Open Access Highly Accessed Research

Pulse-pressure variation and hemodynamic response in patients with elevated pulmonary artery pressure: a clinical study

Moritz Wyler von Ballmoos1, Jukka Takala1, Margareta Roeck1, Francesca Porta1, David Tueller1, Christoph C Ganter1, Ralph Schröder1, Hendrik Bracht1, Bertram Baenziger2 and Stephan M Jakob1*

Author Affiliations

1 Department of Intensive Care Medicine, Bern University Hospital and University of Bern (Inselspital), Freiburgstrasse 10, 3010 Bern, Switzerland

2 Department of Anesthesiology and Pain Therapy, Bern University Hospital and University of Bern (Inselspital), Freiburgstrasse 10, 3010 Bern, Switzerland

For all author emails, please log on.

Critical Care 2010, 14:R111  doi:10.1186/cc9060


See related commentary by Madger, http://ccforum.com/content/14/5/197

Published: 11 June 2010

Abstract

Introduction

Pulse-pressure variation (PPV) due to increased right ventricular afterload and dysfunction may misleadingly suggest volume responsiveness. We aimed to assess prediction of volume responsiveness with PPV in patients with increased pulmonary artery pressure.

Methods

Fifteen cardiac surgery patients with a history of increased pulmonary artery pressure (mean pressure, 27 ± 5 mm Hg (mean ± SD) before fluid challenges) and seven septic shock patients (mean pulmonary artery pressure, 33 ± 10 mm Hg) were challenged with 200 ml hydroxyethyl starch boli ordered on clinical indication. PPV, right ventricular ejection fraction (EF) and end-diastolic volume (EDV), stroke volume (SV), and intravascular pressures were measured before and after volume challenges.

Results

Of 69 fluid challenges, 19 (28%) increased SV > 10%. PPV did not predict volume responsiveness (area under the receiver operating characteristic curve, 0.555; P = 0.485). PPV was ≥13% before 46 (67%) fluid challenges, and SV increased in 13 (28%). Right ventricular EF decreased in none of the fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.0003). EDV increased in 28% of fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.272).

Conclusions

Both early after cardiac surgery and in septic shock, patients with increased pulmonary artery pressure respond poorly to fluid administration. Under these conditions, PPV cannot be used to predict fluid responsiveness. The frequent reduction in right ventricular EF when SV did not increase suggests that right ventricular dysfunction contributed to the poor response to fluids.