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Response to Han et al

In reply: We appreciate the insightful comments of Dr Han and colleagues regarding our report in which we demonstrate that dynamic preload variables do not predict fluid responsiveness in pediatric patients with liver cirrhosis.1 We agree that applying a protective ventilation setting may influence the accuracy of dynamic preload variables. However, we speculate that these influences are irrelevant for the following reasons. First, dynamic preload variables, such as pulse pressure variation, are reliable in H:\journals\W3G\PAN\13898\ PAN_13898.xml dicators at tidal volumes of ≧8 mL/kg.2 Accordingly, we set the tidal volume and positive end-expiratory pressure (PEEP) at 8 mL/kg and 5 cmH2O, respectively, in our previous study, which investigated dynamic preload variables among adults with liver cirrhosis, and found the accuracy of three dynamic variables, namely pulse pressure variation, stroke volume variation, and plethysmographic variability index, to be acceptably reliable.3 Therefore, we consider the tidal volume setting to be less likely relevant to the discrepant accuracy between adult and child patients with cirrhosis that results from the use of dynamic preload variables. Second, the influence of PEEP on dynamic preload variables may be subtle if the PEEP is set below 10 cmH2O. 4 Therefore, we did neither consider the PEEP of 5 cmH2O to be a significant factor in our study. We agree with the suggestions to be cautious in applying our findings to cirrhotic children with hyperdynamic circulation. Diagnosis of hyperdynamic circulation is difficult because accurate measurements of cardiac output and systemic vascular resistance are mandatory; thus, the choice of hemodynamic measurement is crucial. Although studies using transthoracic echocardiography have revealed a high incidence of hyperdynamic circulation among children with cirrhosis, our results indicate a low incidence of hyperdynamic circulation, a result compatible with that of a recent study by de Magnée et al Both studies used the transpulmonary thermodilution method.5 In addition, portal hypertension was common in the patient cohort in the study by de Magnée et al, regardless of the presence or absence of hyperdynamic circulation. This reflects the difficulty and discrepancies in diagnosing hyperdynamic circulation through various methods. Further research is warranted for investigating the accuracy of dynamic preload variables among children with cirrhosis and hyperdynamic circulation.