Pulse pressure variation and prediction of fluid responsiveness in patients ventilated with low tidal volumes

Clarice Daniele Alves de Oliveira-Costa, Gilberto Friedman, Sílvia Regina Rios Vieira, Léa Fialkow, Clarice Daniele Alves de Oliveira-Costa, Gilberto Friedman, Sílvia Regina Rios Vieira, Léa Fialkow

Abstract

Objective: To determine the utility of pulse pressure variation (ΔRESP PP) in predicting fluid responsiveness in patients ventilated with low tidal volumes (V T) and to investigate whether a lower ΔRESP PP cut-off value should be used when patients are ventilated with low tidal volumes.

Method: This cross-sectional observational study included 37 critically ill patients with acute circulatory failure who required fluid challenge. The patients were sedated and mechanically ventilated with a V T of 6-7 ml/kg ideal body weight, which was monitored with a pulmonary artery catheter and an arterial line. The mechanical ventilation and hemodynamic parameters, including ΔRESP PP, were measured before and after fluid challenge with 1,000 ml crystalloids or 500 ml colloids. Fluid responsiveness was defined as an increase in the cardiac index of at least 15%. ClinicalTrial.gov: NCT01569308.

Results: A total of 17 patients were classified as responders. Analysis of the area under the ROC curve (AUC) showed that the optimal cut-off point for ΔRESP PP to predict fluid responsiveness was 10% (AUC = 0.74). Adjustment of the ΔRESP PP to account for driving pressure did not improve the accuracy (AUC = 0.76). A ΔRESP PP ≥ 10% was a better predictor of fluid responsiveness than central venous pressure (AUC = 0.57) or pulmonary wedge pressure (AUC = 051). Of the 37 patients, 25 were in septic shock. The AUC for ΔRESP PP ≥ 10% to predict responsiveness in patients with septic shock was 0.484 (sensitivity, 78%; specificity, 93%).

Conclusion: The parameter D RESP PP has limited value in predicting fluid responsiveness in patients who are ventilated with low tidal volumes, but a ΔRESP PP>10% is a significant improvement over static parameters. A ΔRESP PP ≥ 10% may be particularly useful for identifying responders in patients with septic shock.

Conflict of interest statement

No potential conflict of interest was reported.

Figures

Figure 1
Figure 1
Receiver operating characteristic (ROC) curves comparing pulse pressure variation (ΔRESPPP), ΔRESPPP adjusted to driving pressure (ΔRESPPP/DP), central venous pressure (ROC area: 0.57 [0.38-0.76]) and pulmonary artery occlusion pressure (ROC area 0.51 [0.32-0.70]) to determine patient responses to volume expansion. The area under the curve for ΔRESPPP or ΔRESPPP/DP is greater than that for the central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP). PPV: positive predictive value; NPV: negative predictive value; LR +: positive likelihood ratio; LR: negative likelihood ratio.
Figure 2
Figure 2
Linear correlation between the pulse pressure variation (ΔRESPPP) and cardiac index (CI) variation immediately after a fluid challenge.
Figure 3
Figure 3
Receiver operating characteristic curve for pulse pressure variation (ΔRESPPP) in patients with septic shock ventilated with low tidal volumes. A cut-off value of 10% improved the negative predictive value (NPV) and positive predictive value (PPV).

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