Effect of manual decongestive therapy on cardiac preload in critically ill patients: a randomized controlled trial.

Abstract

Background: Capillary leakage is common in critical illness and can lead to intravascular hypovolemia and edema. Fluid balance, however, is crucial to optimize cardiac preload, vascular filling and tissue perfusion. Intravenously administered fluids are rapidly distributed to the extravascular spaces and further increase edema with consecutive harm for impeded wound healing, weakness, distribution of pharmaceutics to the third space and patient discomfort. We hypothesized that manual decongestive therapy (MDT) followed by elastic bandaging increases cardiac preload and reduces interstitial edema and thus, offers a promising approach to restore the imbalance in fluid distribution between the interstitium and the intravascular space in critically ill patients.

Methods: From November 2021 to May 2023, 34 critical ill requiring advanced hemodynamic monitoring with thermodilution-calibrated pulse contour analysis were randomized to either standard care or MDT followed by elastic bandaging for 24 h. Global end-diastolic volume index (GEDI) as a marker of the cardiac preload was measured 15, 30, 60 min and 24 h after MDT. Wrist and ankle circumferences were measured as markers of the extent of local interstitial edema.

Results: In the intervention group, a significant increase in Δ GEDI was observed 15 min [median 48 (IQR 82) to median -19 (IQR 39)], 60 min [median 75 (IQR 106.5) to median -11 (IQR80)] and 24 h [median 107 (IQR 153) to median -16 (IQR 114)] after the study intervention compared to the control group. After 24 h ankle [median 23.5 (IQR 5) cm to median 24 (IQR 6) cm, p < 0.0001] and wrist] median 18 (IQR 2) cm to median 19 (IQR 2) cm, p < 0.0001] circumferences were increased significantly in the control group. In the intervention group a significant reduction in the ankle circumference [median 24.5 (IQR 5) cm to median 24 (IQR 4.5) cm, p < 0.0001] and a significant reduction in the wrist circumference [median 20 (IQR 3.8) cm to median 18 (IQR 3.5) cm, p < 0.0001], was observed after 24 h.

Conclusions: MDT increases cardiac preload and helps to reduce interstitial fluid overload and edema in critically ill patients.

Trial registration: This prospective randomized controlled trial was registered at the German Clinical Trials Register DRKS00026226 on 17/09/2021.