The influence of the airway driving pressure on pulsed pressure variation as a predictor of fluid responsiveness
Assessing pulse pressure variation (PPV) to predict fluid responsiveness in mechanically ventilated patients with tidal volume (VT) and the impact of VT and airway driving pressure (Pplat − PEEP) on the ability of PPV for predicting fluid responsiveness.
Prospective interventional study.
ICU of a university hospital.
Fifty-seven mechanically ventilated and sedated patients with acute circulatory failure requiring cardiac output (CO) measurement.
Fluid challenge was given in patients with signs of hypoperfusion (oliguria <0.5 ml kg−1 h−1, attempt to decrease vasopressor infusion rate). Fluid responsiveness was defined as an increase in the stroke index (SI) ≥15%. Receiver-operating characteristic (ROC) curves were generated for PPV and central venous pressure (CVP).
The stroke index was increased ≥15% in 41 patients (71%). At baseline, CVP was lower and PPV was higher in responders. The areas under the ROC curves of PPV and CVP were 0.77 (95% CI 0.65–0.90) and 0.76 (95% CI 0.64–0.89), respectively (P = 0.93). The best cutoff values of PPV and CVP were 7% and 9 mmHg, respectively. In 30 out of 41 responders, PPV was <13%. Using a polytomic logistic regression (Pplat − PEEP) was the sole independent factor associated with a PPV value <13% in responders. In these responders, (Pplat − PEEP) was ≤20 cmH2O.
In patients mechanically ventilated with low VT, PPV values <13% do not rule out fluid responsiveness, especially when (Pplat − PEEP) is ≤20 cmH2O.
KeywordsCritical care Fluid challenge
- 1.Antonelli M, Levy M, Andrews PJ, Chastre J, Hudson LD, Manthous C, Meduri GU, Moreno RP, Putensen C, Stewart T, Torres A (2007) Hemodynamic monitoring in shock and implications for management. International Consensus Conference, Paris, France, 27–28 April 2006. Intensive Care Med 33:575–590CrossRefPubMedGoogle Scholar
- 3.Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36:296–327CrossRefPubMedGoogle Scholar
- 7.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
- 14.Cannesson M, Slieker J, Desebbe O, Bauer C, Chiari P, Henaine R, Lehot JJ (2008) The ability of a novel algorithm for automatic estimation of the respiratory variations in arterial pulse pressure to monitor fluid responsiveness in the operating room. Anesth Analg 106:1195–1200 table of contentsCrossRefPubMedGoogle Scholar
- 19.(2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342:1301–1308Google Scholar
- 21.Wolthuis EK, Choi G, Dessing MC, Bresser P, Lutter R, Dzoljic M, van der Poll T, Vroom MB, Hollmann M, Schultz MJ (2008) Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology 108:46–54CrossRefPubMedGoogle Scholar
- 23.Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101:1644–1655CrossRefPubMedGoogle Scholar