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Submitted on 7 May 2018
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Re: Lung and cardiac ultrasound for hemodynamic
monitoring of patients with severe pre-eclampsia.
L. Zieleskiewicz, M. Leone
To cite this version:
L. Zieleskiewicz, M. Leone. Re: Lung and cardiac ultrasound for hemodynamic monitoring of patients
with severe pre-eclampsia.. Ultrasound in Obstetrics and Gynecology = Ultrasound in Obstetrics &
Gynecology, Wiley-Blackwell, 2017, 49 (1, SI), pp.22. �10.1002/uog.17354�. �hal-01489502�
Ultrasound Obstet Gynecol 2017; 49: 22–24
Published online in Wiley Online Library (wileyonlinelibrary.com).
Referee Commentaries
Re: Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia.
J. Ambrozic, G. Brzan Simenc, K. Prokselj, N. Tulz, M. Cvijic and M. Lucovnik. Ultrasound Obstet Gynecol 2017; 49: 104–109.
Using combined heart and lung ultrasound, Ambrozic
et al. assessed extravascular lung water, diastolic left
ven-tricular function and fluid responsiveness in parturients with severe pre-eclampsia and in control parturients. They found that extravascular lung water and left ventricu-lar filling pressure were higher in the parturients with severe pre-eclampsia than in the controls 1 day before and 1 day after delivery. Before any clinical signs, thoracic ultrasound identified interstitial pulmonary edema and elevated filling pressure.
The strength of this study is that it provides a longitudinal view of hemodynamics in parturients with severe pre-eclampsia until 4 days after delivery. Interestingly, the blood flow redistribution associated with delivery did not result in increases in extravascular lung water and filling pressure. Four days after delivery, the parturients with severe pre-eclampsia and the controls showed no difference for all hemodynamic variables.
In clinical practice, the hemodynamic management of parturients with pre-eclampsia is challenging. The medical team should balance the risks between organ hypoperfusion and pulmonary edema. Few studies have examined the potential of thoracic ultrasound for the bedside diagnosis of pulmonary edema, fluid responsiveness and left ventricular filling pressure1.
On lung ultrasound imaging, B-lines, which resemble ‘comet tails’, correspond to vertical artifacts that indicate interstitial syndrome and pulmonary edema2,
with the number of B-lines reflecting the magnitude of extravascular lung water. In most parturients, extravascular lung water is correlated to left ventricular filling pressure1. In other words, a hydrostatic pulmonary edema can be diagnosed easily at the bedside, before any clinical signs could be detected1. Previous studies
have shown that clinical signs are insufficient to guide fluid management in critically ill patients3,4. Of
parturients with pre-eclampsia who develop oliguria,
half are not fluid-responsive4. Thus, hemodynamic
monitoring is crucial in cases of severe pre-eclampsia, and chest ultrasound represents a perfect non-invasive validated tool.
Obstetricians are skilled in the practice of ultrasound, routinely using B-lines to assess fetal lungs. Ultrasound devices are readily available in obstetric departments. The results of this study by Ambrozic et al. invite them to use ultrasound as the new stethoscope in parturients with
organ failure. Combining cardiac and lung ultrasound facilitates both the prediction of fluid responsiveness and the diagnosis of fluid overload1,4.
In brief, Ambrozic et al. should be congratulated. With this study, they have paved the way for extensive use of ultrasound in the hemodynamic management of parturients. Ultrasound has a huge role to play in guiding treatment of parturients with severe pre-eclampsia5.
Future randomized clinical trials should assess the potential of ultrasound-based strategies in this setting.
L. Zieleskiewicz* and M. Leone
Department of Anesthesiology and Critical Care Medicine, North Hospital, Aix Marseille University, Marseille, France *Correspondence. (e-mail: Laurent.Zieleskiewicz@ap-hm.fr) DOI: 10.1002/uog.17354
References
1. Zieleskiewicz L, Contargyris C, Brun C, Touret M, Vellin A, Antonini F, Muller L, Bretelle F, Martin C, Leone M. Lung ultrasound predicts interstitial syndrome and hemodynamic profile in parturients with severe preeclampsia. Anesthesiology 2014;
120: 906–914.
2. Lichtenstein D, Mezi`ere G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med 1998; 24: 1331–1334.
3. Michard F,Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002; 121: 2000–2008.
4. Brun C, Zieleskiewicz L, Textoris J, Muller L, Bellefleur JP, Antonini F, Tourret M, Ortega D, Vellin A, Lefrant JY, Boubli L, Bretelle F, Martin C, Leone M. Prediction of fluid responsiveness in severe preeclamptic patients with oliguria. Intensive Care Med 2013; 39: 593–600.
5. Zieleskiewicz L, Lagier D, Contargyris C, Bourgoin A, Gavage L, Martin C, Leone M. Lung ultrasound-guided management of acute breathlessness during pregnancy.
Anaesthesia 2013; 68: 97–101.
