Solus-Biguenet H, Fleyfel M, Tavernier B, et al: Non-invasive prediction of fluid responsiveness during major hepatic surgery

Federation of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire de Lille, Lille, France.
BJA British Journal of Anaesthesia (Impact Factor: 4.85). 01/2007; 97(6):808-16. DOI: 10.1093/bja/ael250
Source: PubMed


The aim of this study was to evaluate potential predictors of fluid responsiveness obtained during major hepatic surgery. The predictors studied were invasive monitoring of intravascular pressures (radial and pulmonary artery catheter), including direct measurement of respiratory variation in arterial pulse pressure (PPVart), transoesophageal echocardiography (TOE), and non-invasive estimates of PPVart from the infrared photoplethysmography waveform from the Finapres (PPVfina) and the pulse oximetry waveform (PPVsat).
We conducted a prospective study of 54 fluid challenges (250 ml colloid) given for haemodynamic instability in eight patients undergoing hepatic resection. Fluid responsiveness was defined as an increase in stroke volume index (SVI) >or=10%. The following variables were recorded before each fluid challenge: right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), PPVart, PPVfina, PPVsat, and the TOE-derived variables left ventricular end-diastolic area index (LVEDAI), early/late (E/A) diastolic filling wave ratio, deceleration time of the E wave (MDT) of mitral flow and the systolic fraction of the pulmonary venous flow (SF).
Only PPVfina, PPVart (both P<0.001), PPVsat (P=0.02), LVEDAI and MDT (both P=0.04) were different in responder vs non-responder fluid challenges. The areas under the receiver operating characteristic (ROC) curves were 0.81 (PPVfina), 0.79 (PPVart), 0.70 (LVEDAI), 0.68 (PPVsat and MDT), 0.63 (RAP), 0.62 (E/A), 0.55 (PAOP) and 0.42 (SF). The areas under the ROC curves for RAP, E/A, PAOP and SF were significantly less than that for PPVfina (P<0.05 in each case). Only PPVart (r=0.59, P=0.0001) and PPVfina (r=0.56, P=0.0001) correlated with the fluid challenge-induced changes in SVI.
PPVart and PPVfina predict fluid responsiveness during major hepatic surgery. This suggests that intraoperative monitoring of fluid responsiveness may be implemented simply and non-invasively.

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    • "There are conflicting reports on ΔPOP as an alternative to ΔPP to reflect hypovolemia and predict fluid responsiveness [8, 21]. Differences in vasomotor tone, measurement sites, and measurement methodology contribute to discrepant results. "
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    ABSTRACT: Background. Correct volume management is essential in patients with respiratory failure. We investigated the ability of respiratory variations in noninvasive pulse pressure (ΔPP), photoplethysmographic waveform amplitude (ΔPOP), and pleth variability index (PVI) to reflect hypovolemia during noninvasive positive pressure ventilation by inducing hypovolemia with progressive lower body negative pressure (LBNP). Methods. Fourteen volunteers underwent LBNP of 0, -20, -40, -60, and -80 mmHg for 4.5 min at each level or until presyncope. The procedure was repeated with noninvasive positive pressure ventilation. We measured stroke volume (suprasternal Doppler), ΔPP (Finapres), ΔPOP, and PVI and assessed their association with LBNP-level using linear mixed model regression analyses. Results. Stroke volume decreased with each pressure level (-11.2 mL, 95% CI -11.8, -9.6, P < 0.001), with an additional effect of noninvasive positive pressure ventilation (-3.0 mL, 95% CI -8.5, -1.3, P = 0.009). ΔPP increased for each LBNP-level (1.2%, 95% CI 0.5, 1.8, P < 0.001) and almost doubled during noninvasive positive pressure ventilation (additional increase 1.0%, 95% CI 0.1, 1.9, P = 0.003). Neither ΔPOP nor PVI was significantly associated with LBNP-level. Conclusions. During noninvasive positive pressure ventilation, preload changes were reflected by ΔPP but not by ΔPOP or PVI. This implies that ΔPP may be used to assess volume status during noninvasive positive pressure ventilation.
    Full-text · Article · Feb 2014 · Critical care research and practice
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    • "Consequently, many of the important signals may have been lost during this 10-min period, particularly during hemodynamic unstable states. However, the magnitude of an increase in CI after fluid volume loading in fluid responders of this study was comparable or even greater than other fluid responsive studies [6,30], supporting the idea that the poor predictive values of tested variables were not attributable to insufficient signals in post-fluid loading measurements. "
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    ABSTRACT: Background Hypotension is common in the early postoperative stages after abdominothoracic esophagectomy for esophageal cancer. We examined the ability of stroke volume variation (SVV), pulse pressure variation (PPV), central venous pressure (CVP), intrathoracic blood volume (ITBV), and initial distribution volume of glucose (IDVG) to predict fluid responsiveness soon after esophagectomy under mechanical ventilation (tidal volume >8 mL/kg) without spontaneous respiratory activity. Methods Forty-three consecutive non-arrhythmic patients undergoing abdominothoracic esophagectomy were studied. SVV, PPV, cardiac index (CI), and indexed ITBV (ITBVI) were postoperatively measured by single transpulmonary thermodilution (PiCCO system) after patient admission to the intensive care unit (ICU) on the operative day. Indexed IDVG (IDVGI) was then determined using the incremental plasma glucose concentration 3 min after the intravenous administration of 5 g glucose. Fluid responsiveness was defined by an increase in CI >15% compared with pre-loading CI following fluid volume loading with 250 mL of 10% low molecular weight dextran. Results Twenty-three patients were responsive to fluids while 20 were not. The area under the receiver-operating characteristic (ROC) curve was the highest for CVP (0.690) and the lowest for ITBVI (0.584), but there was no statistical difference between tested variables. Pre-loading IDVGI (r = −0.523, P <0.001), SVV (r = 0.348, P = 0.026) and CVP (r = −0.307, P = 0.046), but not PPV or ITBVI, were correlated with a percentage increase in CI after fluid volume loading. Conclusions These results suggest that none of the tested variables can accurately predict fluid responsiveness early after abdominothoracic esophagectomy.
    Full-text · Article · Feb 2013
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    • "In the absence of an automated measurement [58], the variations in the plethysmographic signal should be simply eyeballed, although there are no data regarding the sensitivity and accuracy of such observation. PWV has been shown to accurately reflect changes in circulating blood volume intraoperatively [31,57] and in fluid responsiveness in patients undergoing major abdominal surgery [5,59] and cardiac surgery [58,60]. "
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    ABSTRACT: The administration of a fluid bolus is done frequently in the perioperative period to increase the cardiac output. Yet fluid loading fails to increase the cardiac output in more than 50% of critically ill and surgical patients. The assessment of fluid responsiveness (the slope of the left ventricular function curve) prior to fluid administration may thus not only help in detecting patients in need of fluids but may also prevent unnecessary and harmful fluid overload. Unfortunately, commonly used hemodynamic parameters, including the cardiac output itself, are poor predictors of fluid responsiveness, which is best assessed by functional hemodynamic parameters. These dynamic parameters reflect the response of cardiac output to a preload-modifying maneuver (for example, a mechanical breath or passive leg-raising), thus providing information about fluid responsiveness without the actual administration of fluids. All dynamic parameters, which include the respiratory variations in systolic blood pressure, pulse pressure, stroke volume and plethysmographic waveform, have been repeatedly shown to be superior to commonly used static preload parameters in predicting the response to fluid loading. Within their respective limitations, functional hemodynamic parameters should be used to guide fluid therapy as part of or independently of goal-directed therapy strategies in the perioperative period.
    Full-text · Article · Jan 2013 · Critical care (London, England)
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