Вы находитесь на странице: 1из 2
Anaesth Crit Care Pain Med 34 (2015) 9–10 Editorial Pulse pressure respiratory variation to predict fluid
Anaesth Crit Care Pain Med 34 (2015) 9–10 Editorial Pulse pressure respiratory variation to predict fluid
Anaesth Crit Care Pain Med 34 (2015) 9–10 Editorial Pulse pressure respiratory variation to predict fluid

Editorial

Pulse pressure respiratory variation to predict fluid responsiveness:

From an enthusiastic to a rational view

responsiveness: From an enthusiastic to a rational view A R T I C L E I
responsiveness: From an enthusiastic to a rational view A R T I C L E I

A R T I C L E

I N F O

Keywords:

Physiologic MesH

Hypovolemia MesH

Arterial waveform

Heart-lung interactions

The concept of using respiratory variations of pulse pressure (PPV) as a gauge for the volemic status has gained popularity in the early 2000s [1,2] . PPV raised enthusiasm because the anesthetist or the intensivist would, at last, handle a simple tool providing a reliable answer to one of the most common questions asked when caring for patients with circulatory failure: ‘‘does my patient need fluids?’’. Indeed, meanwhile, several works underlined the poor predictive ability of the classically used indices such as cardiac filling pressures or dimensions [3] . PPV has been proposed to bridge the gap between the deleterious effects of hypo- and hypervolemia [3] and the lack of adequate tools for this purpose. Thus, nearly 15 years after the publication of the first studies underscoring the promising ability of PPV for fluid responsiveness prediction [1,2] , where are we now? One can distinguish three main waves in the design of clinical studies published to date, with slight overlap between these waves.

1. Pathophysiological studies reporting an excellent

performance of PPV

In various settings, an impressive number of studies performed under strictly regulated clinical conditions initiated an era of enthusiasm about dynamic indices [2] .

2. Pathophysiological studies exploring the limitations of PPV

The absence of both inspiratory efforts and arrhythmia are obvious prerequisites for PPV use [3] . Indeed, the measured variations of arterial pressure should only be related to regular (in rate and magnitude) changes in the pleural pressure, not polluted by any kind of arrhythmia. Since tidal volume is the stimulus for respiratory fluctuations of the arterial pressure waveform, it was not surprising to observe the publication of several studies showing that its magnitude impacts the value of PPV. Hence, a low tidal volume [4–6] and its related low change in airway driving pressure [7] (reflecting low change in pleural pressure [8]) were associated with a poor performance of PPV.

A high respiratory rate, more specifically a low heart rate-to- respiratory rate ratio, was also associated with a poor performance of PPV for the prediction of fluid responsiveness [9] . Other clinical factors have been shown to flaw the perfor- mance of PPV, or at least to alter its classic interpretation: acute cor pulmonale [10] , abdominal hypertension [11] , low respira- tory system compliance [12] . Of note, patients with low respiratory system compliance often receive low tidal volumes (as settled by the intensivist) because of presumed low lung compliance, and low Vt is then often the cause for the poor predictive ability of PPV observed in these patients [28] . Along with low tidal volume, another major pathophysiological cause for low respiratory change in pleural pressure is high chest wall compliance [12] .

3. Large observational studies assessing the validity of PPV in real life practice

During the last two decades, several trends in the care of the critically ill and/or patients in the operating theatre have been observed. First, the concept of protective ventilation has been developed. It was first encouraged for the ventilation of patients suffering from ARDS [13] , then for ICU patients with no lung injury [14] , then in the operating theatre [15] . All protective ventilation strategies are associated with low tidal volumes (and the frequently associated application of a high respiratory rate). Therefore, protective ventilation impairs the predictive perfor- mance of PPV [4–6,9] , as it exposes to false negative cases [7,8,16] . Conflicting data were reported when a low tidal volume without high respiratory rate was applied [17] . Second, ICU patients with no inspiratory efforts are nowadays infrequent. Indeed, limited use of sedation [18] , invasive ventila- tion allowing inspiratory efforts (such as pressure support mode) [19] and non-invasive ventilation (almost never in fully controlled ventilation mode) [20] are encouraged. Even in the operating theatre, general anaesthesia has been frequently replaced by regional anaesthesia allowing a spontaneous breathing during the surgical procedure [21] .

2352-5568/ 2015 Published by Elsevier Masson SAS on behalf of the Socie´ te´ franc¸ aise d’anesthe´ sie et de re´ animation (Sfar).

Downloaded from ClinicalKey.com at Universitas Tarumanagara April 27, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.

10

Editorial / Anaesth Crit Care Pain Med 34 (2015) 9–10

Last, arrhythmia is a frequent condition in ICU patients [22] and acute cor pulmonale and abdominal hypertension are not excep- tional, especially in patients in circulatory failure, i.e., patients in whom an index guiding fluid management may be helpful. For all these reasons, nowadays, very few patients satisfy all criteria for valid use of PPV in the ICU, and in a lesser extent in the operating theatre. Indeed, in a recent multicentric one-day observational study in 26 French ICUs (311 patients), only 2% of ICU patients (3% of those carrying an arterial line) satisfied all validity criteria for PPV, as defined by the authors [23] . In the current issue of Anaesthesia, Critical Care and Pain Medicine , Fischer et al. reported a similar prevalence (1.3%) of patients in whom the predictive performance of PPV was valid, i.e., not flawed by clinical factors. The study also took place in French ICUs (465 patients in 36 ICUs) with a one-day observational design. In addition, among patients who received volume expansion during a half-day observation period, PPV was used in 10% of patients [24] . This last finding is consistent with what was also recently observed in French ICUs: nearly 5% of fluid boluses in the 4 first days of shock were associated with a measurement of PPV [25] .

Hence, current knowledge in the field of prediction of fluid responsiveness with PPV could be summarised as follows: PPV is a reliable tool only if used in the right patients, i.e., in patients satisfying all criteria for the valid use of this index including regular cardiac rhythm, mechanical ventilation with no spontane- ous breathing, sufficient ( 8 mL/kg) tidal volume (and sufficient heart rate/respiratory rate ratio) and absence of acute cor pulmonale. On the one hand, these specific patients are seldom in the ICU setting (1–2%) as compared with the operating theatre (39% of anaesthetised patients [26] ). On the other hand, the use of PPV is often tempting as PPV is nowadays automatically displayed on several modern monitors. Therefore, it is important that physicians acknowledge those monitors display misleading values of PPV in most of the patients. This implies a sufficient knowledge of PPV criteria of validity among anaesthetists and intensivists. In the same issue of the Anaesthesia, Critical Care and Pain Medicine , Fischer et al. reported that the knowledge of their pairs ( n = 145) about PPV criteria of validity was clearly insufficient [27] . Before the conduction of a fourth wave of studies such as studies putting PPV to work into fluid management algorithms, educational efforts about the correct use of PPV should be encouraged.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

References

[5]

[14]

[16]

intraoperative applicability in a North American academic center. Anesthes Analg 2011;112:94–6. [27] Fischer MO, Dechanet F, du Cheyron D, Ge´ rard JL, Hanouz JL, Fellahi JL. Evaluation of French Intensivists and Anesthesiologists for the interpretation of the respiratory arterial pulse pressure variation. Anesth Crit Care Pain Med 2015;1 . http://dx.doi.org/10.1016/j.accpm.2014.06.001 . [28] Lakhal K, Ehrmann S, Boulain T. Pulse pressure variation: does lung compli- ance really matter? Crit Care Med 2012;40:1691.

Karim Lakhal a , * a Re´ animation chirurgicale polyvalente, service d’anesthe´ sie-re´ animation, hoˆ pital Lae¨nnec, CHU, boulevard Jacques-Monod, 44093 Nantes cedex 1, France

Matthieu Biais b , c b Emergency department, University hospital of Bordeaux, 33076 Bordeaux cedex, France c Inserm U1034, Cardiovascular Adaptation to Ischemia, National Institute of Health and Medical Research, 33600 Pessac, France

* Corresponding author E-mail address: lakhal_karim@yahoo.fr (K. Lakhal), E-mail address: matthieu.biais@chu-bordeaux.fr (M. Biais)

Downloaded from ClinicalKey.com at Universitas Tarumanagara April 27, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.