Global end-diastolic volume, serum osmolarity, and albumin are risk factors for increased extravascular lung water
Introduction
Pulmonary edema is a common problem and frequently develops in critically ill patients. The extent and underlying cause for pulmonary edema can be determined by the transpulmonary thermodilution technique that enables measurement of extravascular lung water [1].
Pathophysiologically, pulmonary edema can be differentiated into hydrostatic (cardiac) or permeability-related (noncardiac, acute lung injury (ALI)/acute respiratory distress syndrome [ARDS]) edema, and knowledge of the underlying cause is of particular importance for the clinician.
The transpulmonary thermodilution technique enables assessment of a variety of cardiocirculatory variables, including cardiac index (CI) and global end-diastolic volume index (GEDVI) as marker of cardiac filling and extravascular lung water index (EVLWI). Furthermore, pulmonary vascular permeability index (PVPI), PVPI = EVLWI/pulmonary blood volume, has been found to be able to discriminate permeability from hydrostatic causes of elevated EVLWI [2], [3]. The objective of this study was to analyze data derived from the transpulmonary thermodilution technique, central venous pressure (CVP; “conventional” cardiac preload parameter), serum albumin (ALB), and calculated serum osmolarity (OSM), to identify the risk factors for increased EVLWI.
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Patients and methods
The protocol of this retrospective clinical study was approved by the institutional review board of Yamaguchi University Hospital. The information regarding the study was posted on our center web site from December 2008 to February 2009, and no requests to exclude the patients' data were received from patients or their families. We have used the transpulmonary thermodilution technique (PiCCOplus; Pulsion Medical Systems AG, Munich, Germany) in our center since September 2006. Data for this
Results
The characteristics of the 42 patients are shown in Table 1. Median age was 63 years (27 males, 15 females), and median Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology II, and Sequential Organ Failure Assessment scores were 18, 33, and 6, respectively. Median length of ICU stay was 20 days, and ICU mortality was 24%.
Table 2 shows the hemodynamic and laboratory data in patients with normal EVLWI compared with those with increased EVLWI. The number of measurement
Discussion
This study reveals that increased EVLWI (defined by EVLWI > 10 mL/kg) is correlated with GEDVI, ALB, and OSM. Serum albumin was considered a favorable factor to predict increased EVLWI, and GEDVI and OSM were unfavorable factors from the odds ratios (PVPI was eliminated in this logistic regression analysis). There are 2 representative pathophysiologies for increased EVLWI, hydrostatic and permeability. Therefore, GEDVI, ALB, and OSM were also analyzed by the Spearman rank correlation
Acknowledgments
We are very grateful to our center's staff, nurses, and medical residents. We also express our thanks to Yudai Toyama and Masako Ueda for assistance with the paper work.
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Dr Samir G. Sakka is a member of the medical advisory board of Pulsion Medical Systems, a monitoring company that makes a device to measure EVLWI.