How to Predict Fluid

Responsiveness

Denise Veelo
From liberal to restrictive

….1980 1990
2005 2013 …
Wet, dry or something else?

Bellany et al. BJA 2006

Chappell et al. Anesthesiology 2010
Definition of Euvolemia?

Bellany et al. BJA 2006

Marik et al. BJA 2014
Physiology

SV determinants:

• Preload
• Contractility
• Heart Rate
• Afterload

Tyberg JV. Am Heart J 1992

 Physiology

CO determinants:

• SV + HR
• Venous return
• Mean syst filling pressure
• Right atrial pressure
• Venous resistance

Tyberg JV. Am Heart J 1992

The right information???
 Fluid Responsiveness

“a strategy used to select patients who will

respond with a positive reaction (> 10-15%) in a
physiologic parameter upon fluid administration”.
 Predicting fluid responsiveness

• Which strategy (and which not)

• Most commonly used

• Which when to use?

• Definition fluid bolus?

What does the world think?

Cannesson, Crit Care 2011

 The good old….

• Blood pressure

• Heart rate

• Urine output
MAP/HR Volume status

HR
+ 3500 RL
- 1100 Blood + 250 Albumin 20%

Jacob et al. Critical Care 2012 16:R86

Arterial Pressure Volume status

Bighamian R, Hahn J. Biomed Res Int. 2014

 Diuresis Volume status
Surgical Trauma:
• ADH, Aldosteron, RAAS ↑↑↑
• H2O & Na+ retention

• > 95% Oliguria → Ø ARF

• > 85% ARF → Ø Oliguria
⇒ Urine output X
∼ ARF (if blood pressure OK)
Priano LL et al., Head Neck 1993
Alpert RA et al., Surgery 1984
Chappell D et al., Anesthesiology 2008
 Take home message I

• HR/ ABP no indicators volume status

• Influence of medication
• Pain/ stress

• Low diuresis may be physiological

• Inflammatory response
• Neuro-endocrine response

• Maybe at extremes Lakhal, ICM 2013

 Static Pressures

• Central Venous Pressure (CVP)

• Pulmonary Occlusion/Wedge Pressure (PCWP/PAOP)
Static pressures: CVP

Marik P et al., Chest 2008

 Static pressures: CVP

• No correlation CVP and CO

• AUC ~0.5
• CVP responders vs non-resp = NS
• CVP/SI no correlation CO

Marik P et al., Chest 2008

 Static pressures: PAOP

• Assumption:
• PAOP≃PVP≃LAP≃LVEDP≃LVEDV
Static pressures: PAOP
The area under ROC curve 0.63

Osman D. Crit Care Med. 2007

 Take home message II

• Static filling pressures not correlated to

• Position starling curve
• ∆CO / SV
• RVEDV / LVEDV

• Trend marker of cardiac function

Magder. Current opinion crit care 2015

 Dynamic Markers

• Pulse pressure Variation (PPV)

• Stroke Volume Variation (SVV)
• Delta SV / CO
• Passive leg raising
• Fluid bolus
SPV/SVV/PPV

Siegenthaler N, http://www.genevahemodynamic.com
SVV & PPV

Hofer C et al. Chest 2005

 SVV & PPV

• Cut off SVV> 12%, PPV > 13%

• In a highly controlled environment

Marik et al. Crit Care Med 2009

 PPV & SVV
• Less usefull if:
• Right ventricular failure
• Spontaneously breathing

• Vt < 8 ml/kg/IBW

• High abdominal pressures

• Open chest

• Rhythm disorders
Lansdorp et al. BJA 2012
Lakhal et al. Chest 2013
Cannesson et al. Anesthesiology 2011
Mahjoub Y, BJA 2014
Variation in amplitude of CVP curve

Westphal et al. Shock 2006

Passive leg raising

Responsive Non-responsive

Cardiac output

Preload
Passive leg raising

Cavallaro et al, ICM 2010

 Passive leg raising

• Suitable for the critically ill ICU population

• Beware high abdominal pressures

Cavallaro et al, ICM 2010

 Fluid challenge
• Minimal bolus to stretch LV
• Most studies use 200-250 ml
• Over 5-10 min
• Responder if increase SV/CO > 10-15%

Muller et al. Anesthesiology 2011

 What is a fluid challenge

• Minimal bolus to stretch RV

• Most studies use 250-500 ml

• Over 5-10 min

Muller et al. Anesthesiology 2011

How much fluid?

Responders

 CO > 10% / 500 ml

Non-Responders

 CO <10% / 500 ml

Smorenberg et al. Shock 2015 et al.

 Considerations
• Responding to fluids = physiologic

• Position Starling curve to target?

• Evidence for “mini-fluid” challenges

• Prevention overfilling

Marik, BJA 2014

Smorenberg, Shock 2015
 Take home message III
• Dynamic Markers
• Beware limitations
• Variations: VCI, Vasalva

• Passive Leg raising

• ICU
• Reliable under most conditions

• Fluid challenge
• May increase risk of fluid overload
 In Summary

• Heart rate & blood pressure

• Urine output

• Static parameter

• Dynamic parameter

• Passive leg raising

• (Mini) fluid challenges

Thank you for your attention!