Thibault Loupec

Pleth variability index predicts fluid responsiveness in critically ill patients.

Objective:To investigate whether the pleth variability index, a noninvasive and continuous tool, can predict fluid responsiveness in mechanically ventilated patients with circulatory insufficiency. Design:Prospective study. Setting:Surgical intensive care unit of a university hospital. Patients:Forty mechanically ventilated patients with circulatory insufficiency in whom volume expansion was planned by attending physician. Exclusion criteria included spontaneous respiratory activity, cardiac arrhythmia, known intracardiac shunt, severe hypoxemia (Pao2/Fio2 <100 mm Hg), contraindication for passive leg raising, left ventricular ejection fraction of <50%, and hemodynamic instability during the procedure. Interventions:Fluid challenge with 500 mL of 130/0.4 hydroxyethyl-starch if respiratory variations in arterial pulse pressure were ≥13% or with passive leg raising if variations in arterial pulse pressure were <13%. Measurements and Main Results:Pleth variability index, variations in arterial pulse pressure, and cardiac output estimated by echocardiography were recorded before and after fluid challenge. Fluid responsiveness was defined as an increase in cardiac output of ≥15%. Twenty-one patients were responders and 19 were nonresponders. Mean ± sd pleth variability index (28% ± 13% vs. 11% ± 4%) and arterial pulse pressure variation (22% ± 11% vs. 5% ± 2%) values at baseline were significantly higher in responders than in nonresponders. The pleth variability index threshold value of 17% allowed discrimination between responders and nonresponders with a sensitivity of 95% (95% confidence interval, 74% to 100%) and a specificity of 91% (95% confidence interval, 70% to 99%). The pleth variability index at baseline correlated (r = .72, p < .0001) with the percentage change in cardiac output induced by fluid challenge, suggesting that a higher pleth variability index at baseline will correlate with a higher percentage change in cardiac output after volume expansion. Conclusions:The pleth variability index can predict fluid responsiveness noninvasively in intensive care unit patients under mechanical ventilation.

Preoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic SurgeryA Randomized Controlled Trial

What We Already Know about This Topic Epoetin-&agr; is often given to patients scheduled for major orthopedic surgery It remains unknown whether it is best to accompany epoetin-&agr; with oral or intravenous iron What This Article Tells Us That Is New Hemoglobin level the day before surgery was 1 g/dl greater in 50 patients randomized to intravenous iron than in those assigned to oral iron About half the patients given oral iron reported gastrointestinal symptoms Intravenous iron is preferable to oral iron as a supplement to epoetin-&agr; Background: Preoperative administration of epoetin-&agr; with iron is commonly used in anemic patients undergoing major orthopedic surgery, but the optimal route of iron intake is controversial. The aim of this study was to compare the clinical effects of erythropoietin in combination with oral or intravenous iron supplementation. Methods: This study was a prospective, randomized, single-blinded, parallel arm trial. Patients scheduled for elective hip or knee arthroplasty with hemoglobin 10 to 13 g/dl received preoperative injections of erythropoietin with oral ferrous sulfate or intravenous ferric carboxymaltose. The primary endpoint was the hemoglobin value the day before surgery. Results: One hundred patients were included in the analysis. The day before surgery, hemoglobin, increase in hemoglobin, and serum ferritin level were higher in the intravenous group. For the intravenous and oral groups, respectively, hemoglobin was as follows: median, 14.9 g/dl (interquartile range, 14.1 to 15.6) versus 13.9 g/dl (interquartile range, 13.2 to 15.1), group difference, 0.65 g/dl (95% CI, 0.1 to 1.2; P = 0.017); increase in hemoglobin: 2.6 g/dl (interquartile range, 2.1 to 3.2) versus 1.9 g/dl (interquartile range, 1.4 to 2.5), group difference, 0.7 g/dl (95% CI, 0.3 to 1.1; P < 0.001); serum ferritin: 325 µg/l (interquartile range, 217 to 476) versus 64.5 µg/l (interquartile range, 44 to 107), group difference, 257 µg/l (95% CI, 199 to 315; P < 0.001). The percentage of patients with nausea, diarrhea, or constipation was higher in the oral group, 52% versus 2%; group difference, 50% (95% CI, 35 to 64%; P < 0.0001). Conclusions: After preoperative administration of erythropoietin, body iron stores and stimulation of the erythropoiesis were greater with intravenous ferric carboxymaltose than with oral ferrous sulfate supplementation.