Respiratory Variation in Pulse Pressure and Plethysmographic Waveforms

Maguire, Sinead; Rinehart, Joseph; Vakharia, Shermeen; Cannesson, Maxime

doi:10.1213/ane.0b013e318200366b

Cited by 108 publications

(42 citation statements)

References 18 publications

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“…Indeed, recommendations in sedation and in mechanically ventilation tend to favour spontaneously breathing modes in order to decrease the duration of mechanical ventilation [53,54]. These practices may decrease the clinical utility of PPV as recently reported in the anaesthetic setting [55]. In addition, it must be kept in mind that the increase in stroke volume is not always associated to a greater oxygen delivery to cells that is the main objective of a fluid challenge.…”

Section: Discussionmentioning

confidence: 99%

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

Biais¹,

Ehrmann²,

Mari³

et al. 2014

Crit Care

105

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IntroductionPulse 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.MethodsThe 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.ResultsFluid 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%.ConclusionsIn ventilated ICU patients, PPV values between 4 and 17%, encountered in 62% patients exhibiting validity prerequisites, did not predict fluid responsiveness.

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Section: Discussionmentioning

confidence: 99%

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

Biais¹,

Ehrmann²,

Mari³

et al. 2014

Crit Care

105

View full text Add to dashboard Cite

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“…Since pulse oximetry is a standard non-invasive intraoperative monitor, respiratory plethysmographic wave-form variation (PWV) is the most commonly available dynamic parameter in mechanically ventilated anesthetized patients [56]. PWV can be calculated as the difference between the maximal and minimal plethysmographic signal amplitudes divided by the amplitude of the signal during apnea or by the mean of the two values [57].…”

Section: Plethysmographic Waveform Variationmentioning

confidence: 99%

“…A dynamic parameter of major interest is the response of the CO to passive leg-raising [61], a maneuver that can theoretically be used in the many anesthetized patients in whom pressure-derived FHP cannot be used [56]. In contrast to a mechanical breath that normally reduces CO, passive leg-raising causes an endogenous fluid challenge that will increase CO in responders.…”

Section: Other Functional Hemodynamic Parametersmentioning

confidence: 99%

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Bench-to-bedside review: Functional hemodynamics during surgery - should it be used for all high-risk cases?

2013

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The administration of a fluid bolus is done frequently in the perioperative period to increase the cardiac output. Yet fluid loading fails to increase the cardiac output in more than 50% of critically ill and surgical patients. The assessment of fluid responsiveness (the slope of the left ventricular function curve) prior to fluid administration may thus not only help in detecting patients in need of fluids but may also prevent unnecessary and harmful fluid overload. Unfortunately, commonly used hemodynamic parameters, including the cardiac output itself, are poor predictors of fluid responsiveness, which is best assessed by functional hemodynamic parameters. These dynamic parameters reflect the response of cardiac output to a preload-modifying maneuver (for example, a mechanical breath or passive leg-raising), thus providing information about fluid responsiveness without the actual administration of fluids. All dynamic parameters, which include the respiratory variations in systolic blood pressure, pulse pressure, stroke volume and plethysmographic waveform, have been repeatedly shown to be superior to commonly used static preload parameters in predicting the response to fluid loading. Within their respective limitations, functional hemodynamic parameters should be used to guide fluid therapy as part of or independently of goal-directed therapy strategies in the perioperative period.

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“…Additionally, patients have to be in sinus rhythm with their chest closed (open chest, as well as open pericardium strongly modify the cardiopulmonary interactions), while intra-abdominal pressure has to be within normal ranges [21]. One should also keep in mind that around 40 % of all patients undergoing surgical procedures in the operating room met the strict criteria for the monitoring of fluid responsiveness using PPV [22] and that, despite its strong predictive value, PPV may be in the inconclusive "gray zone" (between 9% and 13%) in approximately 25% of patients during general anaesthesia. [23].…”

Section: Complications Of Hypervolemia Complications Of Hypovolemiamentioning

confidence: 99%

Perioperative goal directed therapy using automated closed-loop fluid management: the future?

Joosten¹,

Alexander²,

Delaporte³

et al. 2015

Anaesthesiol Intensive Ther

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Although surgery has become much safer, it has also becoming increasingly more complex and perioperative complications continue to impact millions of patients worldwide each year. Perioperative hemodynamic optimization utilizing Goal Directed Therapy (GDT) has attracted considerable interest within the last decade due to its ability to improve postoperative short and long-term outcomes in patients undergoing higher risk surgeries. The concept of GDT in this context can be loosely defined as collecting data from minimally invasive hemodynamic monitors with the intention of using such data (flow-related parameters and/or dynamic parameters of fluid responsiveness) to titrate therapeutic interventions (intravenous fluids and/or inotropic therapy administration) with the ultimate aim of optimizing end organ tissue perfusion. Recently, the increasing amount of evidence supporting the implementation of GDT strategies has been considered so robust as to allow for the creation of national recommendations in the United Kingdom (UK), France, and Europe. These recommendations from such influential scientific societies and the potential clinical and economic benefits of GDT protocols need to also be examined within the current shift from a "pay for service" to a "pay for performance" health care system. This shift is strongly encouraged within emerging systems such as the Perioperative Surgical Home (PSH) paradigm from the United States. As a result, hospitals and clinicians around the world have become increasingly incentivized to implement perioperative hemodynamic optimization using GDT strategies within their departments. Unfortunately, its adoption continues to be quite limited and a lack of standardized criteria for perioperative fluid administrations has resulted in significant clinical variability among practitioners. This current review will provide a brief up-to-date overview of GDT, discuss current clinical practice, analyze why implementation has been limited and finally, describe the newer closed-loop GDT concept along with its potential risks and benefits.Key words: goal directed therapy; hemodynamic optimization; closed-loop; cardiac output Anaesthesiology Intensive Therapy 2015, vol. 47, no 5, 517-523It has been estimated that approximately 240 million anaesthesia procedures are completed worldwide every year [1]. Of these, approximately 10%, or 24 million, are conducted on "high risk" surgical patients. However, this subset disproportionally accounts for more than 80% of perioperative mortality [2]. Moderate risk surgery is much more common as it represents approximately 40% of annual procedures, or 96 million patients. Thankfully, most of these patients continue on to have an uncomplicated postoperative course. However, it is estimated that approximately 30% of these moderate risk surgeries, or 29 million patients a year, end up having a "minor" postoperative complication (most commonly a gut injury inducing delayed enteral feeding, abdominal distension, nausea, vomiting or wound complications) [3]...

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Respiratory Variation in Pulse Pressure and Plethysmographic Waveforms

Cited by 108 publications

References 18 publications

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

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

Bench-to-bedside review: Functional hemodynamics during surgery - should it be used for all high-risk cases?

Perioperative goal directed therapy using automated closed-loop fluid management: the future?

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