CVP for guiding fluid administration – only if you’re a vet…

Marik PE, Baram M & Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. 2008 CHEST; 134: 172-178.

RHH Journal Club. May 30th, 2013. Dr Kirsty Parsons

Full-text article (if available)

Does Central Venous Pressure Predict Fluid Responsiveness?

Background

CVP used almost universally to guide fluid therapy in hospital patients. Historical and recent data had suggested this approach to be flawed.

Objective

A systematic review of the literature to determine:

  1. The relationship between CVP and blood volume
  2. The ability of CVP to predict fluid responsiveness
  3. The ability of the change in CVP to predict fluid responsiveness

Methods

MEDLINE, Embase, Cochrane register of Controlled Trials, and citation review of relevant primary and review articles searched for clinical trials evaluating relationship between CVP and blood volume or reported changes between CVP/ΔCVP and the change in SV/CI following a fluid challenge. Of 213 articles, 24 studies met inclusion criteria – included adult humans, healthy control subjects, and ICU and OR patients.

Data abstracted on study design, study size, setting, patient population, correlation coefficient between CVP and blood volume, correlation coefficient (or ROC) between CVP/ΔCVP and change in SV/CI, % of patients responding to fluid challenge, and baseline CVP of fluid responders and nonresponses. Metaanalytical techniques used to pool data.

Validity

Assessed using checklist for Meta-analysis (Russo MW. How to review a meta-analysis. Gastroenterol Hepatol (N Y) 2007 ; 3: 637–642.)

Study Question

  • Clearly stated, clinically relevant and focused YES

Literature Search

  • Rigorous selection criteria YES
  • Searched information sources listed (and terms used) YES
  • Manual search for references conducted YES

Data Abstraction

  • Standardized form for data collection YES
  • 3 authors abstracting data (> 2) YES
  • Disagreements between authors not discussed NO
  • Characteristics of studies listed YES
  • Number of excluded studies and reasons stated YES

Evaluation of results

  • Studies were combinable YES
  • Appropriate stats used YES
  • Results displayed YES
  • Sensitivity analysis not conducted NO

Evaluation for publication bias

  • Publication bias not addressed NO

Applicability of results

  • Results generalizable YES

Funding Source

  • No conflict of interest YES
  • Funding source identified NO
Results
  • 7 studies (830 patients across spectrum of specialities): 5 comparing CVP and blood volume; 19 showing CVP and change in cardiac performance following fluid challenge
  • Pooled correlation coefficient between:

–          CVP and blood volume was 0.16 (95% CI, 0.03 to 0.28)

–          CVP and change in SI/CI was 0.18 (95% CI, 0.08 to 0.28)

–          ΔCVP and change in SI/CI was 0.11 95% CI, 0.01 to 0.21)

  • Pooled are under ROC curve 0.56 (95% CI, 0.51 to 0.61)
  • Baseline CVP: 8.7 +/- 2.3mmHg in responders vs 9.7 +/- 2.2mmHg in non-responders (P=0.3)

Conclusions/In practice

  • No association between CVP and circulating blood volume
  • CVP does not predict fluid responsiveness
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