Fluid Assessment by USG

Dr S.K. Jagadish Chandran

Dept. of Critical Care Medicine
St John’s Hospital

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 What is your Interpretation?

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 There is NO single gold standard parameter to
assess volume in critically ill

Use multiple gadgets to assess the most

complicated system in human body to decide on
fluid resuscitation

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 I AM CONFUSED….

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 CONTENTS
• Introduction

• Basic physiology
 Frank-Starling Relationship
 Heart-Lung Interaction

• Role of USG/ECHO in fluid assessment

 Static parameters
 Dynamic parameters

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 INTRODUCTION

Hemodynamic failure/Shock- Common

problem in the ICU

Accurate assessment of intravascular volume

remains one of the most challenging and
important tasks for intensivists

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 WHY???

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 Basic Physiology
• Frank-Starling Relationship

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 Answer is…

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 Fluid resuscitation
Benefits Adverse effects

• Venous return • Hydrostatic pressure-

Pulmonary edema
• Preload
• Extravasation- tissue edema
• Stroke volume
• Cerebral edema
• Cardiac output
• Electrolyte imbalance
• Tissue oxygen delivery
• Blood products- risk of
infections, reactions

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 POSITIVE is NEGATIVE

Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA

Fluid resuscitation in septic shock: a positive
fluid balance and elevated central venous
pressure are associated with increased
mortality. Crit Care Med. 2011 Feb

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 Key question?...

Should the patient receive additional volume

infusions?

Volume responders
vs
volume non-responders

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 Definition
• Volume responders
 Increases in stroke volume by >15% after a
500 ml fluid challenge

 Parameters are examined in both

spontaneously breathers & mechanical
ventilators

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 Lazy vs Energetic

• Lazy man method= Fluid challenge

• Energetic man method= Fluid responsiveness

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 Heart- Lung Interaction

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 Heart-Lung Interaction
• SPONTANEOUS BREATHING:
Inspiration- Decrease ITP

Increased venous return on right heart &

sequestration of more blood in pulmonary
vasculature

less blood to the left heart

Smaller stroke volume

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 Heart-Lung Interaction
• MECHANICALLY VENTILATED:
Inspiration- high ITP

Less blood on the right heart

Less sequestration in pulmonary vasculature, so

more blood to left heart

Increasing stroke volume

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 Measurement tools
• Static parameters
– CVP
– PAOP
– Ventricular size

• Dynamic parameters
– Pulse pressure variation
– Stroke volume variation
– Passive leg raising (PLR) test
– Sonography assessment- IVC indices, Velocity Time Integral
(VTI) with the help of respiratory variation & PLR

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Advantages of using Sonography
• Easy

• Non invasive

• Reproducible

• Causes of the shock

• First line tool

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 Static Parameters
LV Size
• Predicts FR only when it is very small

• Papillary apposition= Kissing Ventricles

 LV end-diastolic area < 10 cm2 in PSAX view

• Confounders are
 LV hypertrophy
 High Inotropic support
 Vasodilated state

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 Kissing Ventricles

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 The Great Veins
• Inferior Vena Cava

• Superior Vena Cava

• Carotid peak systolic velocity

• Jugular vein distensibility index

• Plethysmographic variability index

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 IVC
Static parameter: IVC size/diameter

Dynamic parameter

Respiratory variability indexes

Collapsibility index
Distensibility index

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 Static Parameters
IVC
• IVC size:

 Measured just distal to hepatic vein

 Longitudinal subcostal view & by using M mode

 correlates with CVP (only in spont. Breathers)

IVC diameter < 20 mm = CVP < 10 mmHg

 ventilated patients- Poor correlation

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 Longitudinal Subcostal view

Hepatic vein

RA

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IVC & Heart-Lung Interactions
IVC diameter variation:
• Spontaneous breath= IVC collapses during
inspiration & dilates during expiration

• Mechanically breath= IVC dilates during

inspiration & collapses during expiration

• Respiratory variation in spontaneously

breathing patients has been challenged

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 IVC & Heart-Lung Interactions

Reference: ECHO in ICU, Stanford University

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 IVC in spontaneous breathers
Inspiration

ITP & Intra-abdominal pressure

Diameter of IVC
( Transmural pressure)

Hence, IVC collapsibility index is used only in

Spontaneously breathing patients
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 IVC collapsibility Index

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 IVC collapsibility Index
If a patient is breathing normally,
 Cut off value > 12% indicates fluid
responders
If a patient is breathing fast
 Cut off value > 40% indicates fluid
responders
Brennan JM et al: Reappraisal of the use of
inferior vena cava for estimating right atrial
pressure; 2007
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 IVC collapsibility Index

Cut off value > 42% indicates fluid responders

• Does inferior vena cava respiratory variability predict fluid

responsiveness in spontaneously breathing patients? N.
Airapetian crit care 2015
• Muller L et al: Respiratory variations of inferior vena cava
diameter to predict fluid responsiveness in spontaneously
breathing patients with acute circulatory failure: need for a
cautious use; Crit Care 2012

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 IVC in mechanical ventilators
Inspiration

ITP

Diameter of IVC
( Transmural pressure)

Hence, IVC distensibility index is used only in

mechanically ventilated patients
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 IVC Distensibility Index

100

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• C. Barbier et al: Respiratory changes in inferior vena cava
diameter are helpful in predicting fluid responsiveness in
ventilated septic patients; 2004

• M. Feissel et al: The respiratory variation in inferior vena cava

diameter as a guide to fluid therapy; 2004

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• Barbier et al used IVC distensibility index
 Cutoff value of > 18% indicates fluid
responders

• Feissel et al used IVC diameter variation

 Cutoff value of > 12% indicates fluid
responders

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 Pitfalls of IVC measurement

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 Pitfalls of IVC measurement

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 Pitfalls of IVC measurement

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 Velocity Time Integral (VTI)

• Respiratory variation with VTI

• Passive leg raising test with VTI

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 Respiratory variation with VTI

• Change in VTI with respiration predicts fluid

responsiveness

• Should be measured over 1 respiratory cycle

• Use moderate speed (50-75 mm/sec)

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 Respiratory variation with VTI

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 Respiratory variation with VTI
Moderate speed= 50 mm/sec

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 Respiratory variation with VTI

• Cutoff value >20% predicts fluid responders

• Feissel M et al: Respiratory changes in aortic blood velocity as

an indicator of fluid responsiveness in ventilated patients with
septic shock. Chest. 2001
• Charron C et al: The influ- ence of tidal volume on the
dynamic variables of fluid responsiveness in critically ill
patients. Anesth Analg. 2006

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 Limitations of VTI
• Sinus rhythm
• No spontaneous respiratory effort
• Vt must be atleast 8 ml/kg
• Intra-abdominal pressure – Normal
• Thorax should be intact

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 PLR

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 PLR
• Auto-transfusion

• Rapidly mobilizes about 300 mL of blood from the

lower limbs

• Completely reversible

• From semi recumbent position, pivot the bed to

obtain a head down tilt at 45⚬

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 PLR with VTI

Measure the VTI in semi recumbent position

Perform PLR

Re-measure VTI within 1 to 2 mins

Cutoff value > 12% indicates fluid responders

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 PLR with VTI
Pro’s Con’s
• Spontaneous respiration • Cumbersome technique
• Arrhythmias • Raised intra abdominal
• Reversible pressure
• Pt’s on ECMO • Raised intracranial pressure
• Pain on tilting
• Lower limb amputation
• Peripheral vascular disease

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 Role of Lung USG
• NORMAL LUNG SURFACES:
• Lung sliding is a to-and-fro movement at the pleural line is
called “A LINE” or “A PROFILE”

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 FALLS-protocol (Fluid Administration
Limited by Lung Sonography)
• Acute circulatory failure
• When fluid penetrates the lung, the normal A
PROFILE will be changed to B PROFILE=INTERSTITIAL
SYNDROME
• Interstitial edema always precedes alveolar edema
• It can be detected in an early stage, before gas
exchange impairs
• The change from A- to B-lines indicates the endpoint
for fluid therapy

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 Role of Lung USG
• A-lines indicate fluid responders, B-lines an endpoint
for fluid therapy

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 Final flowchart

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 ARE YOU STILL CONFUSED….

If yes, well!!! My Job is done

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 References
• CRITICAL CARE ULTRASONOGRAPHY by
Alexander Levitov- First edition 2009
• Hemodynamic Monitoring Using ECHO in the
Critically Ill by Daniel De Backer- 2011
• ATS seminars- ICU ultrasound by Daniel de
Becker 2014
• Predicting & measuring fluid responsiveness
with ECHO by Ashley Miller 2016

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 THANK YOU ALL

Dr S.K. JAGADISH CHANDRAN

DEPT. OF CRITICAL CARE MEDICINE
ST JOHN’S HOSPITAL

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