• Jeong Jin Min, Tae Kyong Kim, Jong-Hwan Lee, Jiyeon Park, Hyun Sung Cho, Wook Sung Kim, and Young Tak Lee.
• 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).
• Eur J Anaesthesiol. 2017 May 1; 34 (5): 254-261.

BackgroundPulse pressure variation (PPV) is a well known dynamic preload indicator of fluid responsiveness. However, its usefulness in open-chest conditions remains controversial.ObjectiveWe evaluated whether augmented PPV during a Valsalva manoeuvre can predict fluid responsiveness after sternotomy.DesignA prospective, observational study.SettingSingle-centre trial, study period from October 2014 to June 2015.PatientsForty-nine adult patients who underwent off-pump coronary arterial bypass grafting.InterventionAfter 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).Main Outcome MeasuresThe 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.ResultsTwenty-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).ConclusionAugmented PPV using a Valsalva manoeuvre can be used as a clinically reliable predictor of fluid responsiveness under open-chest condition.Trial RegistrationClinicalTrials.gov identifier: NCT02457572.

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