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Les techniques de monitorage hémodynamique en réanimation pp 167–181Cite as

Évaluation de la réponse au remplissage vasculaire

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Part of the book series: Le point sur ... ((POINT))

Abstrait

Pendant de nombreuses années, la gestion du remplissage vasculaire en réanimation a reposé essentiellement sur le concept de fluid challenge (1). Il s’agit d’une évaluation a posteriori de la réponse au remplissage, basée sur un monitorage invasif du débit cardiaque et des pressions intracardiaques (1). Une expansion volémique est jugée efficace lorsqu’elle entraîne une augmentation significative du débit cardiaque associée à une faible augmentation des pressions de remplissage, le coeur fonctionnant alors sur la portion raide de la courbe de Starling (2); elle est jugée inefficace lorsqu’elle n’entraîne qu’une augmentation modeste voire nulle du débit cardiaque mais importante des pressions de remplissage, le coeur fonctionnant alors sur la portion plate de la courbe de Starling (2). Cette attitude a été rendue nécessaire par l’absence de paramètres hémodynamiques permettant de prédire fidèlement l’efficacité du remplissage. Historiquement, les paramètres évaluant la précharge cardiaque (droite ou gauche) avaient été préconisés pour guider le remplissage vasculaire. La pression veineuse centrale (PVC), comme la pression artérielle pulmonaire d’occlusion, ont été montrées insuffisamment fiables pour prédire le bénéfice hémodynamique du remplissage vasculaire (3, 4). Les dimensions ventriculaires ne le sont pas davantage (5, 6). Si l’efficacité de l’expansion volémique reste vraisemblable pour les valeurs très basses de précharge parfois rencontrées chez les patients non encore réanimés (7), l’attitude basée sur l’analyse des marqueurs statiques de précharge cardiaque est peu recommandable, une fois passées les toutes premières heures de la réanimation hémodynamique.

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Authors and Affiliations

  1. Service de Réanimation médicale CHU Ambroise Paré, Assistance Publique, Hôpitaux de Paris, 92104, Boulogne Cedex

    A. Vieillard-Baron

  2. Service de Réanimation médicale CHU de Bicêtre, Assistance Publique, Hôpitaux de Paris, EA 4046 Université Paris 11, 94270, Le Kremlin-Bicêtre

    J. -L. Teboul

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Vieillard-Baron, A., Teboul, J.L. (2007). Évaluation de la réponse au remplissage vasculaire. In: Les techniques de monitorage hémodynamique en réanimation. Le point sur .... Springer, Paris. https://doi.org/10.1007/978-2-287-71154-1_11

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  • DOI: https://doi.org/10.1007/978-2-287-71154-1_11

  • Publisher Name: Springer, Paris

  • Print ISBN: 978-2-287-71153-4

  • Online ISBN: 978-2-287-71154-1

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