Online monitoring of pulse pressure variation to guide fluid therapy after cardiac surgery.
BACKGROUND
The arterial pulse pressure variation induced by mechanical ventilation (deltaPP) has been shown to be a predictor of fluid responsiveness. Until now, deltaPP has had to be calculated offline (from a computer recording or a paper printing of the arterial pressure curve), or to be derived from specific cardiac output monitors, limiting the widespread use of this parameter. Recently, a method has been developed for the automatic calculation and real-time monitoring of deltaPP using standard bedside monitors. Whether this method is to predict reliable predictor of fluid responsiveness remains to be determined.


METHODS
We conducted a prospective clinical study in 59 mechanically ventilated patients in the postoperative period of cardiac surgery. Patients studied were considered at low risk for complications related to fluid administration (pulmonary artery occlusion pressure < 20 mm Hg, left ventricular ejection fraction > or = 40%). All patients were instrumented with an arterial line and a pulmonary artery catheter. Cardiac filling pressures and cardiac output were measured before and after intravascular fluid administration (20 mL/kg of lactated Ringer's solution over 20 min), whereas deltaPP was automatically calculated and continuously monitored.


RESULTS
Fluid administration increased cardiac output by at least 15% in 39 patients (66% = responders). Before fluid administration, responders and nonresponders were comparable with regard to right atrial and pulmonary artery occlusion pressures. In contrast, deltaPP was significantly greater in responders than in nonresponders (17% +/- 3% vs 9% +/- 2%, P < 0.001). The deltaPP cut-off value of 12% allowed identification of responders with a sensitivity of 97% and a specificity of 95%.


CONCLUSIONS
Automatic real-time monitoring of deltaPP is possible using a standard bedside monitor and was found to be a reliable method to predict fluid responsiveness after cardiac surgery. Additional studies are needed to determine if this technique can be used to avoid the complications of fluid administration in high-risk patients.
Auler
Jose Otavio
JO
Department of Anesthesia and Critical Care, Heart Institute, INCOR, Hospital das Clinicas, University of Sao Paulo, SP, Brazil.
Galas
Filomena
F
Hajjar
Ludhmila
L
Santos
Luciana
L
Carvalho
Thiago
T
Michard
Frédéric
F
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001331:Automation; D006348:Cardiac Surgical Procedures; D002408:Catheters, Indwelling; D003422:Critical Care; D004784:Environmental Monitoring / Q000379:methods*; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006339:Heart Rate / Q000502:physiology*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D009862:Online Systems; D018579:Patient Selection; D011184:Postoperative Period; D011674:Pulse; D012121:Respiration, Artificial / Q000379:methods; D016277:Ventricular Function, Left / Q000502:physiology