title: Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a "gray zone" approach.
abstract: BACKGROUND
  Respiratory arterial pulse pressure variations (PPV) are the best predictors of fluid responsiveness in mechanically ventilated patients during general anesthesia. However, previous studies were performed in a small number of patients and determined a single cutoff point to make clinical discrimination. The authors sought to test the predictive value of PPV in a large, multicenter study and to express it using a gray zone approach.
  
  
  METHODS
  The authors studied 413 patients during general anesthesia and mechanical ventilation in four centers. PPV, central venous pressure, and cardiac output were recorded before and after volume expansion (VE). Response to VE was defined as more than 15% increase in cardiac output after VE. The following approaches were used to determine the gray zones: resampled and two-graph receiver operator characteristic curves. The impact of changes in the benefit-risk balance of VE on the gray zone was also evaluated.
  
  
  RESULTS
  The authors observed 209 responders (51%) and 204 nonresponders (49%) to VE. The area under receiver operating characteristic curve was 0.89 (95% CI: 0.86-0.92) for PPV, compared with 0.57 (95% CI: 0.54-0.59) for central venous pressure (P < 10). The gray zone approach identified a range of PPV values (between 9% and 13%) for which fluid responsiveness could not be predicted reliably. These PPV values were seen in 98 (24%) patients. Changes in the cost ratio of VE moderately affected the gray zone limits.
  
  
  CONCLUSIONS
  Despite a strong predictive value, PPV may be inconclusive (between 9% and 13%) in approximately 25% of patients during general anesthesia.
authors.affiliation: Department of Anesthesiology & Perioperative Care, School of Medicine, University of California, Irvine, Irvine, California, USA. cannesson@hotmail.com
authors.forename: Maxime
authors.initials: M
authors.lastname: Cannesson
authors.forename: Yannick
authors.initials: Y
authors.lastname: Le Manach
authors.forename: Christoph K
authors.initials: CK
authors.lastname: Hofer
authors.forename: Jean Pierre
authors.initials: JP
authors.lastname: Goarin
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Lehot
authors.forename: Benoît
authors.initials: B
authors.lastname: Vallet
authors.forename: Benoît
authors.initials: B
authors.lastname: Tavernier
mesh_terms: D000368:Aged; D001794:Blood Pressure; D002302:Cardiac Output; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D012121:Respiration, Artificial