Stroke volume and pulse pressure variation for prediction of fluid responsiveness in patients undergoing off-pump coronary artery bypass grafting

Triemli City Hospital, Zürich, Zurich, Switzerland
Chest (Impact Factor: 7.48). 08/2005; 128(2):848-54. DOI: 10.1378/chest.128.2.848
Source: PubMed


Stroke volume variation (SVV) and pulse pressure variation (PPV) determined by the PiCCOplus system (Pulsion Medical Systems; Munich, Germany) may be useful dynamic variables in guiding fluid therapy in patients receiving mechanical ventilation. However, with respect to the prediction of volume responsiveness, conflicting results for SVV have been published in cardiac surgery patients. The goal of this study was to reevaluate SVV in predicting volume responsiveness and to compare it with PPV.
Prospective nonrandomized clinical investigation.
University-based cardiac surgery.
Forty patients with preserved left ventricular function undergoing elective off-pump coronary artery bypass grafting.
Volume replacement therapy before surgery.
Following induction of anesthesia, before and after volume replacement (6% hydroxyethyl starch solution, 10 mL/kg ideal body weight), hemodynamic measurements of stroke volume index (SVI), SVV, PPV, global end-diastolic volume index (GEDVI), central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) were obtained. Also, left ventricular end-diastolic area index (LVEDAI) was assessed by transesophageal echocardiography. Prediction of ventricular performance was tested by calculating the area under the receiver operating characteristic (ROC) curves and by linear regression analysis; p < 0.05 was considered significant. All measured hemodynamic variables except heart rate changed significantly after fluid loading. GEDVI, CVP, PCWP, and LVEDAI increased, whereas SVV and PPV decreased. The best area under the ROC curve (AUC) was found for SVV (AUC = 0.823) and PPV (AUC = 0.808); the AUC for other preload indexes ranged from 0.493 to 0.636. A significant correlation with changes of SVI was observed for SVV (r = 0.606, p < 0.001) and PPV (r = 0.612, p < 0.001) only. SVV and PPV were closely related (r = 0.861, p < 0.001).
In contrast to standard preload indexes, SVV and PPV, comparably, showed a good performance in predicting fluid responsiveness in patients before off-pump coronary artery bypass grafting.

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    • "Enfin, cette e ´ tude comporte certaines limites qui doivent e ˆtre discuté es. Nous avons e ´ tudié des patients en postopé ratoire de chirurgie cardiaque, l'utilisation du DPP dans cette situation a e ´ té validé e par plusieurs travaux, y compris pour les patients ayant des FEVG diminué es [6] [22] [26]. En revanche, l'insuffisance cardiaque droite peut repré senter une limite a ` son utilisation [27] [28]. "
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    ABSTRACT: Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation. Double-blind randomized study, cross-over design. Patients in intensive care unit after a cardiac surgery. Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes. Among the 26 patients analyzed, mean ΔPP value was de 14.0±7.3% in VVC and 11.8±6.2% in VPC (P<0,0001). On Bland-Altman representation, mean bias was +2.2±2.3% and inferior and superior limits of agreement were respectively -2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified. ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.
    Full-text · Article · Aug 2013 · Annales francaises d'anesthesie et de reanimation
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    • "The present study has a number of limitations. First, most studies on fluid responsiveness evaluated post-fluid volume loading variables at the completion of fluid volume loading or soon after its completion [6,18,29]. In this study, however, its measurement was performed 10 min after completion of fluid volume loading as reported previously [8], since a minimum interval of 30 min is required for repeated IDVG measurements to avoid sustained hyperglycemia [12]. "
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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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    • "During the first 24 hours after fluid loading ELWI did not increase. Even though the results from these studies are very important , other studies have demonstrated that static pressure and volumetric indices are of poor predictive value whereas dynamic parameters have been proven to be both predictive and reliable [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]. "
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    ABSTRACT: . Circulatory failure secondary to hypovolemia is a common situation in critical care patients. Volume replacement is the first option for the treatment of hypovolemia. A possible complication of volume loading is pulmonary edema, quantified at the bedside by the measurement of extravascular lung water index (ELWI). ELWI predicts progression to acute lung injury (ALI) in patients with risk factors for developing it. The aim of this study was to assess whether fluid loading guided by the stroke volume variation (SVV), in patients presumed to be hypovolemic, increased ELWI or not. Methods . Prospective study of 17 consecutive postoperative, fully mechanically ventilated patients diagnosed with circulatory failure secondary to presumed hypovolemia were included. Cardiac index (CI), ELWI, SVV, and global end-diastolic volume index (GEDI) were determined using the transpulmonary thermodilution technique during the first 12 hours after fluid loading. Volume replacement was done with a strict hemodynamic protocol. Results . Fluid loading produced a significant increase in CI and a decrease in SVV. ELWI did not increase. No correlation was found between the amount of fluids administered and the change in ELWI. Conclusion . Fluid loading guided by SVV in hypovolemic and fully mechanically ventilated patients in sinus rhythm does not increase ELWI.
    Full-text · Article · Oct 2012 · Critical care research and practice
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