Noninvasive pulse pressure variation and stroke volume variation to predict fluid responsiveness at multiple thresholds: a prospective observational study

Jaap Jan Vos, Marieke Poterman, Pieternel Papineau Salm, Kai Van Amsterdam, Michel M R F Struys, Thomas W L Scheeren, Alain F Kalmar, Jaap Jan Vos, Marieke Poterman, Pieternel Papineau Salm, Kai Van Amsterdam, Michel M R F Struys, Thomas W L Scheeren, Alain F Kalmar

Abstract

Background: Pulse pressure variation (PPV) and stroke volume variation (SVV) are dynamic preload variables that can be measured noninvasively to assess fluid responsiveness (FR) in anesthetized patients with mechanical ventilation. Few studies have examined the effectiveness of predicting FR according to the definition of FR, and assessment of inconclusive values of PPV and SVV around the cut-off value (the "grey zone") might improve individual FR prediction. We explored the ability of noninvasive volume clamp derived measurements of PPV and SVV to predict FR using the grey zone approach, and we assessed the influence of multiple thresholds on the predictive ability of the numerical definition of FR.

Methods: Ninety patients undergoing general surgery were included in this prospective observational study and received a 500 mL fluid bolus as deemed clinically required by the attending anesthesiologist. A minimal relative increase in stroke volume index (↑SVI) was used to define FR with different thresholds from 10-25%. The PPV, SVV, and SVI were measured using the Nexfin® device that employs noninvasive volume clamp plethysmography.

Results: The area under the receiver operator characteristic curve gradually increased for PPV / SVV with higher threshold values (from 0.818 / 0.760 at 10% ↑SVI to 0.928 / 0.944 at 25% ↑SVI). The grey zone limits of both PPV and SVV changed from 9-16% (PPV) and 5-13% (SVV) at the 10% ↑SVI threshold to 18-21% (PPV) and 14-16% (SVV) at the 25% ↑SVI threshold.

Conclusion: Noninvasive PPV and SVV measurements allow an acceptable FR prediction, although the reliability of both variables is dependent on the intended increase in SVI, which improves substantially with concomitant smaller grey zones at higher ↑SVI thresholds.

Figures

Fig. 1
Fig. 1
Scatter plot of the percentage change in stroke volume index (ΔSVI) after fluid administration and the associated values of PPV (red circles) and SVV (green circles) before the start of fluid administration. PPV = pulse pressure variation; SVV = stroke volume variation
Fig. 2
Fig. 2
A-B ROC curves for the prediction of fluid responsiveness for PPV (2A) and SVV (2B), n = 81. Shown are the mean ROC curves and the AUROC values together with the associated 99% confidence intervals for the investigated ↑SVI thresholds. AUROC = area under the receiver operator characteristic curve; PPV = pulse pressure variation; ROC = receiver operator characteristic; SVI = stroke volume index; SVV = stroke volume variation
Fig. 3
Fig. 3
A-B Graph showing the sensitivity (dashed curves) and specificity (solid curves) of the PPV (3A) and SVV (3B) to predict increases in stroke volume (↑SVI) after 500 mL fluid administration, n = 81. In addition, the range of the grey zone (dashed horizontal lines) of the PPV and SVV are shown for the different ↑SVI thresholds. The small dashed horizontal line at sensitivity / specificity of 0.9 shows the intercepts of the grey zone limits for the different ↑SVI thresholds. PPV = pulse pressure variation; SVV = stroke volume variation

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