Original article
Monitoring pulse pressure variation during lung resection surgery
Monitorización de la variación de la presión de pulso durante la cirugía de resección pulmonar
J.M. Nieves Alonso
, E. Alday Muñoz, A. Planas Roca
Corresponding author
Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario de La Princesa, Madrid, Spain
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VPP_T1: decúbito lateral, ventilación bipulmonar (8<span class="elsevierStyleHsp" style=""></span>ml/kg), tórax cerrado (previo al colapso pulmonar); VPP_T2: decúbito lateral, ventilación unipulmonar (6<span class="elsevierStyleHsp" style=""></span>ml/kg), tórax abierto (minuto 5); VPP_T3: decúbito lateral, ventilación unipulmonar (6<span class="elsevierStyleHsp" style=""></span>ml/kg), tórax abierto (justo antes de reiniciar ventilación bipulmonar); VPP_T4: decúbito lateral, ventilación bipulmonar (8<span class="elsevierStyleHsp" style=""></span>ml/kg), tórax cerrado (minuto 5).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Nieves Alonso, E. Alday Muñoz, A. Planas Roca" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Nieves Alonso" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Alday Muñoz" ] 2 => array:2 [ "nombre" => "A." 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Nieves Alonso, E. Alday Muñoz, A. Planas Roca" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Nieves Alonso" "email" => array:1 [ 0 => "jesusmna@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Alday Muñoz" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Planas Roca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorización de la variación de la presión de pulso durante la cirugía de resección pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 1582 "Tamanyo" => 74759 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PPV variation at different measurement points. VPP_T1: lateral decubitus, bipulmonary ventilation (8<span class="elsevierStyleHsp" style=""></span>ml/kg), closed chest (prior to pulmonary collapse); VPP_T2: lateral decubitus, one-lung ventilation (6<span class="elsevierStyleHsp" style=""></span>ml/kg), open chest (minute 5); VPP_T3: lateral decubitus, one-lungventilation (6<span class="elsevierStyleHsp" style=""></span>ml/kg), open chest (immediately before restarting bipulmonary ventilation); VPP_T4: lateral decubitus, bipulmonary ventilation (8<span class="elsevierStyleHsp" style=""></span>ml/kg), closed thorax (minute 5).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Restrictive and goal-directed fluid therapy have helped decrease perioperative morbidity in major abdominal surgery<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> by minimising organ hypoperfusion and the risk of acute renal failure.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In lung resection, liberal fluid therapy has been associated with an increased incidence of acute postoperative lung injury.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Pulse pressure variation (PPV) is an effective and widely used dynamic parameter to predict increased cardiac output after fluid administration. Ideally, PPV should be measured with the thorax closed and the patient receiving mechanical ventilation with a tidal volume of 8<span class="elsevierStyleHsp" style=""></span>ml/kg,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,5</span></a> which is why its use in thoracic surgery remains controversial.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to determine PPV values following the start of one-lung ventilation (OLV), and to study the correlation between PPV values before and after the chest opening. As secondary objectives, we determined the correlation between PPV values before and after chest closure, and studied whether PPV values vary according to the surgical approach (videothoracoscopy vs. thoracotomy) and according to compliance in one-lung ventilation (compliance ≥30 vs. <span class="elsevierStyleMonospace"><</span>30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prospective observational study. After obtaining approval from the hospital's ethics committee and informed consent from study subjects, consecutive patients scheduled for open (thoracotomy) or closed (videothoracoscopy) lung surgery were selected in a single centre in Spain.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">We included patients aged ≥18 years scheduled for lobar or sublobar lung resection with ONV lasting at least 60<span class="elsevierStyleHsp" style=""></span>min, with invasive blood pressure monitoring during surgery. Patients with arrhythmias, right ventricular dysfunction and pacemakers were excluded. Patients presenting intraoperative bleeding >200<span class="elsevierStyleHsp" style=""></span>ml and/or mean intraoperative arterial pressure <span class="elsevierStyleMonospace"><</span>60<span class="elsevierStyleHsp" style=""></span>mmHg and who required vasoactive drugs 15<span class="elsevierStyleHsp" style=""></span>min before measurement of PPV were also excluded.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Anaesthesia protocol</span><p id="par0035" class="elsevierStylePara elsevierViewall">Prior to induction, an epidural catheter was placed and intravenous induction was performed with propofol 2<span class="elsevierStyleHsp" style=""></span>mg/kg, rocuronium 0.6<span class="elsevierStyleHsp" style=""></span>mg/kg and fentanyl 5.4<span class="elsevierStyleHsp" style=""></span>mcg/kg. Anaesthesia was maintained with sevoflurane or desflurane, boluses of rocuronium 0.3<span class="elsevierStyleHsp" style=""></span>mg/kg, fentanyl 2.1<span class="elsevierStyleHsp" style=""></span>mcg/kg and/or epidural boluses of 0.25% bupivacaine 3-5<span class="elsevierStyleHsp" style=""></span>ml/h. A left-sided double lumen tube was inserted for intubation, using fibreoptic bronchoscopy to verify placement. The radial artery was cannulated in all patients, and zero pressure was located at the level of the right atrium (4th right intercostal space with median axillary line).</p><p id="par0040" class="elsevierStylePara elsevierViewall">After placing the patient in lateral decubitus and re-checking the position of the double-lumen tube, step-wise alveolar recruitment was performed, obtaining optimal positive end-expiration pressure (PEEP) in all patients, and bipulmonary volume controlled ventilation was delivered with a tidal volume of 8<span class="elsevierStyleHsp" style=""></span>ml/kg of ideal weight. OLV was started before the start of trocar insertion or thoracotomy, decreasing tidal volume (Vt) to 6<span class="elsevierStyleHsp" style=""></span>ml/kg ideal weight. After completing the intervention, bipulmonary ventilation with a Vt of 8<span class="elsevierStyleHsp" style=""></span>ml/kg ideal weight was restarted. All patients received fluid replacement with 2-4<span class="elsevierStyleHsp" style=""></span>ml/kg/h crystalloids.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">The following variables were collected prior to lung isolation (T1): heart rate, breathing rate, Vt, end tidal CO<span class="elsevierStyleInf">2</span> (EtCO<span class="elsevierStyleInf">2</span>), peak pressure (PP), plateau pressure, dynamic lung compliance, mean arterial pressure, and PPV.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Following collapse of the affected lung, the same variables were collected 5<span class="elsevierStyleHsp" style=""></span>min after chest opening (T2).</p><p id="par0055" class="elsevierStylePara elsevierViewall">The same variables were collected at the end of the procedure, immediately before lung re-expansion (T3), and 5<span class="elsevierStyleHsp" style=""></span>min after lung reexpansion and chest closure (T4) prior to alveolar recruitment.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Objectives</span><p id="par0060" class="elsevierStylePara elsevierViewall">The main objective of the study was to analyse the correlation between PPV at T1 (VPPT1) and T2 (VPPT2). Secondary objectives included: (1) correlation between PPV at T3 and T4 (VPPT3 and VPPT4); (2) difference in PPV values according to surgical approach (video-assisted thoracoscopy vs. thoracotomy); (3) and finally, to determine whether dynamic compliance <30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O at some point during surgery could affect the correlation between different PPV measurements.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Pulse pressure variation</span><p id="par0065" class="elsevierStylePara elsevierViewall">PPV was measured using the Carescape B850 (GE®) monitor, which calculates PPV at 5 second intervals by analysing the invasive blood pressure waveforms using the following equation:<elsevierMultimedia ident="eq0005"></elsevierMultimedia>where PPmax is the maximum pulse pressure and PPmin is the minimum pulse pressure during each respiratory cycle.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">A sample size capable of detecting significant Pearson correlation coefficient values of ≥0.4 was calculated. Using standard alpha and beta levels of 0.05 and 0.2 and bilateral comparison, a sample size of 47 patients was required, which was increased to 50 to compensate for possible data losses.</p><p id="par0075" class="elsevierStylePara elsevierViewall">For the descriptive analysis of quantitative variables, mean and/or median were used as measures of central tendency, and standard deviation and/or 25th and 75th percentiles as measures of dispersion. Qualitative variables were shown as frequencies and proportions.</p><p id="par0080" class="elsevierStylePara elsevierViewall">PPV values during surgery were compared using repeated measures ANOVA.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The correlation between PPV values at different measurement points was studied using the Pearson correlation coefficient (<span class="elsevierStyleItalic">r</span>) and the coefficient of determination (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span>). Correlation coefficients were compared with each other using Fischer's <span class="elsevierStyleItalic">Z</span> transformation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The same analysis was performed taking compliance values above and below 30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O as a covariable.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05, and statistical analysis was performed with IBM SPSS 23.0.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">Data from 50 patients were analysed. Patient demographics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Mean PPV decreased to 56.0% and 51.9% over baseline at T2 and T3 (open chest) and recovered to 70.4% over baseline after chest closure (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The mean PPV plus standard deviation (SD) at different measurement points were (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>): T1, 11.14% (6.67); T2, 6.24% (3.21); T3, 5.68% (3.19), and T4, 7.84% (4.61). Repeated measures ANOVA found significant differences between mean PPV values at the different measurement points (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). Post hoc analysis showed that PPV was significantly higher at T1 compared with T2, T3 and T4 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.001 in all tests), PPV at T2 did not differ significantly from PPV at T3 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.000), but was significantly lower than at T4 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.013), and PPV at T3 was significantly lower than at T4 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.020).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The correlation between PPV values at T1 and T2 (VPPT1 and VPPT2) was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.868 ([<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.001], <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.753), while the correlation between T3 and T4 (VPPT3 and VPPT4) was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.616 ([<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001], <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.379).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Variations at VPPT1 and VPPT2 according to approach and lung compliance were also analysed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In patients undergoing thoracotomy, mean (SD) VPPT1 was 10.77% (4.64), decreasing to 5.92% (2.36) at VPPT2 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002), while in patients undergoing videothoracoscopy, mean (SD) VPPT1 was 11.27% (7.31), decreasing to 6.35% (3.49) at VPPT2 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The correlation coefficient between VPPT1 and VPPT2 in patients undergoing thoracotomy was 0.774 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002) and <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.882 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) in patients undergoing videothoracoscopy. No significant differences were observed between these correlation coefficients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.230).</p><p id="par0120" class="elsevierStylePara elsevierViewall">In patients with lung compliance ≥30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O, mean (SD) VPPT1 was 11.95% (7.21), decreasing to 6.63% (3.43) at VPP2 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001), while in patients with lung compliance <30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O, mean (SD) VPPT1 was 8.58% (3.78), decreasing to 5.00% (2.09) at VPP2 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). No significant differences were observed when comparing the correlation between VPPT1 and VPPT2 in patients with lung compliance ≥30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.866) and patients with lung compliance <30<span class="elsevierStyleHsp" style=""></span>ml/cmH<span class="elsevierStyleInf">2</span>O (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.830).</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The results of our study suggest that in pulmonary resection surgery in lateral decubitus, PPV undergoes a series of potentially predictable changes. PPV decreases by nearly half of the value observed during bipulmonary ventilation when the affected lung is collapsed and the chest opened (between T1 and T2). This could be due to several factors can. First, OLV causes a 20%–30% shunt flow through the nonventilated lung that does not contribute to cyclical pulse pressure variations.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Second, the decrease in tidal volume during OLV leads to a decrease in pleural and transpleural pressure variation and, consequently, a decrease in PPV<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7,8</span></a>; and third, most of the pressure generated by the positive ventilation is transmitted to the atmosphere through the open chest.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Subsequently, during open-chest OLV (between T2 and T3), PPV remains stable without major changes, with only minimal difference in values during surgery.</p><p id="par0135" class="elsevierStylePara elsevierViewall">At the end of the surgery, when the lung is reexpanded and the thorax is closed (between T3 and T4), PPV increases again but does not reach its baseline value. PPV at the end of the intervention (T4) does not reach its baseline value (T1), even though T2 and T3 values do not change during the intervention. It is difficult to explain this phenomenon, but we hypothesise that it can be due to: first, the presence of the pleural drainage tube; second, incomplete pulmonary reexpansion, since the measurements were taken before performing these manoeuvres; and third, surgery-induced haemodynamic and inflammatory changes.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Given that PPV values appear to be predictable during OLV, they could be used to predict response to volume replacement in these patients. In a recent meta-analysis, Piccioni et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> evaluated the role of stroke volume variation (SVV) and PPV to predict fluid responsiveness during open chest surgery. They analysed 7 studies in cardiac and thoracic surgery. The 4 studies in lung resection surgery showed contradictory results due to the small sample size and considerable differences in measurement strategies, fluid challenge and response variables. For this reason, the SVV and PPV during OLV and open chest surgery remains unknown.</p><p id="par0145" class="elsevierStylePara elsevierViewall">However, studies published to date provide some data that, in our opinion, are interesting and justify the performance of our observational study.</p><p id="par0150" class="elsevierStylePara elsevierViewall">First, PPV appears to be superior to SVV in OLV and open chest surgery. Fu et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> analysed the capacity of SVV and PPV to predict a 15% increase in stroke volume index after administration of 7<span class="elsevierStyleHsp" style=""></span>ml/kg of 6% hydroxyethyl starch over 15<span class="elsevierStyleHsp" style=""></span>min. They found that PPV had a higher sensitivity and specificity than VVS with different cut-off points and in the 2 groups of patients studied (Vt 6 vs. 8<span class="elsevierStyleHsp" style=""></span>ml/kg). Similarly, after fluid challenge during OLV in lung resection surgery Jeong et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> found no differences in SVV between responders and non-responders, but did find difference in PPV. This prompted us to describe the behaviour of PPV, not of SVV.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Secondly, the best area under the receiver-operating characteristics curve (AUC-ROC) threshold values for SVV and PPV are lower than expected when compared to reference values in patients in conventional ventilation and closed chest surgery.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9–11</span></a> Thus, PPV values greater than 7%–8% may predict haemodynamic response to fluid administration. Furthermore, these threshold values could be influenced by the Vt used. Lee et al. found that the optimal PPV threshold value to predict an increase of 15% in the cardiac index following administration of 7<span class="elsevierStyleHsp" style=""></span>ml/kg of colloids over 15<span class="elsevierStyleHsp" style=""></span>min was 5.8%. At this point, the AUC-ROC was 85.7% in patients with Vt 6<span class="elsevierStyleHsp" style=""></span>ml/kg in OLV, which was reduced to 52.4% in patients with Vt 10<span class="elsevierStyleHsp" style=""></span>ml/kg in OLV.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In our study, we did not find significant differences when comparing patients according to the surgical approach or lung compliance during OLV. Other authors have suggested that PPV during OLV in patients undergoing thoracotomy should be lower than in patients undergoing videothoracoscopic surgery.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> In our opinion, the intrathoracic pressure of the open hemithorax is equal to atmospheric pressure in both techniques, which would explain our findings.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The main limitation of our study is its observational design, which ruled out the possibility of performing volume prediction tests. However, the results obtained are favourable with respect to the predictive capacity of PPV, since the linear correlation between the PPV in closed and open chest surgery is very high. We also found that PPV in open chest surgery and in OLV, without changes in blood volume, are proportional and linearly lower than in closed chest interventions. This suggests that the threshold value to predict volume responsiveness is lower than the 10% value used in abdominal surgery. Undoubtedly, more studies are needed to confirm this finding. In our opinion, these should be designed with Vt 6<span class="elsevierStyleHsp" style=""></span>ml/kg in OLV, taking PPV as the reference parameter.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Secondly, volume responsiveness may be determined by a decrease in intravascular volume, by changes in vascular tone, or by both. In fact, some authors propose using the PPV/SVV ratio, called dynamic arterial elastance, to predict volume responsivenes in patients on mechanical or spontaneous ventilation.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">14,15</span></a> To control these factors, we excluded patients with >200cc blood loss or need for vasoactive drugs 15<span class="elsevierStyleHsp" style=""></span>min before measuring PPV. However, we did not control the relationship between these measurements and the time from administration of an epidural bolus.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0175" class="elsevierStylePara elsevierViewall">In conclusion, PPV is predictable during lung resection surgery. It is characterised by a decrease of almost half the baseline value at the beginning of OLV and chest opening, and subsequently remains stable throughout surgery when there are no changes in the volume.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1145558" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1075743" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1145559" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1075742" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Anaesthesia protocol" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Variables" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Objectives" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Pulse pressure variation" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-05" "fechaAceptado" => "2018-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1075743" "palabras" => array:3 [ 0 => "Haemodynamic monitoring" 1 => "Pulse pressure variation" 2 => "Thoracic surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1075742" "palabras" => array:3 [ 0 => "Monitorización hemodinámica" 1 => "Variación de presión de pulso" 2 => "Cirugía torácica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Although pulse pressure variation (PPV) is an effective dynamic parameter widely used to predict the increase in cardiac output after the administration of fluids in abdominal surgery, its use in thoracic surgery is controversial. A study was designed to describe the behaviour of PPV during lung resection surgery.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was conducted on adult patients scheduled for lung resection surgery. Patients with bleeding greater than 200cc, or those who required vasopressors during data collection, were excluded. The PPV values were collected during different phases: in bipulmonary ventilation (T1), after the start of single lung ventilation, and the opening of the thorax (T2), at the end of the procedure prior to the restoration of the bipulmonary ventilation (T3), and after the closure of the thorax in bipulmonary ventilation (T4). The correlation coefficient of the PPV values at the different times was calculated.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 50 consecutive patients. The mean values and standard deviations of PPV in the different phases were: T1, 11.14% (6.67); T2 6.24% (3.21, T3 5.68% (3.19); and T4 7.84% (4.61). The repeated ANOVA measurements found significant differences between the mean values of PPV in the different phases (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The correlation between the PPV values during T1 and T2 (PPVT1 and PPVT2) was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.868 ([<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001], <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.753), while between T3 and T4 (PPVT3 and PPVT4) the correlation was <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.616 ([<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001], <span class="elsevierStyleItalic">r</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.379) between the PPV values in T3 and T4.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">PPV presents a predictable behaviour in the course of lung resection surgery, characterised by a decrease of almost half at the beginning of the unipulmonary ventilation and opening of the thorax. It then remains stable throughout the surgery when there are no changes in the intravascular blood volume.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La variación de presión de pulso (VPP) es un parámetro dinámico eficaz y ampliamente empleado para predecir el aumento del gasto cardiaco tras la administración de fluidos en cirugía abdominal, sin embargo su uso en cirugía torácica es controvertido. Se diseñó un estudio para describir el comportamiento de la VPP durante cirugía de resección pulmonar.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional prospectivo en pacientes adultos programados para cirugía de resección pulmonar. Se excluyeron los pacientes con sangrado mayor de 200cc o con necesidad de vasopresores durante la recogida de datos. Se recogieron los valores de la VPP durante diferentes fases: en ventilación bipulmonar (T1), tras el inicio de la ventilación unipulmonar y la apertura del tórax (T2), al finalizar el procedimiento previo a la reinstauración de la ventilación bipulmonar (T3) y tras el cierre del tórax en ventilación bipulmonar (T4). Se calculó el coeficiente de correlación de los valores de VPP en los diferentes momentos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 50 pacientes consecutivos. Los valores medios y desviaciones estándar de VPP en las diferentes fases fueron: T1: 11,14% (6,67); T2: 6,24% (3,21; T3: 5,68% (3,19) y T4: 7,84% (4,61). El ANOVA de medidas repetidas encontró diferencias significativas entre los valores medios de VPP en las diferentes fases (<span class="elsevierStyleItalic">p</span> <<span class="elsevierStyleHsp" style=""></span>0,001).</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La correlación entre los valores de VPP durante T1 y T2 (VPPT1 y VPPT2) fue de r = 0,868 ([<span class="elsevierStyleItalic">p</span> <<span class="elsevierStyleHsp" style=""></span>0,001], r2 = 0,753), mientras que entre T3 y T4 (VPPT3 y VPPT4) la correlación fue de r<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,616 ([<span class="elsevierStyleItalic">p</span> <<span class="elsevierStyleHsp" style=""></span>0,001], r2<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,379) entre los valores de VPP en T3 y T4.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La VPP presenta un comportamiento predecible en el transcurso de cirugía de resección pulmonar, caracterizado por una disminución de casi el 50% al inicio de la ventilación unipulmonar y apertura del tórax y posteriormente se mantiene estable a lo largo de la cirugía cuando no hay cambios en la volemia.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nieves Alonso JM, Alday Muñoz A, Planas Roca A. Monitorización de la variación de la presión de pulso durante la cirugía de resección pulmonar. Rev Esp Anestesiol Reanim. 2019;66:78–83.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 1582 "Tamanyo" => 74759 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PPV variation at different measurement points. VPP_T1: lateral decubitus, bipulmonary ventilation (8<span class="elsevierStyleHsp" style=""></span>ml/kg), closed chest (prior to pulmonary collapse); VPP_T2: lateral decubitus, one-lung ventilation (6<span class="elsevierStyleHsp" style=""></span>ml/kg), open chest (minute 5); VPP_T3: lateral decubitus, one-lungventilation (6<span class="elsevierStyleHsp" style=""></span>ml/kg), open chest (immediately before restarting bipulmonary ventilation); VPP_T4: lateral decubitus, bipulmonary ventilation (8<span class="elsevierStyleHsp" style=""></span>ml/kg), closed thorax (minute 5).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BMI: body mass index; FEV1: forced expiratory flow in the first second; SD: standard deviation; VTS: videothoracoscopic surgery.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient and intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (years); mean</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">±</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Women, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Men, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI (kg/m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">) mean (SD)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Preoperative FEV1: % of theoretical (DS)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of surgery; n (%)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lobectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (56) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilobectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Segmentectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (40) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Left sided surgery; n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (48) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Video-thoracoscopic surgery (VTS); n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (74) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955085.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Pc: pulmonary compliance; PPV: pulse pressure variation; R: Pearson's correlation coefficient; SD: standard deviation; VTS: videothoracoscopic surgery.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">r</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overall PPV, mean (DS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4% (6.67). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.24% (3.21). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.868 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV thoracotomy, mean (DS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.77% (4.64). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.92% (2.36). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.774 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV VTS, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.27% (7.31). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.35% (3.49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.882 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV Csr<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>30, mean (DS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.95% (7.21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.63% (3.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.866 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV Pc<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30, mean (DS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.58% (3.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.0% (2.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.830 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1955084.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Pulse pressure variation during surgery. 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