Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial

Published:December 16, 2022DOI:


      • What is currently known about this topic?
      • PVI has been shown to be an accurate predictor of fluid responsiveness in mechanically ventilated paediatric patients.
      • What new information is contained in this article?
      • PVI-guided fluid therapy is associated with faster recovery of bowel function & lower hemodilution after bowel surgery.



      PVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery.


      42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either ‘conventional liberal intraoperative fluids’ (liberal group) or ‘goal-directed intraoperative fluids’ (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes.


      The mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001).


      Intraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy.
      Type of study: Randomized Clinical Trial.
      Level of evidence: Treatment Study (LEVEL 1).



      BE (Base excess), ECG (Electrocardiogram), GDT (Goal directed therapy), MABL (Maximum allowable blood loss), MAP (Mean arterial pressure), PI (Perfusion index), PVI (Plethysmographic variability index), RL (Ringer's lactate), EBV (Estimated blood volume)
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        • Kendrick J.B.
        • Kaye A.D.
        • Tong Y.
        • Belani K.
        • Urman R.D.
        • Hoffman C.
        • et al.
        Goal-directed fluid therapy in a perioperative setting.
        J Anaesthesiol Clin Pharmacol. 2019; 35: S29-S34
        • Apfel C.C.
        • Meyer A.
        • Orhan-Sungur M.
        • Jalota L.
        • Whelan R.P.
        • Jukar-Rao S.
        Supplemental intravenous crystalloids for the prevention of postoperative nausea and vomiting: quantitative review.
        Br J Anaesth. 2012; 108: 893-902
        • Bundgaard N.M.
        • Secher N.H.
        • Kehlet H.
        ‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy—a critical assessment of the evidence.
        Acta Anaesthesiol Scand. 2009; 53: 843-851
        • Holliday M.A.
        • Segar W.E.
        The maintenance need for water in parenteral fluid therapy.
        Pediatrics. 1957; 19: 823-832
        • Marik P.E.
        • Cavallazzi R.
        Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense.
        Crit Care Med. 2013; 41: 1774-1781
        • Noblett S.E.
        • Snowden C.P.
        • Horgan A.F.
        Randomized clinical trial assessing the effect of Doppler –optimized fluid management on outcome after elective colorectal resection.
        Br J Surg. 2006; 93: 1069-1076
        • Lefrant J.Y.
        • Bruelle P.
        • Aya A.G.
        • Saissi G.
        • Dauzat M.
        • de La Coussage J.E.
        • et al.
        Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients.
        Intensive Care Med. 1998; 24: 347-352
        • Bedford R.F.
        • Wollman H.
        Complications of percutaneous radial-artery cannulation: an objective prospective study in man.
        Anesthesiology. 1973; 38: 228-236
        • Bagci S.
        • Muller N.
        • Muller A.
        • Heydweiller A.
        • Bartmann P.
        • Franz A.R.
        A pilot study of the pleth variability index as an indicator of volume-responsive hypotension in newborn infants during surgery.
        J Anesth. 2013; 27: 192-198
        • de Souza Neto E.P.
        • Grousson S.
        • Duflo F.
        • Ducreux C.
        • Joly H.
        • et al.
        Predicting fluid responsiveness in mechanically ventilated children under general anesthesia using dynamic parameters and transthoracic echocardiography.
        Br J Anaesth. 2011; 106: 856-864
        • Desgranges F.P.
        • Evain J.N.
        • de Souza Neto E.P.
        • Raphael D.
        • Desebbe O.
        • et al.
        Does the plethysmographic variability index predict fluid responsiveness in mechanically ventilated children? A meta-analysis.
        Br J Anaesth. 2016; 117: 409-410
        • Blain S.
        • Paterson N.
        Paediatric massive transfusion.
        BJA Educ. 2016; 16: 269-275
        • Yu Y.
        • Dong J.
        • Xu Z.
        • Shen H.
        • Zheng J.
        Pleth variability index-directed fluid management in abdominal surgery under combined general and epidural anesthesia.
        J Clin Monit Comput. 2015; 29: 47-52
      1. Puri S, Bandyopadhyay A, Ashok V. Supplemental intraoperative crystalloids for paediatric on postoperative nausea and vomiting - A systematic review and meta-analysis. Pediatr Anesth.

        • Forget P.
        • Lois F.
        • de Kock M.
        Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management.
        Anesth Analg. 2010; 111: 910-914
        • Byon H.J.
        • Lim C.W.
        • Lee J.H.
        • Park Y.H.
        • Kim H.S.
        • Kim C.S.
        Prediction of fluid responsiveness in mechanically ventilated children undergoing neurosurgery.
        Br J Anaesth. 2013; 110: 586-591
        • Schloss B.
        • Naguib A.
        • Bissonnette B.
        • Winch P.
        • Rice J.
        • Mark G.
        • et al.
        Plethysmography variability index response to isovolemic hemodilution in children prior to surgery for congential heart disease.
        J Pediatr Intensive Care. 2014; 3: 35-40
        • Fischer M.O.
        • Pellissier A.
        • Saplacan V.
        • Gérard J.L.
        • Hanouz J.L.
        • Fellahi J.L.
        Cephalic versus digital plethysmographic variability index measurement: a comparative pilot study in cardiac surgery patients.
        J Cardiothorac Vasc Anesth. 2014; 28: 1510-1515
        • Ashok V.
        • Bala I.
        • Bharti N.
        • Jain D.
        • Samujh R.
        Effects of intraoperative liberal fluid therapy on postoperative nausea and vomiting in children – a randomized controlled trial.
        Ped Anesth. 2017; 27: 810-815
        • Mandee S.
        • Butmangkun W.
        • Aroonpruksakul N.
        • Tantemsapya N.
        • Bormann B.V.
        • Suraseranivongse S.
        Effects of a restrictive fluid regimen in pediatric patients undergoing major abdominal surgery.
        Pediatr Anesth. 2015; 25: 530-537
        • Nisanevich V.
        • Felsenstein I.
        • Almogy G.
        • Weissman C.
        • Einav S.
        • Matot I.
        Effect of intraoperative fluid management on outcome after intra-abdominal surgery.
        Anesthesiology. 2005; 103: 25-32
        • Corcoran T.
        • Rhodes J.E.J.
        • Clarke S.
        • Myles P.S.
        • Ho K.M.
        Perioperative fluid management strategies in major surgery: a stratified meta-analysis.
        Anesth Analg. 2012; 114: 640-651
        • Marik P.E.
        • Cavallazzi R.
        • Vasu T.
        • Hirani A.
        Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature.
        Crit Care Med. 2009; 37: 2642-2647
        • Gan H.
        • Cannesson M.
        • Chandler J.R.
        • Ansermino J.M.
        Predicting fluid responsiveness in children: a systematic review.
        Anesth Analg. 2013; 117: 1380-1392
        • Mery C.M.
        • De León L.E.
        • Rodriguez J.R.
        • Nieto R.M.
        • Zhang W.
        • Adachi I.
        • et al.
        Effect of gastrointestinal malformations on the outcomes of patients with congenital heart disease.
        Ann Thorac Surg. 2017; 104: 1590-1596
        • Monnet X.
        • Guérin L.
        • Jozwiak M.
        • Bataille A.
        • Julien F.
        • Richard C.
        • et al.
        Pleth variability index is a weak predictor of fluid responsiveness in patients receiving norepinephrine.
        Br J Anaesth. 2013; 110: 207-213