Journal of Anesthesia (2018) 32:316–325
Positive end‑expiratory pressure‑induced increase in external jugular
venous pressure does not predict uid responsiveness in laparoscopic
· Seokha Yoo
· Jung‑Yoon Choi
· Sun‑Kyung Park
· Dhong Eun Jung
· Won Ho Kim
· Jin‑Tae Kim
Received: 9 December 2017 / Accepted: 22 February 2018 / Published online: 27 February 2018
© Japanese Society of Anesthesiologists 2018
Background Dynamic change in central venous pressure (CVP) was associated with ﬂuid responsiveness. External jugular
venous pressure (EJVP) may reliably estimate CVP and have the advantages of being less invasive. We investigated whether
increase in EJVP induced by positive end-expiratory pressure (PEEP) could be a reliable predictor of ﬂuid responsiveness
in patients undergoing robot-assisted laparoscopic prostatectomy (RALP).
Methods Fifty patients who underwent RALP with steep Trendelenburg position were enrolled. PEEP of 10 cmH
applied for 5 min and then 300 ml of colloid was administered. EJVP, stroke volume variation (SVV), and cardiac index
calculated by pulse contour method were measured before and after the PEEP challenge and colloid administration. Increase
in cardiac index > 10% was used to deﬁne the ﬂuid responsiveness.
Results Twenty-six patients were ﬂuid responders. Neither the increase in EJVP after the initial PEEP nor SVV was signiﬁ-
cantly diﬀerent between responders and non-responders. They were not signiﬁcantly correlated with an increase in cardiac
index. The areas under the receiver operating characteristic curve (AUC) of these two variables were not signiﬁcantly greater
than 0.5. However, a post hoc analysis revealed that AUC of a decrease in EJVP after removal of PEEP was signiﬁcantly
greater than 0.50.
Conclusion Our study results suggested that SVV and increase in EJVP after applying PEEP were not accurate predictors of
ﬂuid responsiveness during RALP. Further studies are required to ﬁnd an adequate preload index in robot-assisted urologic
surgery with steep Trendelenburg position.
Keywords Laparoscopy · Robot surgery · Cardiac output · Central venous pressure · Fluid responsiveness
It is important to accurately predict a patient’s intravascular
volume status to properly manage the patient during surgery.
Inadequate blood pressure and cardiac output due to hypo-
volemia may result in tissue hypoperfusion, organ damage
and poor clinical outcomes [1, 2]. Therefore, maintaining
adequate cardiac preload and cardiac output is essential.
To predict the patient’s ﬂuid volume status, central venous
pressure (CVP) and pulmonary capillary wedge pressure
(PCWP) have been used as a surrogate for left ventricu-
lar ﬁlling pressures. In recent years, as the concept of ﬂuid
responsiveness has arisen, stroke volume variation (SVV)
has been validated for assessing intravascular volume sta-
tus for patients receiving mechanical ventilation. However,
these predictors have limitations under certain clinical set-
During robot-assisted laparoscopic urologic surgery
in steep Trendelenburg position, cardiac workload and
cerebral hemodynamics can be altered by the eﬀects of
patient’s position and CO
pneumoperitoneum [6–9]. CVP,
PCWP as well as arterial pressure increase markedly during
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0054 0-018-2475-y) contains
supplementary material, which is available to authorized users.
* Won Ho Kim
Department of Anesthesiology and Pain Medicine, Seoul
National University Hospital, 101 Daehak-ro, Jongno-gu,
Seoul 03080, Republic of Korea