Intensive Care Medicine

, Volume 31, Issue 4, pp 517–523 | Cite as

Pulse pressure variations to predict fluid responsiveness: influence of tidal volume

  • Daniel De Backer
  • Sarah Heenen
  • Michael Piagnerelli
  • Marc Koch
  • Jean-Louis Vincent
Original

Abstract

Objective

To evaluate the influence of tidal volume on the capacity of pulse pressure variation (ΔPP) to predict fluid responsiveness.

Design

Prospective interventional study.

Setting

A 31-bed university hospital medico-surgical ICU.

Patients and participants

Sixty mechanically ventilated critically ill patients requiring fluid challenge, separated according to their tidal volume.

Intervention

Fluid challenge with either 1,000 ml crystalloids or 500 ml colloids.

Measurements and results

Complete hemodynamic measurements including ΔPP were obtained before and after fluid challenge. Tidal volume was lower than 7 ml/kg in 26 patients, between 7–8 ml/kg in 9 patients, and greater than 8 ml/kg in 27 patients. ROC curve analysis was used to evaluate the predictive value of ΔPP at different tidal volume thresholds, and 8 ml/kg best identified different behaviors. Overall, the cardiac index increased from 2.66 (2.00–3.47) to 3.04 (2.44–3.96) l/min m2 ( P <0.001). It increased by more than 15% in 33 patients (fluid responders). Pulmonary artery occluded pressure was lower and ΔPP higher in responders than in non-responders, but fluid responsiveness was better predicted with ΔPP (ROC curve area 0.76±0.06) than with pulmonary artery occluded pressure (0.71±0.07) and right atrial (0.56±0.08) pressures. Despite similar response to fluid challenge in low (<8 ml/kg) and high tidal volume groups, the percent of correct classification of a 12% ΔPP was 51% in the low tidal volume group and 88% in the high tidal volume group.

Conclusions

ΔPP is a reliable predictor of fluid responsiveness in mechanically ventilated patients only when tidal volume is at least 8 ml/kg.

Keywords

Cardiac output Preload Fluid challenge Fluid responsiveness 

Supplementary material

supp.pdf (65 kb)
(PDF 65 KB)

References

  1. 1.
    Sakka SG, Bredle DL, Reinhart K, Meier-Hellmann A (1999) Comparison between intrathoracic blood volume and cardiac filling pressures in the early phase of hemodynamic instability of patients with sepsis or septic shock. J Crit Care 14:78–83CrossRefPubMedGoogle Scholar
  2. 2.
    Michard F, Teboul JL (2002) Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 121:2000–2008CrossRefPubMedGoogle Scholar
  3. 3.
    Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P (1998) Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology 89:1313–1321Google Scholar
  4. 4.
    Coriat P, Vrillon M, Perel A, Baron JF, Le Bret F, Saada M, Viars P (1994) A comparison of systolic blood pressure variations and echocardiographic estimates of end-diastolic left ventricular size in patients after aortic surgery. Anesth Analg 78:46–53Google Scholar
  5. 5.
    Perel A, Pizov R, Cotev S (1987) Systolic blood pressure variation is a sensitive indicator of hypovolemia in ventilated dogs subjected to graded hemorrhage. Anesthesiology 67:498–502Google Scholar
  6. 6.
    Pinsky MR (2004) Using ventilation-induced aortic pressure and flow variation to diagnose preload responsiveness. Intensive Care Med 30:1008–1010CrossRefGoogle Scholar
  7. 7.
    Vieillard-Baron A, Loubieres Y, Schmitt JM, Page B, Dubourg O, Jardin F (1999) Cyclic changes in right ventricular output impedance during mechanical ventilation. J Appl Physiol 87:1644–1650PubMedGoogle Scholar
  8. 8.
    Vieillard-Baron A, Chergui K, Augarde R, Prin S, Page B, Beauchet A, Jardin F (2003) Cyclic changes in arterial pulse during respiratory support revisited by Doppler echocardiography. Am J Respir Crit Care Med 168:671–676CrossRefPubMedGoogle Scholar
  9. 9.
    Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL (2000) Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 162:134–138PubMedGoogle Scholar
  10. 10.
    Berkenstadt H, Margalit N, Hadani M, Friedman Z, Segal E, Villa Y, Perel A (2001) Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg 92:984–989Google Scholar
  11. 11.
    Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL (2001) Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest 119:867–873Google Scholar
  12. 12.
    Reuter DA, Felbinger TW, Schmidt C, Kilger E, Goedje O, Lamm P, Goetz AE (2002) Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med 28:392–398Google Scholar
  13. 13.
    Szold A, Pizov R, Segal E, Perel A (1989) The effect of tidal volume and intravascular volume state on systolic pressure variation in ventilated dogs. Intensive Care Med 15:368–371Google Scholar
  14. 14.
    Reuter DA, Bayerlein J, Goepfert MS, Weis FC, Kilger E, Lamm P, Goetz AE (2003) Influence of tidal volume on left ventricular stroke volume variation measured by pulse contour analysis in mechanically ventilated patients. Intensive Care Med 29:476–480PubMedGoogle Scholar
  15. 15.
    The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRefPubMedGoogle Scholar
  16. 16.
    Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351:327–336CrossRefPubMedGoogle Scholar
  17. 17.
    Jardin F, Genevray B, Brun-Ney D, Bourdarias JP (1985) Influence of lung and chest wall compliances on transmission of airway pressure to the pleural space in critically ill patients. Chest 88:653–658Google Scholar
  18. 18.
    Michard F, Chemla D, Richard C, Wysocki M, Pinsky MR, Lecarpentier Y, Teboul JL (1999) Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effects of PEEP. Am J Respir Crit Care Med 159:935–939Google Scholar
  19. 19.
    Teboul JL, Pinsky MR, Mercat A, Anguel N, Bernardin G, Achard JM, Boulain T, Richard C (2000) Estimating cardiac filling pressure in mechanically ventilated patients with hyperinflation. Crit Care Med 28:3631–3636Google Scholar
  20. 20.
    Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguia C, Nightingale P, Arroliga AC, Tobin MJ (2002) Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 287:345–355CrossRefPubMedGoogle Scholar
  21. 21.
    Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, Lewandowski K, Bion J, Romand JA, Villar J, Thorsteinsson A, Damas P, Armaganidis A, Lemaire F (2004) Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 30:51–61CrossRefPubMedGoogle Scholar
  22. 22.
    Denault AY, Gasior TA, Gorcsan J, Mandarino WA, Deneault LG, Pinsky MR (1999) Determinants of aortic pressure variation during positive-pressure ventilation in man. Chest 116:176–186Google Scholar
  23. 23.
    Bradley TD, Holloway RM, McLaughlin PR, Ross BL, Walters J, Liu PP (1992) Cardiac output response to continuous positive airway pressure in congestive heart failure. Am Rev Respir Dis 145:377–382Google Scholar
  24. 24.
    Jardin F (2004) Cyclic changes in arterial pressure during mechanical ventilation. Intensive Care Med 30:1047–1050Google Scholar
  25. 25.
    Vieillard-Baron A, Chergui K, Rabiller A, Peyrouset O, Page B, Beauchet A, Jardin F (2004) Superior vena caval collapsibility as a gauge of volume status in ventilated septic patients. Intensive Care Med 30:1734–1739PubMedGoogle Scholar
  26. 26.
    Bendjelid K, Suter PM, Romand JA (2003) The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol 96:337–342Google Scholar
  27. 27.
    Romand JA, Shi W, Pinsky MR (1995) Cardiopulmonary effects of positive pressure ventilation during acute lung injury. Chest 108:1041–1048Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Daniel De Backer
    • 1
  • Sarah Heenen
    • 1
  • Michael Piagnerelli
    • 1
  • Marc Koch
    • 1
  • Jean-Louis Vincent
    • 1
  1. 1.Department of Intensive CareErasme University Hospital of the Free University of BrusselsBrusselsBelgium

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