REVIEW

CURRENT
OPINION Parameters of fluid responsiveness
Rui Shi a,b, Xavier Monnet a,b, and Jean-Louis Teboul a,b

Purpose of review
On the basis of recent literature, we summarized the new advances on the use of available dynamic
indices of fluid responsiveness.
Recent findings
Reliability of passive leg raising to assess fluid responsiveness is well established provided that a real-time
haemodynamic assessment is available. Recent studies have focused on totally noninvasive techniques to
assess its haemodynamic effects with promising results. Presence of intra-abdominal hypertension is
associated with false-negative cases of passive leg raising. Use of pulse pressure and stroke volume
variations is limited and other heart–lung interaction tests have been developed. The tidal volume
challenge may overcome the limitation of low tidal volume ventilation. Preliminary data suggest that
changes in pulse pressure variation during this test well predict fluid responsiveness. Growing evidence
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKbH4TTImqenVIdHfOa5cT8dwRynBEk5ozc9TOhAy6IjP2CKzfQnVRNi on 05/22/2020

confirms the good predictive performance of the end-expiratory occlusion test. All these dynamic tests
allow selecting appropriate fluid responders and preventing excessive fluid administration. Performance of
a mini-fluid challenge may help for the decision-making process of fluid management if other tests are not
available.
Summary
Several new dynamic variables and monitoring techniques to predict fluid responsiveness were investigated
in the past years. Nevertheless, further research investigating their reliability and feasibility in larger cohorts
is warranted.
Video abstract
http://links.lww.com/COCC/A32
Keywords
cardiac output, fluid administration, fluid responsiveness, haemodynamic monitoring

INTRODUCTION PASSIVE LEG RAISING

Fluid administration is the cornerstone therapy of
acute circulatory failure [1]. Nevertheless, repeated
fluid boluses increase the risk of fluid overload, and
then worsen outcomes, especially in patients with
septic shock and acute respiratory distress syndrome
&
(ARDS) [2 ,3]. Apart from that, about half of the
haemodynamically unstable patients in the ICU
do not benefit from fluid infusion in terms of
increase in cardiac output (CO). Thus, after the
initial phase of resuscitation, predicting fluid
responsiveness is advised before further fluid admin-
&
istration [2 ,3]. It is now recommended using
dynamic indices of preload responsiveness over
&&
static markers of cardiac preload [4 ].
This review aims to summarize the recent avail-
able literature regarding dynamic indices of preload
responsiveness and to provide clues for future
research.
The passive leg raising (PLR) test mimics the hae-
modynamic effects of an about 300-ml blood chal-
lenge by mobilizing the blood from the lower part of
the body towards the intrathoracic compartment
[5]. Importantly, PLR is a reversible test that does
not need any drop of fluid infusion [5]. Numerous
a
Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP,
Université Paris-Saclay, Le Kremlin-Bicêtre and bINSERM UMR_S999
LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson,
France
Correspondence to Jean-Louis Teboul, MD, PhD, Service de Médecine
Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay,
78 rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France.
Tel: +33 145213547; fax: +33 154213551;
e-mail: jean-louis.teboul@aphp.fr
Curr Opin Crit Care 2020, 26:319–326
DOI:10.1097/MCC.0000000000000723

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Cardiopulmonary monitoring
KEY POINTS
 Plethysmographic perfusion index and bioreactance-
based CO measurements may be reliable noninvasive
methods to assess haemodynamic effects of PLR.
 Simply measuring the changes in PPV during a TVC
seems to be reliable to predict fluid responsiveness
during low tidal volume ventilation.
 Heart–lung interaction tests, such as end-expiratory
occlusion, combination of end-expiratory occlusion and
end-inspiratory occlusion, lung recruitment and sigh
manoeuvres, are reliable tests when PPV fails to predict
fluid responsiveness.
 The mini-fluid challenge is an alternative to PLR, but its
assessment needs precise CO measurements.
studies using real-time measurement of CO or its
direct surrogates showed its reliability to predict
fluid responsiveness in ICU patients, including
those with spontaneous breathing, atrial fibrilla-
tion, low lung compliance or ventilated with a
low tidal volume (VT) [6].
As the PLR effects are transient, a real-time hae-
modynamic assessment is required [5]. Noninvasive
methods have been recently tested for that purpose.
In spite of disappointing results concerning changes
in simple haemodynamic variables as heart rate or
&
blood pressure [7 ] and changes in Doppler femoral
or carotid blood flows [8], promising results were
& & &
reported with other methods [9 ,10 ,11 ] as described
below.
The peripheral perfusion index, derived from
the plethysmography signal of pulse oximetry, has
&
been proposed for that purpose [9 ]. The plethys-
mography signal has two components: a pulsatile
&
and a nonpulsatile component [9 ]. The pulsatile
component is a variable amount of light absorbed by
the pulsatile arterial blood flow. It reflects changes
in the finger blood volume during one cardiac cycle,
which may also reflect changes in stroke volume.
The nonpulsatile component is supposed to be a
constant amount of light absorbed by skin, bone
and tissues. The perfusion index, calculated by the
ratio of the amplitude of the pulsatile signal over
that of the nonpulsatile signal, was shown to have
an acceptable predictive ability to assess preload
&
responsiveness (Fig. 1) [9 ]. An increase in perfusion
index more than 9% during PLR could detect an
increase in pulse contour CO during PLR more than
10% with a sensitivity of 91% (76–98%), a specific-
ity of 79% (63–90%) and an area under receiver-
operating characteristic curve (AUROC) of 0.89
&
(0.80–0.95) [9 ]. As an increase in CO during PLR
is an excellent predictor of fluid responsiveness [6],
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it can thus be assumed that changes in perfusion
index during PLR can serve to predict fluid respon-
siveness (Fig. 1). Precision and least significant
change values for the perfusion index measurement
&
were 1.6 and 1.2%, respectively [9 ]. These values
were far lower than the threshold value (9%) to
detect a positive PLR test, confirming that this ple-
thysmographic-derived variable can be properly
used for that purpose. Further studies are mandatory
to confirm those results.
The bioreactance-based CO monitor is a totally
noninvasive device that uses four skin sensor pads
placed on the patient’s thorax. It can estimate stroke
volume by using the phase shift of an oscillating
high frequency and low-voltage current that occurs
when it crosses the thorax. Galarza et al. [10 ]
&
showed that an increase in bioreactance-based CO
during PLR more than 10% was able to detect an
increase in pulse contour CO during PLR more than
10% with an acceptable accuracy (AUROC ¼ 0.88).
In this study, the bioreactance monitor averaged CO
over 8 s and thus can be appropriately used for a PLR
test as the haemodynamic effects of PLR reach their
maximum between 30 and 60 s [5]. In a previous
study, a bioreactance-based CO monitor averaging
CO over 30 s was unable to track the changes in pulse
contour CO during PLR [12]. Such a long averaging
time could have been one of the reasons explaining
the poor results reported in that study [12]. This
emphasizes the need to use a quasi-real-time CO
monitor to track the effects of a brief test, such as PLR.
Capillary refill time (CRT) is used in ICU patients
for assessing peripheral perfusion [13]. There has
been a renewed interest in the use of CRT following
the publication of the ANDROMEDA-SHOCK
multicentre randomized controlled trial (RCT) that
compared CRT-guided vs. lactate-guided strategies
of haemodynamic resuscitation in the early phase of
septic shock [14,15] with outcome benefits found in
favour of the CRT guidance [15,16].
One recent study used changes in CRT to assess
&
the haemodynamic response to PLR [11 ]. It showed
that a decrease in CRT during PLR (cut-off ¼ –27%)
predicted a decrease in CRT – by at least 25% –
following fluid challenge with an AUROC of 0.94
&
[11 ]. The predictive value of the changes in CRT was
&
better than that of the baseline CRT [11 ]. In that
study, increase in pulse contour CO during PLR more
than 9% well predicted fluid responsiveness con-
firming previous findings [6]. However, the fluid
responders using the CO response (standard defini-
tion) were not strictly the same as the fluid respond-
ers using the CRT response: among the 13 fluid
responders using CO only, seven were fluid respond-
&
ers using CRT [11 ]. This raises important questions
about the definition of fluid responsiveness and
Volume 26  Number 3  June 2020
 Parameters of fluid responsiveness Shi et al.

FIGURE 1. Typical waveform of perfusion index and cardiac index signals during a passive leg raising (PLR) test and volume
expansion in preload responders (a) and in preload nonresponders (b). Reprinted with permission from Beurton et al. [9 ].&

emphasizes on the dissociation between macrohae-
modynamics and microcirculation. In addition,
among the 21 fluid nonresponders using CO, eight
&
were fluid responders using CRT [11 ], a finding
more difficult to explain (rheological benefits or
methodological issues?).
&
Beurton et al. [17 ] confirmed that intra-abdom-
inal hypertension (IAH) could be a limitation for a
correct interpretation of PLR. The authors showed
that PLR reliably predicted fluid responsiveness in
the absence of IAH (AUROC ¼ 0.98), whereas it
failed to predict fluid responsiveness in the presence
of IAH (AUROC ¼ 0.60), essentially because of the
&
presence of false negatives [17 ]. Further studies
examining the components of venous return during
PLR in cases of IAH could be helpful.
HEART–LUNG INTERACTION INDICES
Pulse pressure variation and stroke volume
variation
In controlled mechanical ventilation, pulse pressure
variation (PPV) and stroke volume variation (SVV)

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Cardiopulmonary monitoring
are widely used to predict fluid responsiveness in
particular in the operating room settings, where
their predictive value is acceptable [18–20]. A
meta-analysis that includes RCTs comparing stan-
dard care with dynamic assessment of fluid respon-
siveness (using SVV or PPV) during the perioperative
management showed improved postoperative out-
comes [21]. One recent study in patients during
major abdominal surgery showed that fluid resusci-
tation prompted by a PPV value higher than 13%
(preload dependence state) led to optimization of
both macrocirculation and sublingual microcircula-
& &
tion [22 ]. This finding suggests immediate correc-
tion of preload dependence to prevent reduced
microcirculation and stresses the importance of
PPV to guide fluid management during surgery.
However, an interpretation of PPV or SVV is unreli-
able in cases of spontaneous breathing, cardiac
arrhythmias and doubtful in cases of low VT, low
lung compliance and IAH, all conditions commonly
&
observed in ICU patients [23 ]. Other tests using
heart–lung interactions have been developed to
overcome some of these limitations.
Tidal volume challenge
The tidal volume challenge (TVC) was recently pro-
posed to overcome the limitation of PPV and SVV in
the case of low VT (6 ml/kg) ventilation [24]. This
test consists of transiently increasing VT from 6 to
8 ml/kg for 1 min. A pilot study showed that an
increase in the absolute value of PPV at least 3.5% or
SVV at least 2.5% during a TVC reliably predicted
fluid responsiveness in cases of low VT ventilation
[24]. Similar results were reported in neurosurgical
patients studied in the operating room in supine
position (AUROC ¼ 0.94) [25] as well as in prone
position (AUROC ¼ 0.96) [26]. A major advantage of
the TVC is that it allows predicting fluid responsive-
ness in patients ventilated with low VT without
using any sophisticated device as a simple arterial
catheter is suitable to follow the changes in PPV. It
remains to be confirmed that TVC is reliable in
patients with ARDS ventilated with low VT, knowing
that low lung compliance could be an additional
factor altering the reliability of the test.
Respiratory variation of vena cava diameters
Reliability of the respiratory variation of the
inferior vena cava diameter (DIVCd) – obtained
using transthoracic echocardiography – to predict
fluid responsiveness has been questioned in a recent
&
large meta-analysis [27 ] and in a large clinical
multicentre observational study [28]. Several
limitations of DIVCd, which are comparable to
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those of PPV (e.g. low VT, IAH [29] and low lung
compliance) may have accounted for the poor pre-
&
dictive value [27 ,28]. Nevertheless, even in condi-
tions of correct applicability of PPV, DIVCd was
found to be less accurate than SVV to predict fluid
responsiveness after cardiac surgery [30]. Note that
Zhang et al. [31] reported an acceptable predictive
value of DIVCd in 129 patients receiving low VT
ventilation except in the presence of isolated left
ventricular dysfunction. In patients with spontane-
ous breathing, a fair prediction of fluid responsive-
ness using DIVCd was reported in a meta-analysis
(pooled AUROC ¼ 0.80) [27 ]. Recently, Bortolotti
et al. [32] proposed to predict fluid responsiveness in
spontaneously breathing patients by calculating
DIVCd using a deep inspiration and passive exhala-
tion. In a series of 55 nonintubated patients with
arrhythmias, the predictive performance of DIVCd,
here defined as collapsibility index of the inferior
vena cava, was acceptable (AUROC ¼ 0.93; cut-
off ¼ 39%) [32]. Further larger scale studies are obvi-
ously required to confirm these findings.
Reliability of the superior vena cava collapsibil-
ity index – obtained using a transoesophageal
approach – has been confirmed during abdominal
surgery (AUROC ¼ 0.85; cut-off ¼ 21%) [33] and vas-
cular surgery (AUROC ¼ 0.92; cut-off ¼ 37%) [34].
However, poorer results (AUROC ¼ 0.75) were
reported in ICU patients even in those with none
of the limitations of respiratory variation-based
preload responsiveness indices [28].
End expiratory occlusion test
The end expiratory occlusion (EEO) test consists of
interrupting mechanical ventilation at end-expira-
tion for 15 s and in measuring the related changes in
&
CO or surrogates (Fig. 2) [35 ]. Because of its short
duration, a real-time haemodynamic assessment is
&
mandatory (Fig. 2) [35 ]. A meta-analysis, including
nine studies, showed that 5% increase in CO during
EEO reliably predicted fluid responsiveness with a
&
pooled AUROC of 0.96 [36 ].
Two recent studies have questioned the reliabil-
ity of the EEO test in cases of low VT ventilation
[24,25]. It might be intuitive that the lower the VT,
the lower the haemodynamic effects of EEO. How-
ever, Jozwiak et al. [37] reported an excellent predic-
tive value of EEO (AUROC ¼ 0.98) in ICU patients
ventilated with a mean VT of 6.2 ml/kg predicted
body weight (PBW). Similar results were reported in
the operating room setting [38]. Further studies are
thus required.
A potential limitation of the EEO test is ventila-
tion in prone position. In patients with ARDS venti-
lated in prone position with a VT of 6 ml/kg PBW,
Volume 26  Number 3  June 2020

FIGURE 2. Procedure to perform an end-expiratory occlusion (EEO) test. Reprinted with permission from Gavelli et al. [35 ].&
Yonis et al. [39] showed that EEO could not reliably
predict fluid responsiveness (AUROC ¼ 0.65). In
prone neurosurgical patients, EEO could not predict
fluid responsiveness at either 6 or 8 ml/kg PBW [26].
Interestingly, in the latter study, an increase in PPV
during a TVC had a better predictive performance
(AUROC ¼ 0.96) [26]. Whether the poor perfor-
mance of the EEO test during prone position was
related only to low VT or due to another mechanism
needs to be elucidated.
Like the PLR test, the EEO test requires a precise
and real-time haemodynamic assessment to be
&
properly interpreted [35 ]. The pulse contour analy-
sis method is appropriate thanks to its good preci-
sion with a low least significant change value (1.2%)
&
compared to the cut-off value (5%) [40 ]. Caution is
required if a less precise method, such as Doppler-
echocardiography, is used to assess the effects of
EEO. To overcome this potential limitation, combi-
nation of the changes in VTI during EEO and end-
inspiratory occlusion had been proposed [37]. In a
series of 30 patients, the sum of absolute values of
changes in VTI during both occlusions accurately
predicted fluid responsiveness with a cut-off of 13%
[37], a value which is compatible with the precision
&
of echocardiography [41 ]. Similar findings were
recently reported with oesophageal Doppler (cut-
off ¼ 9%) [42].
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Parameters of fluid responsiveness Shi et al.
Other heart–lung interaction tests
Lung recruitment manoeuvres can also be used
to predict fluid responsiveness in patients with
low VT ventilation [43]. Recently, Messina et al.
&
[44 ] proposed to perform four sigh manoeuvres at
different inspiratory airway pressures (0, 15, 25 and
35 cmH2O) and follow the changes in haemody-
namics to predict fluid responsiveness during
pressure support ventilation (PSV) by considering
the nadir value of haemodynamic variables at each
step. The best predictor was the (negative) slope of
the systolic arterial pressure (AUROC ¼ 0.99; cut-
off ¼ –4.48) [44 ]. To be more practicable in the
&
future, this test needs automatization for the calcu-
lation of the blood pressure slope and for the
transfer from PSV to PSV þ pressure-controlled
synchronized intermittent mandatory ventilation
mode. In neurosurgery patients ventilated with a
low VT, it was recently reported that the magnitude
of the decrease in CO produced by a brief increase in
PEEP by 5 cmH2O predicted fluid responsiveness
better than baseline PPV and SVV [45]. Further
studies are required to confirm such findings.
MINI-FLUID CHALLENGE
An increase of at least 15% in CO following admin-
istration of 250–500 ml fluid over less than 30 min
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Cardiopulmonary monitoring

Table 1. Summary of methods predicting fluid responsiveness with available monitoring techniques, main advantages and
drawbacks
Fluid responsiveness Available haemodynamic
tests techniques Main advantages Main drawbacks

PLR test Pulse contour analysis (CO) Applicable in ventilated Requires real-time haemodynamic assessment
Echocardiography (VTI) and nonventilated patients Unreliable in cases of IAH
Oesophageal Doppler (ABF)
Bioreactance (CO)
Pulse oximeter (PI)
PPV Arterial catheter Continuous monitoring Unreliable in cases of SB, cardiac arrhythmias
No need for CO monitoring and IAH
False negatives in cases of low VT and low
lung compliance
SVV Pulse contour analysis Continuous monitoring Unreliable in cases of SB, cardiac arrhythmias
and IAH
False negatives in cases of low VT and low
lung compliance
EEO test Pulse contour analysis Easy to perform Requires precise and real-time measurement of
CO
Impossible to perform in cases of intense SB
activity
EEO þ EIO tests Less invasive assessment Requires precise and real-time measurement of
Echocardiography CO
Oesophageal Doppler Impossible to perform in cases of intense SB
activity
Cumbersome procedure
DIVCd Transthoracic No need for CO monitoring Requires experienced operator
echocardiography Limited value in cases of IAH
Questions exist regarding its reliability in
ventilated patients even in cases of normal
VT
Its value in nonintubated patients able to
sustain deep inspiration needs confirmation
SVC collapsibility Transoesophageal No need for CO monitoring Requires experienced operator
index echocardiography Impossible to perform in nonventilated patients
Doubts on its reliability even in cases of normal
VT
TVC Arterial catheter Reliable in low VT ventilation Applicability to specific conditions (mechanical
No need for CO monitoring ventilation with SB, severe ARDS and IAH)
needs confirmation
Reliability during prone position needs further
investigation
Mini-fluid Pulse contour analysis Applicable even when the Its low cut-off value (5%) requires a very
challenge (Echocardiography?) other tests are not available precise measurement
Limited risk of fluid overload
LRM Pulse contour analysis Quite easy to perform Risk of misinterpretation as LRM can also
increase the right ventricular afterload
Reliability and applicability require further
confirmation
Sigh manoeuvre Arterial catheter Applicable during PSV Requires automatization to be routinely
No need for CO monitoring applicable
Risk of misinterpretation as sign manoeuvre
can also increase the right ventricular
afterload
Reliability and applicability require further
confirmation
PEEP test Pulse contour analysis Easy to perform Requires real-time measurement of CO

DIVCd, respiratory variation of inferior vena cava diameter; ABF, descending aorta blood flow; CO, cardiac output; EEO, end-expiratory occlusion; EIO, end-
inspiratory occlusion; IAH, intra-abdominal hypertension; LRM, lung recruitment manoeuvre; PEEP, positive end-expiratory pressure; PI, perfusion index; PLR,
passive leg raising; PPV, pulse pressure variation; PSV, pressure support ventilation; SB, spontaneous breathing; SVC, superior vena cava; TVC, tidal volume
challenge; VT, tidal volume; VTI, velocity time integral.

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usually defines fluid responsiveness, although a
huge variability of the clinicians’ practices exists
[46]. Provided that measurements of CO are avail-
able, the fluid challenge is a direct method to assess
fluid responsiveness but it cannot predict it at all. As
around 50% of patients are fluid nonresponders,
deliberate performance of fluid challenge would
result in infusion of unnecessary fluids in many
patients with risks of fluid overload if repeated. This
is why a mini-fluid challenge, consisting of admin-
istering only 100 ml fluid over a short period, has
been proposed [47]. In patients ventilated with a low
VT during surgery, Biais et al. [48] showed that a 6%
increase in pulse contour CO induced by a mini-
fluid challenge over 2 min could predict fluid
responsiveness (AUROC ¼ 0.95; cut-off ¼ 5%) better
than PPV (AUROC ¼ 0.63) and changes in CO
induced by a micro-fluid challenge of 50 ml over
1 min (AUROC ¼ 0.83). A recent meta-analysis of
seven published studies reported a pooled AUROC
of the mini-fluid challenge of 0.91 (0.85–0.97) with
& including the last one.
a sensitivity of 82% and specificity of 83% [36 ]. The
mini-fluid challenge is thus attractive when no
other test can be used. However, it needs real-time
CO measurements to assess its effects and thus has
no advantage over PLR. In addition, the cut-off
value is low (5%) so that like for EEO, precise CO
measurements are required.
CONCLUSION
Prediction of fluid responsiveness allows selecting
patients who can benefit from fluid administration
and preventing unnecessary fluid infusion in non-
responders, as recently reported [49]. Recent litera-
ture has focused on improvement of the existing
dynamic indices, on development of innovative tests
&
(Table 1) and predictive methodology [50 ]. In the
ICU, PLR can be used in ventilated as well as in
nonventilated patients, except in cases of IAH. In
order to spread the use of this test, development of
noninvasive simple tools facilitating its real-time
assessment is necessary. In the operating room set-
ting, dynamic indices, such as PPV, are still useful but
limited in cases of low VT ventilation. Development
of new heart–lung interaction tests, which can over-
come such a limitation, have been developed over the
past years. In any case, the decision of administering
fluids should not be based only on the presence of
fluid responsiveness but must also consider the pres-
ence of signs of haemodynamic instability and the
absence of high risks of fluids overload.
Acknowledgements
We thank Dr Nello De Vita for his helpful technical
assistance.
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Parameters of fluid responsiveness Shi et al.
Financial support and sponsorship
None.
Conflicts of interest
J-LT and XM are members of the Medical Advisory
Board of Pulsion Medical Systems. The company did
not provide funding for the preparation of this article.
RS declares no conflicts of interests.
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& responsible for false negatives to the passive leg raising test. Crit Care
Med 2019; 47:e639–e647.
This study showed that PLR well predicted fluid responsiveness in patients without
IAH but failed to do it in patients with IAH due to a high rate of false-negative cases.
This study points out an important limitation of the PLR test.
18. Messina A, Pelaia C, Bruni A, et al. Fluid challenge during anesthesia: a
systematic review and meta-analysis. Anesth Analg 2018; 127:1353–1364.
19. Ganter MT, Geisen M, Hartnack S, et al. Prediction of fluid responsiveness in
mechanically ventilated cardiac surgical patients: the performance of seven
different functional hemodynamic parameters. BMC Anesthesiol 2018;
18:55.
20. Ali A, Abdullah T, Sabanci PA, et al. Comparison of ability of pulse pressure
variation to predict fluid responsiveness in prone and supine position: an
observational study. J Clin Monit Comput 2019; 33:573–580.
21. Benes J, Giglio M, Brienza N, et al. The effects of goal-directed fluid therapy
based on dynamic parameters on postsurgical outcome: a meta-analysis of
randomized controlled trials. Crit Care 2014; 18:584.
22. Bouattour K, Teboul JL, Varin L, et al. Preload dependence is associated with
& reduced sublingual microcirculation during major abdominal surgery. An-
esthesiology 2019; 130:541–549.
This study showed a strong association between preload dependence condi-
tions (assessed using pulse pressure variation) and the sublingual microcircula-
tion state during major abdominal surgery. This suggests that in such
intraoperative conditions, microcirculation is not totally dissociated from macro-
circulation.
23. Teboul JL, Monnet X, Chemla D, Michard X. Arterial pulse pressure
& variation with mechanical ventilation. Am J Respir Crit Care Med 2019;
199:22–31.
This comprehensive review summarizes all the aspects of pulse pressure varia-
tion that have been developed over the past 20 years, in terms of conceptual
meaning, advantages for the intensive care providers and benefits for the
patient’s outcome, technological improvement to obtain proper values, limita-
tions to its appropriate interpretation and in terms of its possible evolution in the
future.
24. Myatra SN, Prabu NR, Divatia JV, et al. The changes in pulse pressure
variation or stroke volume variation after a ‘tidal volume challenge’ reliably
predict fluid responsiveness during low tidal volume ventilation. Crit Care Med
2017; 45:415–421.
25. Messina A, Montagnini C, Cammarota G, et al. Tidal volume challenge to
predict fluid responsiveness in the operating room: an observational study.
Eur J Anaesthesiol 2019; 36:583–591.
26. Messina A, Montagnini C, Cammarota G, et al. Assessment of fluid respon-
siveness in prone neurosurgical patients undergoing protective ventilation:
role of dynamic indices, tidal volume challenge, and end-expiratory occlusion
test. Anesth Analg 2020; 130:752–761.
27. Das SK, Choupoo NS, Pradhan D, et al. Diagnostic accuracy of inferior vena
& caval respiratory variation in detecting fluid unresponsiveness: a systematic
review and meta-analysis. Eur J Anaesthesiol 2018; 35:831–839.
This is a large meta-analysis showing a fair accuracy of the inferior vena cava
diameter respiratory variation to predict fluid responsiveness. Note that the degree
of prediction found in patients with spontaneous breathing did not differ from that
found in patients who received mechanical ventilation with an AUROC around of
0.80 for both.
28. Vignon P, Repesse X, Begot E, et al. Comparison of echocardiographic
indices used to predict fluid responsiveness in ventilated patients. Am J Respir
Crit Care Med 2017; 195:1022–1032.
29. Vieillard-Baron A, Evrard B, Repesse X, et al. Limited value of end-expiratory
inferior vena cava diameter to predict fluid responsiveness impact of intra-
abdominal pressure. Intensive Care Med 2018; 44:197–203.
30. Ma GG, Hao GW, Yang XM, et al. Internal jugular vein variability predicts fluid
responsiveness in cardiac surgical patients with mechanical ventilation. Ann
Intensive Care 2018; 8:6.
31. Zhang H, Zhang Q, Chen X, et al. Respiratory variations of inferior vena cava
fail to predict fluid responsiveness in mechanically ventilated patients with
isolated left ventricular dysfunction. Ann Intensive Care 2019; 9:113.
32. Bortolotti P, Colling D, Colas V, et al. Respiratory changes of the inferior vena
cava diameter predict fluid responsiveness in spontaneously breathing pa-
tients with cardiac arrhythmias. Ann Intensive Care 2018; 8:79.
326 www.co-criticalcare.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
33. Cheng Z, Yang QQ, Zhu P, et al. Transesophageal echocardiographic
measurements of the superior vena cava for predicting fluid responsiveness
in patients undergoing invasive positive pressure ventilation. J Ultrasound Med
2019; 38:1519–1525.
34. Bubenek-Turconi SI, Hendy A, Baila S, et al. The value of a superior vena cava
collapsibility index measured with a miniaturized transoesophageal mono-
plane continuous echocardiography probe to predict fluid responsiveness
compared to stroke volume variations in open major vascular surgery: a
prospective cohort study. J Clin Monit Comput 2019. [Epub ahead of print]
35. Gavelli F, Teboul JL, Monnet X. The end-expiratory occlusion test: please, let
& me hold your breath! Crit Care 2019; 23:274.
This article summarizes the procedure, applicability and feasibility of the end-
expiratory occlusion test to predict fluid responsiveness in mechanically ventilated
patients.
36. Messina A, Dell’Anna A, Baggiani M, et al. Functional hemodynamic tests: a
& systematic review and a metanalysis on the reliability of the end-expiratory
occlusion test and of the mini-fluid challenge in predicting fluid responsive-
ness. Critical Care 2019; 23:264.
In this article, including two meta-analyses, both the end-expiratory occlusion test
(nine studies) and the mini-fluid challenge (seven studies) predicted fluid respon-
siveness with good accuracy.
37. Jozwiak M, Depret F, Teboul JL, et al. Predicting fluid responsiveness in
critically ill patients by using combined end-expiratory and end-inspiratory
occlusions with echocardiography. Crit Care Me 2017; 45:e1131–e1138.
38. Biais M, Larghi M, Henriot J, et al. End-expiratory occlusion test predicts fluid
responsiveness in patients with protective ventilation in the operating room.
Anesth Analg 2017; 125:1889–1895.
39. Yonis H, Bitker L, Aublanc M, et al. Change in cardiac output during
Trendelenburg maneuver is a reliable predictor of fluid responsiveness in
patients with acute respiratory distress syndrome in the prone position under
protective ventilation. Crit Care 2017; 21:295.
40. de Courson H, Ferrer L, Cane G, et al. Evaluation of least significant changes of
& pulse contour analysis-derived parameters. Ann Intensive Care 2019; 9:116.
In this study, the authors calculated the least significant changes in CO obtained
by pulse contour analysis, and confirmed that this method is very precise to track
small changes in CO.
41. Jozwiak M, Mercado P, Teboul JL, et al. What is the lowest change in cardiac
& output that transthoracic echocardiography can detect? Crit Care 2019;
23:116.
This study that includes 100 haemodynamic stable patients showed that the least
significant change for echocardiographic variables, including velocity-time integral,
is at least 10%. This should make cautious the use of such variables when small
changes in CO are expected, for example when an end-expiratory occlusion test is
performed.
42. Depret F, Jozwiak M, Teboul JL, et al. Esophageal Doppler can predict fluid
responsiveness through end-expiratory and end-inspiratory occlusion tests.
Crit Care Med 2019; 47:e96–e102.
43. Monnet X, Teboul JL. Assessment of fluid responsiveness: recent advances.
Curr Opin Crit Care 2018; 24:190–195.
44. Messina A, Colombo D, Barra FL, et al. Sigh maneuver to enhance assess-
& ment of fluid responsiveness during pressure support ventilation. Crit Care
2019; 23:31.
In order to predict fluid responsiveness during PSV, the authors proposed to
perform four sigh manoeuvres at different airway pressures and to follow the
induced-changes in haemodynamics. The best predictor was the slope of the
systolic arterial pressure. This test could gain future popularity if its automatization
is possible.
45. Ali A, Aygun E, Abdullah T, et al. A challenge with 5 cmH2O of positive end-
expiratory pressure predicts fluid responsiveness in neurosurgery patients
with protective ventilation: an observational study. Minerva Anestesiol 2019;
85:1184–1192.
46. Toscani L, Aya HD, Antonakaki D, et al. What is the impact of the fluid
challenge technique on diagnosis of fluid responsiveness? A systematic
review and meta-analysis. Crit Care 2017; 21:207.
47. Muller L, Toumi M, Bousquet PJ, et al. An increase in aortic blood flow after an
infusion of 100 ml colloids over 1 min can predict fluid responsiveness: the
mini fluid challenge study. Anesthesiology 2011; 15:541–547.
48. Biais M, De Courson H, Lanchon R, et al. Mini-fluid challenge of 100 ml of
crystalloid predicts fluid responsiveness in the operating room. Anesthesiol-
ogy 2017; 127:450–456.
49. Michard F, Teboul JL. Predictive analytics: beyond the buzz. Ann Intensive
Care 2019; 9:46.
50. Kattan E, Ospina Tascón GA, Teboul JL, et al. Systematic assessment of fluid
& responsiveness during early septic shock resuscitation: secondary analysis of
the ANDROMEDA-SHOCK trial. Crit Care 2020; 24:23.
This secondary analysis of the ANDROMEDA-SHOCK trial showed that the
presence of fluid unresponsiveness, systematically searched by functional tests,
resulted in less fluid administration during early septic shock resuscitation.
Volume 26  Number 3  June 2020