Stroke volume variation obtained with FloTrac/VigileoTM fails to predict fluid responsiveness in coronary artery bypass graft patients
Utrecht, The Netherlands Aachen, Germany
* E-mail: e.e.c.dewaal{at}azu.nl
Editor—Recently, a new cardiac output monitoring device (VigileoTM, Edwards Lifesciences, Irvine, CA, USA) has been introduced in clinical practice which is based on arterial pulse contour lacking the necessity of external calibration.1 This device offers the possibility of a nearly beat-to-beat measurement of cardiac output, stroke volume, and stroke volume variation (SVV). In patients undergoing coronary artery bypass grafting (CABG), this system has been demonstrated to measure cardiac output with clinically acceptable accuracy.2 However, the reliability of SVV measured with this system in predicting fluid responsiveness is unknown. We therefore studied 18 CABG patients monitored with a FloTrac/VigileoTM-system (using software version 01.01) to analyse whether this new device is suited for functional preload monitoring.
Fourteen male and four female patients [67 (7) yr, 79 (9) kg, 174 (9) cm, mean (SD), and BSA range 1.69–2.20 m2] undergoing CABG surgery were included in this study. The study was approved by the institutional review board. All patients had given written informed consent. Stroke volume index (SVI) was measured with transpulmonary thermodilution (PiCCOTM, Pulsion Medical Systems, Munich, Germany) before and after a volume load (VL) of 10 ml·kg–1 hydroxyethyl starch 6% 1 h after arrival of the patients on the intensive care unit. In addition, central venous pressure (CVP) and SVV were recorded. Patients were mechanically ventilated (volume control) with a tidal volume of 8 ml·kg–1 (FIO2 0.4, PEEP 5 cm H2O) maintaining normocapnia. According to the available literature, fluid-responders were defined by an increase in SVI
12% subsequent to the VL.3 Statistical analysis was performed using SPSS version 15.0 (SPSS Inc, Chicago, IL, USA). Pearson's correlation analysis was used to describe the linear relation between preload parameters before a VL and the change in SVI (
SVI) induced by that VL. The ability to predict fluid responsiveness was quantified for each preload parameter by calculating the area under the receiver operating characteristic (ROC) curve.4 A P-value of <0.05 was considered statistically significant.
Nine patients did not respond to the fluid load. The correlation coefficient for the relationship between SVI and CVP prior to the volume load was 0.244 (P=0.329), and between SVI and SVV 0.452 (P=0.069). ROC analysis showed that both preload indicators failed to predict fluid responsiveness. The area under the ROC curve for CVP and for SVV were 0.685 (P=0.185) and 0.660 (P=0.268) respectively.
The failure of CVP in predicting fluid responsiveness is in accordance with increasing evidence that static preload indicators are not suited for functional haemodynamic monitoring.5 In contrast, a growing number of clinical studies have clearly demonstrated the ability of dynamic preload indicators (including SVV) to accurately predict the response of an individual patient to a volume challenge.6 7 In contrast to these reports, we found SVV (obtained with the FloTrac/VigileoTM system) failed to predict fluid responsiveness. This finding might be attributed to the fact that in our system, the first software generation (version 01.01) was implemented. This version operates with a re-calibration interval of 10 min, which is probably too long to accurately measure changes in respiratory variations in the arterial pressure curve. In fact, by employing shorter re-calibration intervals in a newer software version, the accuracy of the FloTrac/VigileoTM system in measuring cardiac output had been markedly improved.8 Therefore, our findings warrant further investigation whether the application of shorter re-calibration intervals will allow using the FloTrac/VigileoTM system for functional haemodynamic monitoring.
References
1 Manecke GR. Edwards FloTrac sensor and Vigileo monitor: easy, accurate, reliable cardiac output assessment using the arterial pulse wave. Expert Rev Med Devices (2005) 2:523–7.[CrossRef][Web of Science][Medline]
2 De Waal EEC, Kalkman CJ, Rex S, Buhre WF. Validation of a new arterial pulse contour-based cardiac output device. Crit Care Med (2007) 35:1904–9.[CrossRef][Web of Science][Medline]
3 Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology (2005) 103:419–28.[CrossRef][Web of Science][Medline]
4 Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology (1983) 148:839–43.
5 Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med (2007) 35:1–5.[CrossRef][Web of Science]
6 Rex S, Brose S, Metzelder S, et al. Prediction of fluid responsiveness in patients during cardiac surgery. Br J Anaesth (2004) 93:782–8.
7 Reuter DA, Felbinger TW, Schmidt C, et al. Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med (2002) 28:392–8.[CrossRef][Web of Science][Medline]
8 Button D, Weibel L, Reuthebuch O, Genoni M, Zollinger A, Hofer CK. Clinical evaluation of the FloTrac/Vigileo system and two established continuous cardiac output monitoring devices in patients undergoing cardiac surgery. Br J Anaesth (2007) 99:329–36.
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