title: Evaluation of augmented pulse pressure variation using the Valsalva manoeuvre as a predictor of fluid responsiveness under open-chest conditions: A prospective observational study.
abstract: BACKGROUND
  Pulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial.
  
  
  OBJECTIVE
  We evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy.
  
  
  METHODS
  A prospective, observational study.
  
  
  METHODS
  Single-centre trial, study period from October 2014 to June 2015.
  
  
  METHODS
  Forty-nine adult patients who underwent off-pump coronary arterial bypass grafting.
  
  
  METHODS
  After midline sternotomy, haemodynamic parameters were measured before and after volume expansion (6 ml kg of crystalloids). PPV was calculated both automatically (PPVauto) and manually (PPVmanual). For PPV augmentation, we performed Valsalva manoeuvres with manual holding of the rebreathing bag and constant airway pressure of 30 cmH2O for 10 s before fluid loading and calculated PPV during the Valsalva manoeuvre (PPVVM).
  
  
  METHODS
  The predictive ability of PPVVM for fluid responsiveness using receiver-operating characteristic curve analysis. Responders were identified when an increase in cardiac index of at least 12% occurred after fluid loading.
  
  
  RESULTS
  Twenty-one patients were responders and 28 were nonresponders. PPVVM successfully predicted fluid responsiveness with an area under the curve (AUC) of 0.88 [95% confidence interval (95% CI) 0.75 to 0.95; sensitivity 91%, specificity 79%, P < 0.0001] and a threshold value of 55%. Baseline PPVauto and PPVmanual also predicted fluid responsiveness [AUC 0.75 (0.62 to 0.88); sensitivity 79%, specificity 75%; and 0.76 (0.61 to 0.87]; sensitivity 71%, specificity 71%, respectively). However, only PPVVM showed a significant AUC-difference from that of central venous pressure (P = 0.008) and correlated with the change of cardiac index induced by volume expansion (r = 0.6, P < 0.001).
  
  
  CONCLUSIONS
  Augmented PPV using a Valsalva manoeuvre can be used as a clinically reliable predictor of fluid responsiveness under open-chest condition.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier: NCT02457572.
authors.affiliation: From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (JJM, J-HL, JP, HSC), Department of Anesthesiology and Pain Medicine, Seoul National University Hospital (TKK), and Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (WSK, YTL).
authors.forename: Jeong Jin
authors.initials: JJ
authors.lastname: Min
authors.forename: Tae Kyong
authors.initials: TK
authors.lastname: Kim
authors.forename: Jong-Hwan
authors.initials: JH
authors.lastname: Lee
authors.forename: Jiyeon
authors.initials: J
authors.lastname: Park
authors.forename: Hyun Sung
authors.initials: HS
authors.lastname: Cho
authors.forename: Wook Sung
authors.initials: WS
authors.lastname: Kim
authors.forename: Young Tak
authors.initials: YT
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology; D001795:Blood Pressure Determination / Q000379:methods / Q000592:standards; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods / Q000592:standards; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions / Q000008:administration & dosage; D011237:Predictive Value of Tests; D011446:Prospective Studies; D056346:Sternotomy / Q000379:methods / Q000592:standards; D014636:Valsalva Maneuver / Q000187:drug effects / Q000502:physiology
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions