Valeur et déterminants de la pression systémique moyenne en réanimation

Abstract : Introduction : Mean systemic filling pressure (Pmsf) is a major determinant of venous return. Its value is unknown in critically ill patients (ICU). Our objectives were to report Pmsf in critically ill patients and to look for its clinical determinants, if any. Material and method : We performed a prospective study in 202 patients who died in the ICU with a central venous and/or arterial catheter. One minute after the heart stopped beating, intravascular pressures were recorded in the supine position after ventilator disconnection. Parameters at admission, during the ICU stay, and at the time of death were prospectively collected. Results : One-minute Pmsf was 12.8 ± 5.6 mmHg. It did not differ according to gender, severity score, diagnosis at admission, fluid balance, need for and duration of mechanical ventilation, or length of stay. Nor was there any difference according to suspected cause of death, classified as shock (cardiogenic, septic, and hemorrhagic) and nonshock, although a large variability of values was observed. The presence of norepinephrine at the time of death (102 patients) was associated with a higher 1-min Pmsf (14 ± 6 vs. 11.4 ± 4.5 mmHg), whereas the decision to forgo life-sustaining therapy (34 patients) was associated with a lower 1-min Pmsf (10.9 ± 3.8 vs. 13.1 ± 5.3 mmHg). In a multiple-regression analysis, norepinephrine (β = 2.67, P = 0.0004) and age (β = -0.061, P = 0.022) were associated with 1-min Pmsf. One-minute Pmsf appeared highly variable without any difference according to the kind of shock and fluid balance, but was higher with norepinephrine. Discussion : This is the first description of Pmsf in critically ill patients. Our results are coherent with previous animal studies. Some studies reported higher values on patient with atrial fibrillation but the equilibrium point between arterial and venous pressures was not achived. Howewer, our values are different from the Guyton’s extrapolated values. This could suggest a difference between a « theoretical » Pmsf and a « physiological » Pmsf. Our Pmsf values are highly variable with no difference, and this underline the great complexity of this value. The only coefficient influencing the Pmsf value is norepinephrine infusion, as the fluid balance has no influence. This reinforce our idea that Pmsf is a reflection of the stressed volume. The different type of shock did not influence the Pmsf value, witch is different from previous studies were higher values were measured in patients with cardiogenic shock. The fact that our patients had more acute than chronic cardiopathy could explain this fact, because the fluid balance was strictly controlled. The main limitations of our study is the selection of an extremely severe type of patients and the lack of central venous
Keywords : Venous return
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Master Thesis
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Julia Fink Rubin. Valeur et déterminants de la pression systémique moyenne en réanimation. Médecine humaine et pathologie. 2016. ⟨dumas-01614921⟩

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