Clinical relevance of pulse pressure variations for predicting fluid responsiveness in mechanically ventilated intensive care unit patients: the grey zone approach

Matthieu Biais, Stephan Ehrmann, Arnaud Mari, Benjamin Conte, Yazine Mahjoub, Olivier Desebbe, Julien Pottecher, Karim Lakhal, Dalila Benzekri-Lefevre, Nicolas Molinari, Thierry Boulain, Jean-Yves Lefrant, Laurent Muller, AzuRea Group, Matthieu Biais, Stephan Ehrmann, Arnaud Mari, Benjamin Conte, Yazine Mahjoub, Olivier Desebbe, Julien Pottecher, Karim Lakhal, Dalila Benzekri-Lefevre, Nicolas Molinari, Thierry Boulain, Jean-Yves Lefrant, Laurent Muller, AzuRea Group

Abstract

Introduction: Pulse pressure variation (PPV) has been shown to predict fluid responsiveness in ventilated intensive care unit (ICU) patients. The present study was aimed at assessing the diagnostic accuracy of PPV for prediction of fluid responsiveness by using the grey zone approach in a large population.

Methods: The study pooled data of 556 patients from nine French ICUs. Hemodynamic (PPV, central venous pressure (CVP) and cardiac output) and ventilator variables were recorded. Responders were defined as patients increasing their stroke volume more than or equal to 15% after fluid challenge. The receiver operating characteristic (ROC) curve and grey zone were defined for PPV. The grey zone was evaluated according to the risk of fluid infusion in hypoxemic patients.

Results: Fluid challenge led to increased stroke volume more than or equal to 15% in 267 patients (48%). The areas under the ROC curve of PPV and CVP were 0.73 (95% confidence interval (CI): 0.68 to 0.77) and 0.64 (95% CI 0.59 to 0.70), respectively (P<0.001). A grey zone of 4 to 17% (62% of patients) was found for PPV. A tidal volume more than or equal to 8 ml.kg(-1) and a driving pressure (plateau pressure - PEEP) more than 20 cmH2O significantly improved the area under the ROC curve for PPV. When taking into account the risk of fluid infusion, the grey zone for PPV was 2 to 13%.

Conclusions: In ventilated ICU patients, PPV values between 4 and 17%, encountered in 62% patients exhibiting validity prerequisites, did not predict fluid responsiveness.

Figures

Figure 1
Figure 1
Flow chart of the study.
Figure 2
Figure 2
Changes in cardiac output (%) induced by volume expansion according to the baseline PPV value (%). PPV, pulse pressure variation.
Figure 3
Figure 3
Bootstrapping of ROC curves of pulse pressure variation (PPV) (a) and central venous pressure (CVP) (b). ROC curve areas are expressed as mean value with 95% confidence interval.
Figure 4
Figure 4
Grey zones of pulse pressure variation (PPV) (a) and central venous pressure (CVP) (b). Blue curve: sensitivity; red curve: specificity; green curve: percentage of patients.
Figure 5
Figure 5
Grey zone according to the centre (centres in which the number of inclusion was under 70 were pooled together) and factors influencing on the ability of PPV to predict fluid responsiveness. Each bar represents the grey zone of the corresponding centre with its lowest limit (specificity ≥90%), its best threshold and its highest limit (sensitivity ≥90%).

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