Application Of Dynamic Indices In Patients With Obstructive Jaundice In The Perioperative Period

Perioperative fluid administration is one of essential preventative strategiesto control the postoperative complications and mortality in patients. The current,routinely used static indicators of cardiac preload have been shown to be poorpredictors of fluid responsiveness. Previous studies have shown that the dynamicvariables such as stroke volume variation (SVV), pulse pressure variation (PPV)or pleth variability index (PVI) could be successfully used for predicting fluidresponsiveness in different patient populations, with the suggestion that theseapproaches could improve postoperative outcomes. However, the validation ofSVV and PPV in patients with obstructive jaundice has not been studied so far.The aim of this study was to validate the ability of SVV, PPV and PVI topredict fluid responsiveness in patients with obstructive jaundice, and thesedynamic indexes’ influence on postoperative morbidity and mortality.PartⅠAssessment of dynamic indices for predicting fluid responsiveness inpatients with obstructive jaundiceObjective: To validate the ability of SVV, PPV and PVI to predict fluidresponsiveness in mechanically ventilated patients with obstructivejaundice.Methods: Thirty-five patients with obstructive jaundice received volumeexpansion with250mlcolloids immediately after induction of anesthesia or afteran exploratory laparotomy had been completed. Hemodynamic variables wererecorded before and after volume expansion. Fluid responsiveness was defined asan increase in stroke volume index>10%after volume expansion. The ability ofSVV, PPV and PVI to predict fluid responsiveness was assessed by calculation ofthe area under the receiver operating characteristic (ROC) curve. Results:Preoperative volume expansion, the area under ROC curves of SVV, PPV and PVIwere0.955,0.875and0.593respectively. The optimal threshold (sensitivity andspecificity,%) values in predicting fluid responsiveness were10%(100.0/92.3)for SVV,8%(91.7/69.2) for PPV and13%(58.3/53.8) forPVIrespectively.Intraoperative volume expansion, the area under ROC curves of SVV, PPV and PVI were0.699,0.710and0.567respectively. The optimalthreshold (sensitivity and specificity,%) values in predicting fluid responsivenesswere10%(45.5/85.73) for SVV,7.5%(63.6/71.4) for PPV and15%(63.6/57.1)for PVIrespectively. Conclusion: Preoperatively, SVV and PPV were able topredict fluid responsiveness, PVI was not shown to be a reliable predictor of fluidresponsiveness in patients with obstructive jaundice.Intraoperatively, SVV andPVI were not reliable predictors of fluid responsiveness, but PPV has some valuepredicting fluid responsiveness in patients with obstructive jaundice.PartⅡIntraoperative fluid optimization using pulse pressure variation inpatients with obstructive jaundiceObjective: To evaluate the influence of PPV guided perioperative fluidoptimization on postoperative outcomes in patients with obstructive jaundice.Methods: Sixty patients with obstructive jaundice undergoing elective abdominalsurgery were randomized to the PPV group (n=30) or to the control group (n=30).In PPV group, fluid treatment was guided by PPV, which was minimized to8%orless by volume loading. In control group, fluid treatment was performed at thediscretion of the treating anesthesiologist. The lactate levels in perioperativeperiod, the number of infectious and organ complications on day30after theoperation, and the hospital and ICU length of stay and mortality were evaluated.Results: During surgery, PPV group received more colloid than control group(1245±350VS776±391ml，P＜0.001), there were no significant differences inthe amount of fluids balance and the number of patients receiving vasopressorsbetween the groups. Lactate levels at the end of surgery were lower in PPVgroup(1.45±0.63VS1.93±0.88mmol/L，P=0.024). The result showed a trendtowards fewer postoperative complications in the PPV group (25.9%VS39.3%，P=0.291), but without reaching statistical significance. There were no significantdifferences between the two groups for mortality, length of hospital stay andlength of ICU stay. Conclusion: Intraoperative fluid optimization using PPV hassome value to reduce postoperative complications in patients with obstructivejaundice.