The tidal volume challenge improves the reliability of dynamic preload indices during robot-assisted laparoscopic surgery in the Trendelenburg position with lung-protective ventilation

Joo-Hyun Jun, Rack Kyung Chung, Hee Jung Baik, Mi Hwa Chung, Joon-Sang Hyeon, Young-Goo Lee, Sung-Ho Park, Joo-Hyun Jun, Rack Kyung Chung, Hee Jung Baik, Mi Hwa Chung, Joon-Sang Hyeon, Young-Goo Lee, Sung-Ho Park

Abstract

Background: The reliability of pulse pressure variation (PPV) and stroke volume variation (SVV) is controversial under pneumoperitoneum. In addition, the usefulness of these indices is being called into question with the increasing adoption of lung-protective ventilation using low tidal volume (VT) in surgical patients. A recent study indicated that changes in PPV or SVV obtained by transiently increasing VT (VT challenge) accurately predicted fluid responsiveness even in critically ill patients receiving low VT. We evaluated whether the changes in PPV and SVV induced by a VT challenge predicted fluid responsiveness during pneumoperitoneum.

Methods: We performed an interventional prospective study in patients undergoing robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV, SVV, and the stroke volume index (SVI) were measured at a VT of 6 mL/kg and 3 min after increasing the VT to 8 mL/kg. The VT was reduced to 6 mL/kg, and measurements were performed before and 5 min after volume expansion (infusing 6% hydroxyethyl starch 6 ml/kg over 10 min). Fluid responsiveness was defined as ≥15% increase in the SVI.

Results: Twenty-four of the 38 patients enrolled in the study were responders. In the receiver operating characteristic curve analysis, an increase in PPV > 1% after the VT challenge showed excellent predictive capability for fluid responsiveness, with an area under the curve (AUC) of 0.95 [95% confidence interval (CI), 0.83-0.99, P < 0.0001; sensitivity 92%, specificity 86%]. An increase in SVV > 2% after the VT challenge predicted fluid responsiveness, but showed only fair predictive capability, with an AUC of 0.76 (95% CI, 0.60-0.89, P < 0.0006; sensitivity 46%, specificity 100%). The augmented values of PPV and SVV following VT challenge also showed the improved predictability of fluid responsiveness compared to PPV and SVV values (as measured by VT) of 6 ml/kg.

Conclusions: The change in PPV following the VT challenge has excellent reliability in predicting fluid responsiveness in our surgical population. The change in SVV and augmented values of PPV and SVV following this test are also reliable.

Trial registration: This trial was registered with Clinicaltrials.gov, NCT03467711 , 10th March 2018.

Keywords: Fluid responsiveness; Pneumoperitoneum; Pulse pressure variation; Stroke volume variation; Tidal volume challenge; Trendelenburg position.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study protocol. Arrows indicate time points at which measurements were made. PnP, pneumoperitoneum; VT, tidal volume; PBW, predicted body weight
Fig. 2
Fig. 2
Study diagram
Fig. 3
Fig. 3
Relationship between volume expansion-induced changes in pulse pressure variation and stroke volume variation and volume expansion-induced percentage changes in the stroke volume index (SVI). ΔPPVVE, changes in pulse pressure variation after volume expansion; ΔSVVVE, changes in stroke volume variation after volume expansion
Fig. 4
Fig. 4
Comparison of receive -operating characteristic curves of PPV6, PPV8, ΔPPV6–8, SVV6, SVV8 and ΔSVV6–8 to predict fluid responsiveness during robot-assisted laparoscopic surgery in the Trendelenburg position under lung-protective ventilation. PPV6, pulse pressure variation during tidal volume at 6 ml/kg predicted body weight (PBW); PPV8, pulse pressure variation during tidal volume at 8 ml/kg PBW; ΔPPV6–8, change in value of pulse pressure variation after tidal volume challenge; SVV6, stroke volume variation during tidal volume at 6 ml/kg predicted body weight (PBW); SVV8, stroke volume variation during tidal volume at 8 ml/kg PBW; ΔSVV6–8, change in value of stroke volume variation after tidal volume challenge; area under the ROC curve appears in cartouche with 95% confidence interval

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