorten theduration of mechanical ventilation, and improve survival. A possible risk ofthis approach is a decrease in cardiac output and worsening of nonpulmonaryorgan function. The liberal fluid approach essentially reverses these potentialpriorities and risks. Appropriate fluid management strategies on improvingALI/ARDS pulmonary edema will play an important role of in treatment ofALI/ARDS. At present, a randomized controlled trial which is a restrictivetransfusion strategy can reduce the extravascular lung water, ventilation timeand shorten the ICU hospitalization time. And it is the main treatment of thefluid management of ALI/ARDS patient.At present, Vigi1eo system for hemodynamic monitoring, through thecontinuous monitoring of arterial pressure waveform information calculatedby the cardiac output and other hemodynamic indices, is practicing in clinic.At the same time, the arterial pressure, cardiac output （APCO） monitoring isalso detected. Compared with other monitor methods, it is with less trauma,index comprehensive, dynamic, good sensitivity and strong features. Passiveleg raise test is a new method to predicte capacity response, and the strokevolume or its replacement index induced by passive leg lift is monitored in thetest. The test can accurately predict fluid responsiveness, and is simple, safe,and without spontaneous breathing and arrhythmias interference, and freefrom the limited advantages of the monitoring equipment. The purpose of thisstudy is Vigileo with passive leg raising test the guidance of ALI/ARDS,limiting the capacity of management to ensure adequate on the basis of thecapacity of the body to make the early negative fluid balance, to look forwardto improve the prognosis.The purpose of this study is using a restrictivevolume management which is the Vigileo with passive leg raising test to guide ALI/ARDS treatment, and to ensure the sufficient capacity based on the earlyreach negative fluid balance, in the purpose of improving prognosis.Methods: Thirty-two patients with ARDS were randomly divided into2groups（n=16each）:①C VP monitoring-treated group, in which the traditionalrestricted fliud management strategy was given according to mean arterialpressure, central venous pressure, urine volume, heart rate and othertraditional clinical signs.②vigileo monitoring-treated group, in which arestrictive fliud management was given according to the vigileo monitoring ofhemodynamic data in combination with the heart rate, urine output and meanarterial pressure. Then the amount of liquid into and out volume, fliud balance,after passive leg raising test stroke volume variation rate （PLR SV）, strokevolume variation （SVV） and oxygenation index （PaO₂/FiO₂） change wererecord during study days1to7. The ventilation days, length of stay and the28-days mortality were also recorded too. Statistical analysis was performedusing SPSS13.0software package. Data were expressed as mean±SD. Thecomparison of two-samples was used Student’s t-tests. The means of eachgroup were analyzed with ANOVA. The two-sample rate comparison was usedchi-square test. The relationship between SVV with after passive leg raisingtest, stroke volume variation rate （PLR SV） and CVP were analyzed by line acorrelation analysis. A statistical significant was P-value＜0.05.Results:1No statistical difference were found in the overall28-day mortality betweenthe two groups（12.5%VS12.5%,P>0.05）.The mean cumulative fluid inputduring1to7day was（12480.0±6534.9ml） in Vigileo groupand（18815.1±5306.3ml） in CVP group, respectively（P<0.01）. The balance ofthe two groups of liquid was（1768.4±2283.6ml）in the Vigileo group,and（4471.1±2049.4）ml in the CVP group（P<0.01）during the first seven days.The time of the negative fluid balance was achieved was earlier in the Vigileogroup than that in the CVP group （2.7±1.3d vs4.1±1.8d, P<0.01）. Theoxygenation index of day3（255.60±33.97vs197.76±50.64, P<0.05） and day5（371.08±107.93vs267.48±51.91, P<0.05） was better in the Vigileo group than that in the CVP group. In the Vigileo group, the decrease of the time ofventilator days （2.7±1.3d vs4.4±2.4d, P<0.05） and ICU length of stay（4.6±2.0dVS10.5±8.9d, P<0.05） could be found. The Incidence rate of liverand kidney failure was not increased in the Vigileo group than that in the CVPgroup. There was a positive correlation between ventilator days and theachievement of negative fluid balance time（r=0.621, P<0.01）.2The correlation among stroke variation rate （SVV） after passive leg raisingtest, stroke volume variation rate （PLR SV） and CVP.There was a positive correlation between stroke variation rate（SVV） andstroke volume variation rate（PLR SV） after passive leg raising test（r=0.563,P<0.01）. There was not a correlation between CVP and strokevolume variation rate （PLR SV） after passive leg raising test （r=0.093,P>0.05）. There was not a correlation between CVP and stroke variation rate（SVV）（r=0.061, P>0.05）.3Other lab index in two groups of ALI/ARDS patientsIn the study, we also monitored the changes of1,3,5days of LAC, pH,PaO₂/FiO₂, BE, ALB, Cr and BUN. The oxygenation index were significantlyimproved between Vigileo group and CVP group in day3（255.60±33.97vs197.76±50.64, P<0.05） and day5（371.08±107.93vs267.48±51.91, P<0.05）.The oxygenation index were significantly improved in Vigileo group in day5than that in day1, day3, respectively （371.08±107.93vs210.21±51.44,255.60±33.97, P<0.05）. The oxygenation index were significantly improved inCVP group in day5than that in day1, day3, respectively（267.48±51.91vs176.31±50.74,197.76±50.64, P<0.05）.Conclusions: Vigileo monitor with passive leg raising test couldeffective instruct restrictive fluid management in ALI/ARDS than that ofCVP monitoring. It could shorten the duration of mechanical ventilation andICU length of stay, better improve oxygenation index, and dad the effect ofearlier negative fluid balance. It did not increase the disfunction ofextrapulmonary organs, but the mortality was not decreased.