Abstract
Fluid infusion is one of the most common critical care interventions, yet approximately 50 % of all fluid interventions are unnecessary and potentially harmful. An improved approach to identification of fluid responsiveness is of clinical importance. Currently fluid responsiveness is most frequently identified by blood pressure (BP) measurements or a surrogate. However fluid responsiveness is simply the increase in stroke volume (SV) associated with volume expansion, and may not be reflected in BP or BP surrogates. Guyton demonstrated that BP = CO x SVR, and it is know that baroreceptor mediated autonomic nervous system regulation of SV and SVR to preserve BP may mask significant and critical changes in haemodynamics. Dr Pinsky in his recent J Clin Monit Comput Editorial evaluated the relative merits of pulse pressure variability (PPV) methods, a variant on BP measurement, for assessment of fluid responsiveness and promoted the use of physiologic challenges to augment the applicability of PPV. However this guidance is only half right. This letter reminds clinicians of the physiologic limitations of PPV as a measure of fluid responsiveness, even when combined with physiologic challenges, and recommends the replacement of BP with SV measurements. The combination of accurate Doppler measurement of SV and physiologic challenges, as Dr Pinsky recommends, is a physiologically rational and effective approach to identification of fluid responsiveness with established evidence. The direct monitoring of SV and SV changes has the potential to improve a long standing critical care and anaesthetic conundrum; when to give fluid and when to stop.
Highlights
While we have the utmost respect for both the great baseball philosopher Yogi Berra and Michael Pinsky, it would seem that in Pinsky’s recent Editorial ‘‘It is amazing what you can see if you look’’ on fluid responsiveness and physiologic challenges, we have been provided with only half the clues [1].Dr Pinsky’s central point is that physiologic challenges improve the effectiveness and applicability of pulse pressure variability (PPV) monitoring for identifying fluid responsiveness, and this is incontestable
Dr Pinsky in his recent J Clin Monit Comput Editorial evaluated the relative merits of pulse pressure variability (PPV) methods, a variant on blood pressure (BP) measurement, for assessment of fluid responsiveness and promoted the use of physiologic challenges to augment the applicability of PPV
While detection of fluid responsiveness by PPV is limited to approximately 2–51 % of ICU patients [2, 3], Pinsky suggests that dPPV before and after a dynamic physiologic challenge can improve this applicability
Summary
Dr Pinsky’s central point is that physiologic challenges improve the effectiveness and applicability of PPV monitoring for identifying fluid responsiveness, and this is incontestable. While detection of fluid responsiveness by PPV is limited to approximately 2–51 % of ICU patients [2, 3], Pinsky suggests that dPPV before and after a dynamic physiologic challenge can improve this applicability.
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