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Fluid responsiveness in

the ICU
To bolus or not to bolus
that is the question.
PulmCrit.com

Case
49

yo M is BIB ambulance after being found down by friends last seen 48 hours earlier

Initial

VS: 101.5F 85/50 102 27 83%/RA Poor mental status

PE

significant for an unresponsive obese disheveled man, LE edema, crackles on lung


exam GCS 7

In

ED: Intubated, anti-bx, 2L crystalloid, Levofed. After intubation requiring 80% FIO2/10
PEEP for sats 92%

Initial

labs: CBC: 13>9/27<150 CHEM: 131/4.9/100/18/28/2.7/200

Bedside

Echo showing tachycardia but normal cardiac function, no RV failure

CXR

large infiltrate in RLL and LLL

BNP

450, Trops neg, lactate 4.4, UA+ Cultures pending

Case
The

patient is anuric, hypotensive, septic, hypoxemic and has


bilateral lower extremity edema

What

do you do next?

A Give a 1L Crystalloid challenge


B Give a 500 cc Crystalloid challenge
C Give 12.5 grams albumin
D Start Vasopressin
E Perform a passive leg raise (PLR) while monitoring PPV

Objectives
Define

the concept of volume


responsiveness

Understand

the pathophysiology of volume


responsiveness

Review

the various methods for measuring


volume responsiveness

What is fluid responsiveness aka


volume responsiveness?
A

measure of the patients response to a change in preload

Aim

is to try to combat tissue hypoperfusion

Increase

in stroke volume by 10-15% after the patient


receives 500 ml of crystalloid over 10-15 minutes

Fluid

responsive patients have preload reserve so will


increase stroke volume when given fluids

Predictors

of fluid response can be dynamic or static


Crit Care Med 2013;41:177481.

Signs of tissue hypoperfusion


Decreased
Increased

venous oxygen saturation

lactate levels

Oliguria
Altered

mental status/confusion

Clinical use of fluid responsiveness


To

predict fluid responsiveness, two methods must be


combined:

Generate the changes in preload

Measure the subsequent changes in stroke volume

Cardiac Output
CO=SVxHR

SV impacted by preload, afterload and cardiac =


contractility

Frank-Starling curve

Preload
Arthur

Guyton superimposed the venous return curve on the


cardiac function curve, as both are a function of RAP

Venous

return can be raised by 1) lowering RAP 2) decreasing


Rv, and 3) increasing MSFP

MSFP=Mean Systemic Filling Pressure

Venous return curve: Right atrial


pressure (RAP) vs. cardiac output

Neth Heart J. 2013 Dec; 21(12): 530536

Fluid challenges why not just


give to everyone a fluid bolus?
Cohort,

multiple-center, observational study 198 intensive


care units in 24 European countries.3,147 adult patients,
median age of 64 yrs, 1,177 (37.4%) had sepsis - A positive
fluid balance was among the strongest prognostic
factors for death

ARDSNet

: Cumulative fluid balance day 4 was predictive of


hospital mortality as well as ventilator- and ICU-free days

Crit Care Med 2006; 34: 34453.

Mechanical Ventilation & Cardiac


Output

MV vs. Spontaneous Breathing


affects CO/SV
Spontaneously

breathing patients:

Increase in negative intrathoracic pressure during inspiration


blood pools in pulmonary circulation reduced left heart filling
and lower stroke volume

In

MV pts:

LV stroke volume increases during insufflation because left


ventricular preload increases (left ventricular afterload decreases)

RV stroke volume decreases during insufflation because right


ventricular preload decreases (right ventricular afterload
increases)

Hemodynamic effects of
mechanical ventilation

MV effects on PPV

Static and dynamic predictors of


fluid responsiveness
Static tests
Clinical

static endpoints (e.g. heart rate, blood pressure, collapsed


veins, capillary refill time, previous urine output)

CVP/PCWP
CXR
PiCCO
EVLW
One

collection of lactate or SvO2

Static and dynamic predictors of


fluid responsiveness
Dynamic test
Passive

leg raise

End-expiratory
Ultrasound:
Systolic

(SVV)

occlusion test

cardiac, IVC, SVC, lung

pressure, pulse pressure (PPV) and stroke volume

Static vs. dynamic predictors of


fluid responsiveness
CVP

is the classic static measure many studies show poor


predictors of fluid responsiveness

Low

cardiac filling pressures do not imply that a patient is


fluid responsive

Despite

CVP being a reflection of RAP (and determinant of


right ventricular filling) it is NOT a reliable indicator of
preload or fluid responsiveness

Curr Opin Crit Care. 2010 Aug;16(4):289-96.

CVP cannot predict fluid


responsiveness

Evid Based Med doi:10.1136/eb-2013-10149

Static parameters are inferior to


dynamic parameters in predicting
fluid responsiveness

Neth Heart J. 2013 Dec; 21(12): 530536

Right and left ventricular enddiastolic area or volume


Right

and left ventricular end-diastolic area / volume cannot


establish the patients position on the combined venous
return/cardiac function curve

decline in cardiac performance decreases the slope of the


relationship between end-diastolic volume and stroke volume

Right and left ventricular end-diastolic area / volume cannot


accurately predict an increase in stroke volume upon fluid
loading either

Pleth Variability Index (PVI)


PVI:

an automated measure of the dynamic change in the


perfusion index that occurs during a respiratory cycle

Perfusion

index: an infrared pulsatile signal indexed against


the non-pulsatile signal and reflects the amplitude of the
pulse oximeter waveform

PVI:

significant correlation and good agreement with the PPV


and has accurately predicted fluid responsiveness

http://www.masimo.cn/pvi/

Echocardiography
Respiratory

changes in aortic flow velocity and stroke volume


can be assessed by Doppler echocardiography

Assumes

that the aortic annulus diameter is constant over


the respiratory cycle, the changes in aortic blood flow should
reflect changes in LV stroke volume

Feissel

et al: respiratory changes in aortic blood velocity


predicted fluid responsiveness in mechanically ventilated
patients but not reproducible by other studies
Chest 2001; 119: 86773.

Positive Pressure Ventilation


Induced Changes in Vena Caval
Diameter
Cyclic

changes in superior (SVC) and inferior vena caval (IVC)


diameter as measured by echocardiography have been used
to predict fluid responsiveness

SVC

collapsibility index: more reliable than the IVC


distensibility index in predicting fluid responsiveness

Major

drawback: SVC can only be adequately visualized by


TEE - not conducive to continuous monitoring.

Dynamic monitoring: SVV and PPV


Pulse

pressure: pulse contour analysis methods using the


arterial pressure waveforms continously calculates stroke
volume

Removes
Stroke

need for invasive pulmonary artery catheterization

volume calculation is determined by the pressure


decay profile and magnitude of the arterial pressure for a
given arterial input impedance

Testing fluid responsiveness: SVV


and PPV

To test fluid responsiveness, a change in preload must be provoked


while monitoring the subsequent change in stroke volume or its
derivatives such as pulse pressure

Stroke volume variation (SVV) - using mechanical ventilationinduced changes in preload resulting in variation of stroke volume

Pulse pressure variation (PPV) - using mechanical ventilationinduced changes in preload resulting in variation of pulse pressure
Pulse pressure variation (PPV) = (PPmax PPmin) / Ppmean

PPV

PPV and SVV


PPV

is obtained directly from the peripheral arterial pressure waveform

SVV

is peripherally derived from pulse contour analysis of arterial


pressure waveform

Both

peripherally derived dynamic parameters are an accurate


reflection of central SVV

SVV

and PPV have been found to be far better predictors than static
indicators

value > 12% has shown to be highly predictive of fluid


responsiveness.

Settings where SVV use is limited


Small

tidal volumes (tidal volume must be at least 8 mL/kg)

Spontaneous

breathing (patient must have 100% controlled mechanical


ventilations at a fixed rate)

ARDS
PEEP

and low lung compliance (false negatives more likely)


(may increase SVV)

Arrhythmia
Low

(R-R interval must be regular on ECG)

heart rate/respiratory rate ratio

Open

chest

Right

ventricular systolic dysfunction

Meds:

norepinephrine (may decrease SVV), vasodilators (may increase SVV), bblockers

Equipment
SVV

from CHEETAH NICOM and Starling SV

SVV

FloTrac/Vigileo systems

CNAP

PPV

Pulse pressure vs stroke volume

Changes in cardiac output upon PLR have been demonstrated to have


a better predictive value compared with changes in pulse pressure

This difference explained by the fact that pulse pressure is not only a
direct measure of stroke volume, but also depends on arterial
compliance

Response of arterial pressure upon fluid loading is dependent on


arterial tone in contrast to the response of stroke volume
Intensive Care Med. 2010 Sep;36(9):1475-83

A word on arterial tone


Arterial

tone measured by dynamic arterial elastance (Eadyn)=pulse


pressure variation (PPV) / stroke volume variation (SVV) ratio

One

study of 26 mv patients: Eadyn was significantly different between


MAP responders (MAP increase 15% after VE) and MAP nonresponders.

Volume

expansion-induced increases in MAP were strongly correlated with


baseline Eadyn (r2 = 0.83; P < 0.0001).

The

only predictor of MAP increase was Eadyn (AUC, 0.986 0.02; 95% CI,
0.84-1)

baseline Eadyn value >0.89 predicted a MAP increase after fluid


administration with a sensitivity of 93.75% and a specificity of 100%
Critical Care2011 15:R15 DOI: 10.1186/cc9420

Other dynamic tests to measure


volume responsiveness
End-expiratory

occlusion test

Upper arm occlusion pressure

PEEPinduced

increase in central venous pressure

Clinical use of fluid responsiveness


To

predict fluid responsiveness, two methods must be


combined:

Generate the changes in preload

Measure the subsequent changes in stroke volume on the other


hand

Generating changes in preload


Passive

leg raising (PLR) creates a temporary increase in


biventricular preload with a maximum increase within a
minute

Has shown the capability to predict fluid responsiveness

Fluid

bolus downside = since only approximately 50% of


critically ill patients respond to a fluid challenge, half of
patients will receive unnecessary fluid loading.

Passive leg raise 5 rules

Crit Care. 2015; 19(1): 18.

Other parameters to monitor


Extravascular

lung water (EVLW) - determined by


transpulmonary thermodilution and IAP monitoring

Measuring

interstitial fluid volume (tissue edema) and may


aid in the assessment of volume overload

'normal' value for EVLW is reported to be 57 mL/kg with


values as high as 30 mL/kg during severe pulmonary edema

Mortality ~ 65% in ICU patients with an EVLW > 15 mL/kg


whereas the mortality was 33% in patients with an EVLW <
10 mL/kg

Protocol for early goal-directed


resuscitation of patients with
sepsis

J Cardiothorac Vasc Anesth. 2013

Conclusion: To bolus or not to


bolus
To

successfully predict fluid responsiveness, i.e. the response


of stroke volume to fluid loading, two requirements must be
met:

Change in preload must be generated

Measuring subsequent changes in stroke volume or its derivatives


such as pulse pressure

Conclusion: To bolus or not to


bolus
Static

markers of cardiac preload are unable to predict fluid


responsiveness - dynamic markers are superior

Problem

with dynamic markers: high TVs, mechanical


ventilation, regular heart rhythm

PLR

when used with PPV - predict fluid responsiveness


despite spontaneous breathing activity or cardiac
arrhythmias

avoids unnecessary and potentially harmful fluid loading and


inotropics

Case
The

patient is anuric, hypotensive, septic, hypoxemic and has


bilateral lower extremity edema

What

do you do next?

A Give a 1L Crystalloid challenge


B Give a 500 cc Crystalloid challenge
C Give 12.5 grams albumin
D Start Vasopressin
E Perform a passive leg raise (PLR) while monitoring PPV

References

Marik PE, Cavallazzi R. Does the central venous pressure (CVP) predict fluid responsiveness: an update meta-analysis
and a plea for some common sense. Crit Care Med 2013;41:177481.

Marik PE, 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
Sep;37(9):2642-7.

Feissel M, Michard F, Mangin I, et al. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness
in ventilated patients with septic shock. Chest 2001; 119: 86773.

Maizel J, Airapetian N, Lorne E, et al. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med
2007; 33: 11338.

Lamia B, Ochagavia A, Monnet X, et al. Echocardiographic prediction of volume responsiveness in critically ill patients
with spontaneously breathing activity. Intensive Care Med 2007; 33: 112532.

Boyd JH, Forbes J, Nakada T, et al: Fluid resuscitation in septic shock: A positive fluid balance and elevated central
venous pressure increase mortality. Crit Care Med 39:259-265, 2011

Barbier C, Loubires Y, Schmit C, Hayon J, Ricme JL, Jardin F, et al. Respiratory changes in inferior vena cava diameter
are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):17406.