Continuous, noninvasive hemoglobin measurement via Pulse CO-Oximetry demonstrated clinically acceptable accuracy of hemoglobin measurement within 1.5 g/dL compared with a standard laboratory reference device when used during complex spine surgery. This technology may provide more timely information on hemoglobin status than intermittent blood sample analysis and thus has the potential to improve blood management during surgery.

gray zone was also evaluated. Two hundred nine (51%) of the responders and 204 nonresponders (49%) to VE were observed. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.86Y0.92) compared with 0.57 (95% confidence interval, 0.54Y0.59) for central venous pressure. The gray zone approach identified a range of PPV values (between 9% and 13%) for which fluid responsiveness could not be predicted reliably. Such PPV values were seen in 98 patients (24%). Changes in the cost ratio of VE had a moderate effect on gray zone limits. Notwithstanding a strong predictive value, PPV may be inconclusive (between 9% and 13%) in approximately 25% of patients during general anesthesia. COMMENTThis is an excellent investigation because it goes beyond the usual binary results of most studies and provides a rationale for how to tailor information to optimize the care of a specific patient or patient type. This is a simple, yet often difficult, task to accomplish. In this case, the authors created 3 ranges of PPV measurements. They were likely to increase cardiac output, unlikely to increase cardiac output, and unable to predict the effect on cardiac output.Providers often need to use their best judgment when managing a patient in this gray zone. The current investigators provide a rationale for how to adjust one's management based on the relative importance of avoiding excessive volume administration versus preference to use volume rather than inotropic agents to improve cardiac output.

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