EVLW and its Importance in Fluid Management

Fluid management and optimization is one of the most frequently observed problems in anesthesiology and critical care. An ideal hemodynamic management increases oxygen supply to tissues, improves postoperative outcomes and decreases surgical costs. Extravascular lung water (EVLW) measurement has gained widespread acceptance in the early prediction and management of adverse effects caused by fluid treatment. The fundamental aim of acute circulatory failure treatment is to improve tissue perfusion and oxygenation while avoiding fluid overload. EVLW consists of extravascular interstitial, intracellular, alveolar and lymphatic fluid in the lungs and its normal values are 3-7 ml kg-1. Studies have reported that values above 10 ml kg-1 as a cut-off value points to pulmonary edema. Although the gold standard in EVLW measurement is the gravimetric method, lung ultrasound and transpulmonary thermodilution is more widely utilized since gravimetric measurement can only be performed post-mortem. EVLW measurement is expected to gain importance in the hemodynamic measurement of ALI/ARDS patients and future studies will benefit from focusing on EVLW based fluid therapy.

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The Importance of Extravascular Lung Water Measurement in Major Surgeries

Journal of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care Society ◽

10.5222/gkdad.2021.04935 ◽

2021 ◽

Author(s):

Baturay Kansu Kazbek ◽

Perihan Ekmekçi

Keyword(s):

Extravascular Lung Water ◽

Fluid Management ◽

Gravimetric Method ◽

Pulmonary Complications ◽

Pulmonary Vasculature ◽

High Peep ◽

Pharmacological Interventions ◽

Lung Water ◽

New Research ◽

Water Measurement

The incidence of postoperative pulmonary complications varies between 1-23 % and these complications can cause serious mortality. Measurement of extravascular lung water (EVLW) is beneficial not only for the prevention of complications but also in weaning, fluid management and monitorization of response to pharmacological interventions. EVLW consists of interstitial, intracellular, alveolar and lymphatic fluid in lungs except for pulmonary vasculature. Its normal range is 3-7 m/kg in healthy adults, values greater than 10 ml/kg point to pulmonary edema. Although the gold standard for measurement of EVLW is the gravimetric method, due to the fact it can only be applied postmortem, measurement methods by using ultrasonography and transpulmonary thermodilution have been developed. EVLW measurement can be affected by renal replacement therapy, extracorporeal membrane oxygenation (ECMO), pleural effusions and high PEEP. New research focusing on the effect of EVLW measurement on postoperative hemodynamic management is necessary in the future.

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Accuracy of transpulmonary thermodilution versus gravimetric measurement of extravascular lung water

Critical Care Medicine ◽

10.1097/01.ccm.0000130995.18334.8b ◽

2004 ◽

Vol 32 (7) ◽

pp. 1550-1554 ◽

Cited By ~ 182

Author(s):

Rita Katzenelson ◽

Azriel Perel ◽

Haiim Berkenstadt ◽

Sergei Preisman ◽

Samuel Kogan ◽

...

Keyword(s):

Extravascular Lung Water ◽

Transpulmonary Thermodilution ◽

Gravimetric Measurement ◽

Lung Water

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Individualized Hemodynamic Management in Sepsis

Journal of Personalized Medicine ◽

10.3390/jpm11020157 ◽

2021 ◽

Vol 11 (2) ◽

pp. 157

Author(s):

Marcell Virág ◽

Tamas Leiner ◽

Mate Rottler ◽

Klementina Ocskay ◽

Zsolt Molnar

Keyword(s):

Fluid Overload ◽

Fluid Management ◽

Multiple Organ ◽

Treatment Protocols ◽

Hemodynamic Management ◽

New Approach ◽

Hemodynamic Optimization ◽

The Individual ◽

Sepsis And Septic Shock ◽

Insight Into

Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and “restrictive” infusion strategies have been recommended by guidelines over “liberal” approaches for several years. Unfortunately, these “fixed regimen” treatment protocols neglect the patient’s individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.

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COVID-19 ARDS is characterized by higher extravascular lung water than non-COVID-19 ARDS: the PiCCOVID study

Critical Care ◽

10.1186/s13054-021-03594-6 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Rui Shi ◽

Christopher Lai ◽

Jean-Louis Teboul ◽

Martin Dres ◽

Francesca Moretto ◽

...

Keyword(s):

Extravascular Lung Water ◽

Transpulmonary Thermodilution ◽

Diffuse Alveolar Damage ◽

Lung Mechanics ◽

Arterial Oxygen ◽

Prone Positioning ◽

University Hospitals ◽

Lung Water ◽

Pulmonary Vascular Permeability ◽

Water Index

Abstract Background In acute respiratory distress syndrome (ARDS), extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) measured by transpulmonary thermodilution reflect the degree of lung injury. Whether EVLWi and PVPI are different between non-COVID-19 ARDS and the ARDS due to COVID-19 has never been reported. We aimed at comparing EVLWi, PVPI, respiratory mechanics and hemodynamics in patients with COVID-19 ARDS vs. ARDS of other origin. Methods Between March and October 2020, in an observational study conducted in intensive care units from three university hospitals, 60 patients with COVID-19-related ARDS monitored by transpulmonary thermodilution were compared to the 60 consecutive non-COVID-19 ARDS admitted immediately before the COVID-19 outbreak between December 2018 and February 2020. Results Driving pressure was similar between patients with COVID-19 and non-COVID-19 ARDS, at baseline as well as during the study period. Compared to patients without COVID-19, those with COVID-19 exhibited higher EVLWi, both at the baseline (17 (14–21) vs. 15 (11–19) mL/kg, respectively, p = 0.03) and at the time of its maximal value (24 (18–27) vs. 21 (15–24) mL/kg, respectively, p = 0.01). Similar results were observed for PVPI. In COVID-19 patients, the worst ratio between arterial oxygen partial pressure over oxygen inspired fraction was lower (81 (70–109) vs. 100 (80–124) mmHg, respectively, p = 0.02) and prone positioning and extracorporeal membrane oxygenation (ECMO) were more frequently used than in patients without COVID-19. COVID-19 patients had lower maximal lactate level and maximal norepinephrine dose than patients without COVID-19. Day-60 mortality was similar between groups (57% vs. 65%, respectively, p = 0.45). The maximal value of EVLWi and PVPI remained independently associated with outcome in the whole cohort. Conclusion Compared to ARDS patients without COVID-19, patients with COVID-19 had similar lung mechanics, but higher EVLWi and PVPI values from the beginning of the disease. This was associated with worse oxygenation and with more requirement of prone positioning and ECMO. This is compatible with the specific lung inflammation and severe diffuse alveolar damage related to COVID-19. By contrast, patients with COVID-19 had fewer hemodynamic derangement. Eventually, mortality was similar between groups. Trial registration number and date of registration ClinicalTrials.gov (NCT04337983). Registered 30 March 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04337983.

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Extravascular lung water and pulmonary arterial wedge pressure for fluid management in patients with acute respiratory distress syndrome

Multidisciplinary Respiratory Medicine ◽

10.1186/2049-6958-9-3 ◽

2014 ◽

Vol 9 (1) ◽

Cited By ~ 10

Author(s):

Wei Hu ◽

Chang-Wen Lin ◽

Bing-Wei Liu ◽

Wei-Hang Hu ◽

Ying Zhu

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Extravascular Lung Water ◽

Distress Syndrome ◽

Fluid Management ◽

Lung Water ◽

Pulmonary Arterial ◽

Wedge Pressure

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PLETH VARIABILITY INDEX-GUIDED FLUID THERAPY LOWERS POST-OPERATIVE LACTATE LEVELS IN DOGS UNDERGOING ELECTIVE ABDOMINAL SURGERY: A RANDOMIZED CONTROLLED TRIAL

Taiwan Veterinary Journal ◽

10.1142/s168264851750010x ◽

2018 ◽

Vol 44 (01) ◽

pp. 7-14

Author(s):

Chun-Hsiang Hu ◽

Tien-Huan Hsu ◽

Kuan-Sheng Chen ◽

Wei-Ming Lee ◽

Hsien-Chi Wang

Keyword(s):

Abdominal Surgery ◽

Fluid Therapy ◽

Controlled Trial ◽

Fluid Management ◽

Tissue Perfusion ◽

Control Group ◽

Pleth Variability Index ◽

Elective Abdominal Surgery ◽

Variability Index ◽

Lactate Levels

To evaluate the hemodynamic optimization effect of pleth variability index (PVI)-guided fluid therapy during abdominal surgery on tissue perfusion, 19 client-owned dogs that underwent elective abdominal surgery were randomized into control ([Formula: see text]) and PVI ([Formula: see text]) groups. In the control group, perioperative fluid management was based on the 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats. In the PVI group, the fluid rate was maintained based on basic daily requirements. If PVI was higher than 15% for [Formula: see text][Formula: see text]min, 3–5[Formula: see text]mL/kg of crystalloid fluid bolus was infused. The tissue perfusion indicator, lactate levels, was measured at the time of intubation, extubation, and 6, 12 and 24[Formula: see text]h postoperatively. There were no significant differences in total and average fluid infused between control and PVI groups. The control group had significantly higher lactate levels than that of the PVI group at 12[Formula: see text]h postoperatively ([Formula: see text][Formula: see text]mmol/L versus [Formula: see text][Formula: see text]mmol/L, [Formula: see text]) and overall postoperatively ([Formula: see text][Formula: see text]mmol/L versus [Formula: see text][Formula: see text]mmol/L, [Formula: see text]). The control group revealed more profound hemodilution, as indicated by significantly decreased postoperative blood urea nitrogen (BUN), creatinine, and total protein. PVI-guided fluid therapy lowers lactate levels after elective abdominal surgery in dogs. Therefore, based on the result of this study PVI may provide customized fluid therapy to improve tissue perfusion and avoid unnecessary fluid overload.

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Lung water measurements with the mean transit time approach

Journal of Applied Physiology ◽

10.1152/jappl.1985.59.3.673 ◽

1985 ◽

Vol 59 (3) ◽

pp. 673-683 ◽

Cited By ~ 41

Author(s):

R. M. Effros

Keyword(s):

Transit Time ◽

Mean Transit Time ◽

Tissue Perfusion ◽

Time Data ◽

Lung Water ◽

Thermal Signal ◽

The Mean ◽

Points Of View ◽

Vascular Obstruction ◽

Pulmonary Vascular Obstruction

The potential usefulness and limitations of the double-indicator mean transit time approach for measuring lung water are evaluated from both theoretical and empirical points of view. It is concluded that poor tissue perfusion is the most serious factor that can compromise the reliability of this approach. Replacement of the conventional water isotopes with a thermal signal enhances indicator delivery to ischemic areas but the diffusion of heat is not sufficiently rapid to permit measurements of water in macroscopic collections of fluid which remain unperfused. The frequency of pulmonary vascular obstruction in patients with pulmonary edema related to lung injury suggests that interpretation of transit time data will be complicated by uncertainties concerning perfusion. Thermal-dye measurements of lung water may prove more helpful in situations where pulmonary blood flow remains relatively uniform.

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Transpulmonary Thermodilution Enables to Detect Small Short-Term Changes in Extravascular Lung Water Induced by a Bronchoalveolar Lavage

Critical Care Medicine ◽

10.1097/ccm.0000000000000341 ◽

2014 ◽

Vol 42 (8) ◽

pp. 1869-1873 ◽

Cited By ~ 16

Author(s):

Martin Dres ◽

Jean-Louis Teboul ◽

Laurent Guerin ◽

Nadia Anguel ◽

Virginie Amilien ◽

...

Keyword(s):

Bronchoalveolar Lavage ◽

Extravascular Lung Water ◽

Transpulmonary Thermodilution ◽

Short Term ◽

Lung Water

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Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter

AJP Lung Cellular and Molecular Physiology ◽

10.1152/ajplung.00277.2006 ◽

2006 ◽

Vol 291 (6) ◽

pp. L1118-L1131 ◽

Cited By ~ 74

Author(s):

Warren Isakow ◽

Daniel P. Schuster

Keyword(s):

Cardiac Output ◽

Pulmonary Artery ◽

Pulmonary Artery Catheter ◽

Critically Ill ◽

Extravascular Lung Water ◽

Ejection Time ◽

Lung Water ◽

Descending Aorta ◽

Hemodynamic Management ◽

Flow Through

The recently completed Fluid and Catheter Treatment Trial conducted by the National Institutes of Health ARDSNetwork casts doubt on the value of routine pulmonary artery catheterization for hemodynamic management of the critically ill. Several alternatives are available, and, in this review, we evaluate the theoretical, validation, and empirical databases for two of these: transpulmonary thermodilution measurements (yielding estimates of cardiac output, intrathoracic blood volume, and extravascular lung water) that do not require a pulmonary artery catheter, and hemodynamic measurements (including estimates of cardiac output and ejection time, a variable sensitive to intravascular volume) obtained by esophageal Doppler analysis of blood flow through the descending aorta. We conclude that both deserve serious consideration as a means of acquiring useful hemodynamic data for managing shock and fluid resuscitation in the critically ill, especially in those with acute lung injury and pulmonary edema, but that additional study, including carefully performed, prospective clinical trials demonstrating outcome benefit, is needed.

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