Assessment of Fluid Responsiveness

Introduction:
- Intravenous fluids were & still the cornerstone of treating patients with shock. Only
approximately 50% of hemodynamically unstable patients in ICU and OR respond to a fluid
challenge. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction;
however, over-prescription of fluid also appears to impede oxygen delivery and compromise
patient outcome.
- Fluid responsiveness is frequently defined as an increase in cardiac output (≥15% from baseline)
with a fluid challenge. In simple terms, assessing fluid responsiveness asks the question: will the
cardiac output increase with fluid administration?
- Preload can be defined as the volume present at the end of diastole before contraction of the
ventricle has started. preload may be separated into right ventricular (RV) and left ventricular (LV)
preload. Jugular venous pressure (JVP) and CVP are used as surrogate estimates of RV preload.
Pulmonary artery occlusion pressure (obtained using pulmonary artery catheter, see below) is
used as a surrogate estimate of LV preload.
- Studies performed during the past 30 years have demonstrated that cardiac filling pressures are
unable to predict fluid responsiveness. More than 100 studies have been published to date that
have demonstrated no relationship between the CVP (or change in CVP) and fluid responsiveness
in various clinical settings. CVP should no longer be routinely used for guiding fluid management
in the ICU, OR, or ER
- The normal healthy heart is fluid responsive. The demonstration of fluid responsiveness is not an
indication, by itself, to administer fluids. Fluid therapy should only be given if the patient is fluid
responsive and there is evidence of hypoperfusion.
- Preload & Frank-Starling Law

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 Static and Dynamic Measures Of Preload Assessment

Static Methods:
1) INTRACARDIAC PRESSURES
- Central venous pressure (CVP)/right atrial pressure (RAP)
- Pulmonary artery occlusion pressure (PAOP)

2) CARDIOVASCULAR VOLUMES
- Echocardiography: - RVEDV
- Left ventricular end-diastolic area (LVEDA)/volume (LVEDV)
- Thermodilution: - Right ventricular end-diastolic volume (RVEDV)
- Transpulmonary thermodilution: - Global end-diastolic volume (GEDV)
- Intrathoracic blood volume (ITBV)
- IVC diameter

Dynamic Methods
1) RESPONSE TO FLUID CHALLENGE/ MINI-FLUID CHALLENGE
2) PASSIVE LEG RAISING (PLR)
- Change in aortic blood flow
- Change in pulse pressure

3) HEART-LUNG INTERACTION DURING MANDATORY MECHANICAL VENTILATION

- Pulse pressure variation (PPV)
- Systolic pressure variation (SPV)
- Stroke volume variation (SVV)
- IVC Collapsibility/Distensibility.
- Dynamic changes in aortic flow velocity

4) END EXPIRATORY OCCLUSION TEST

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 Static measures of preload:

1) Central Venous Pressure (CVP):

Central venous pressure (CVP) is considered a method of assessing right atrial pressure (RAP). It
can be measured directly by placing a catheter in the superior vena cava. Traditionally, CVP has
been used by intensivists to guide fluid management, but it is a poor predictor of fluid
responsiveness and may not accurately reflect preload: due to the changes in venous tone,
intrathoracic pressures, LV and RV compliance, and geometry that occur in critically ill patients,
there is a poor relationship between the CVP and RV end-diastolic volume.

** CVP CLASSIC TRAC

a wave= atrial contraction
c wave= right ventricular contraction
v wave= passive atrial filling

Normal Values of CVP:

- Normal mean CVP = 0-5 mmHg in spontaneously breathing patient.
- Upper normal limit CVP = 10 mmHg in mechanically ventilated patient.

Clinical Uses of CVP:

- CVP >15 mmHg = always pathological (e.g. volume overload, right ventricular failure, cor
pulmonale, congestive cardiac failure, cardiac tamponade, tension pneumothorax).
- No relationship between the CVP (or change in CVP) and fluid responsiveness in various clinical
settings. CVP should no longer be routinely used for guiding fluid management in the ICU, OR,
or ER
- An elevated CVP does not necessarily indicate adequate preload and should not prevent a fluid
challenge if indicated.
- Observe response to fluid therapy: A marked rise in CVP with fluid challenge may indicates a
failing ventricle.

ScvO2 (Central venous oxygen saturation)

- ScvO2 is a global indicator of tissue oxygenation and has been shown to be useful in guiding
resuscitation in the early stages of septic shock.
- The normal range of ScvO2 in critically ill patients is 70-75%, ScvO2 value <65% may indicate
global tissue hypoperfusion in sepsis.

2) Pulmonary artery occlusion pressure (PAOP):

- same as CVP but assess the Left side of the heart (LA)

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3) Global end-diastolic volume (GEDV), Extravascular lung water (EVLW) &
Intrathoracic blood volume (ITBV):
All volumetric parameters are obtained by advanced analysis of the Thermo dilution Curve:

Volume calculations

ITTV = CO * MTtTDa RAEDV RVEDV PTV LAEDV LVEDV

PTV = CO * DStTDa PTV

GEDV = ITTV - PTV RAEDV RVEDV LAEDV LVEDV

ITBV = 1.25 * GEDV RAEDV RVEDV PBV LAEDV LVEDV

EVLW*

EVLW = ITTV - ITBV

EVLW*
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Intrathoracic Thermal Volume
ITTV = MTt x CO

Pulmonary Thermal Volume

PTV = Dst x CO

Pulmonary Vascular Permeability Index

Pulmonary Vascular Permeability Index (PVPI*) is the ratio of Extra vascular Lung
Water (EVLW*) to pulmonary blood volume (PBV). It allows to identify the type of
pulmonary oedema.
Normal
EVLW
PBV


PVPI = Norma Lung
Normal PBV
Extra Vascular Pulmonarv Blood Normal
Lung Water Volume

Elevated
EVLW Hydrostatic Pulmonary Odema
PBV


PVPI =
Normal PBV
Elevated

Elevated
EVLW Permeability


PBV PVPI = pulmonary edema

Elevated PBV
Normal
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NORMAL VALUES FOR VOLUMETRIC PARAMATERS

EVLWI 3.0- 7.0 mL/kg

GEDI 600–800 mL/ m2
ITBI 850–1000 mL/ m2
PVPI 1–3
RVEDVI 60–100 mL/m2

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 Dynamic measures of preload: predicting fluid responsiveness:
Dynamic tests dynamically monitor the Change In Stroke Volume after a MANEUVER that
increases or decreases Venous Return (preload) and challenges the patients’ Frank-Starling curve.
1) RESPONSE TO FLUID CHALLENGE/ MINI-FLUID CHALLENGE
- At the bedside, a rapid and easy way to assess fluid responsiveness.
- Give 300-500 mL of crystalloid (or 250mL colloid) over 10-15 minutes.
- Observe effect on blood pressure, central venous pressure, or stroke volume.
- Threshold of 15% increase in CO can predict fluid responsiveness
MINI-FLUID CHALLENGE
- Give 100 mL of crystalloid over 10-15 minutes.
- Avoid volume overload, can be done in myopathic patients
- Threshold of 6% increase in CO can predict fluid responsiveness
2) PASSIVE LEG RAISING
- An alternative to a fluid challenge
- Produces an ‘autotransfusion’ of blood from the veins in the abdomen and lower limbs.

Technique:
- The patient is transferred from 45 degrees semi-recumbent position to the passive leg raise
(PLR) position, by using the automatic pivotal motion of the patient’s bed. For adequate
autotransfusion to occur the patient should be maintained in the PLR position for at least
one minute, when the hemodynamic effects should be observed.
- Change in CO can be assessed Pre- & Post-technique by:
o Change in VTI by TTE
o Change in CO or pulse pressure by PiCCO or Vigileo
o Change in aortic blood flow by Esophageal Doppler
o Change in CO by Bioreactance CO monitoring
- > 10 % increase in CO has been shown in several studies to predict fluid responsiveness

Advantages:
o Easily reversible.
o Can be used in spontaneously breathing patients & mechanically ventilated patients.
Limitations:
- Intra-abdominal HTN (intra-abdominal pressure > 16 mmHg) impairs venous return and
reduces the ability of PLR to detect fluid responsiveness

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3) Heart-Lung Interactions During Mandatory Mechanical Ventilation

Dynamic preload measures are based on the ‘normal’ physiological effects of positive pressure
ventilation on the right and left sides of the heart. During positive pressure inspiration, the
increased intrathoracic pressure is associated with decreased venous return to the RV. At the same
time, during inspiration, LV filling is increased due to compression of the pulmonary veins. This
causes an increase in LV stroke volume. During expiration the LV stroke volume decreases due to
reduced RV filling. These changes in LV stroke volume are most marked when a patient is
hypovolemic. The dynamic parameters include: pulse pressure variation (PPV), systolic pressure
variation (SPV), and stroke volume variation (SVV).

I) Pulse Pressure Variation (PPV):

Pulse pressure is the difference between the arterial systolic and diastolic pressure. PPV refers
to the difference between the maximum (PPmax) and minimum (PPmin) pulse pressure over a
single mechanical breath. To document inspiration and expiration, the respiratory waveform should
be simultaneously measured with the arterial waveform.
PPV value can be calculated manually, or automatically using an appropriate monitoring device.
It is calculated as follows:
PPV% = 100 x {(PPmax – PPmin )/ (PPmax + PPmin)/2}

Prerequisites for the adequate use of PPV include

(1) Sinus rhythm
(2) Absence of right heart failure
(3) Absence of spontaneous ventilatory effort (sedated)
(4) On controlled mode with a tidal volume ≥8 mL/kg.

A PPV of ≥ 13-15 % has been shown to be a specific and sensitive indicator of preload
responsiveness.

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II) Systolic Pressure Variation (SPV):
The change in systolic pressure over one mechanical breath is termed systolic pressure
variation. Changes in systolic pressure with mechanical inspiration may predict response to volume
expansion, but with less sensitivity and specificity than PPV.

III) Stroke Volume Variation (SVV):

Stroke volume can be measured by arterial waveform analysis. It can also be measured using
oesophageal Doppler technology and echocardiography.

SVV = 100 x (SVmax - SVmin)/SVmean

SVV of ≥10% has also been shown to be a specific and sensitive predictor of fluid responsiveness.

Conditions where pulse pressure and stroke volume variations are less reliable
** Spontaneous breathing ** Cardiac arrhythmias
** Low Vt/low lung compliance ** Open chest
** Increased intra-abdominal pressure ** Very high respiratory rate (HR/RR < 3.6)
** Right heart failure

IV) IVC/ SVC Collapsibility by transthoracic/transoesophageal echocardiography:

Positive pressure ventilation also produces change in both superior vena cava (SVC) and inferior
vena cava (IVC) diameter. Cyclical changes in SVC and IVC diameter, termed ‘Collapsibility’, during
mechanical ventilation may therefore be used to predict fluid responsiveness.

** Can be used but less reliable in spontaneous breathing patient

** Can be used in case of arrhythmia
** IVC Diameter should be measured approximately 2 cm from its junction Right Atrium.

In mechanically ventilated patients who are passive on the vent,

Positive pleural pressure >> decrease VR >> IVC extrathoracic course will distend while SVC
intrathoracic course will collapse
- Fluid responsiveness is likely if the IVC distensibility > 12- 18%.

IVC distensibility = (max diameter – min diameter) / (min diameter) x 100

In spontaneously breathing patients,

Negative intrathoracic pressure >>> increase venous return >>>>> collapse of IVC
- the following measurements suggest a patient is likely to be fluid responsive:
a. IVC measuring < 2 cm in diameter coupled with
b. IVC collapsibility > 12%

IVC collapsibility = (max diameter – min diameter) / (mean diameter) x 100

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V) Dynamic changes in aortic flow velocity/stroke volume by Doppler methods:
The respiratory changes in aortic flow velocity and stroke volume can be assessed by
Transthoracic Doppler echocardiography. Assuming that the aortic annulus diameter is constant
over the respiratory cycle, the changes in aortic blood velocity should reflect changes in LV stroke
volume.
- Variation of aortic blood velocity > 12% or VTI > 20 % is predictor of fluid responsiveness
- Feissel and colleagues demonstrated that the respiratory changes in aortic blood velocity as
measured by transesophageal echocardiography predicted fluid responsiveness in mechanically
ventilated patients.
- Similarly, ventilator- induced variation in descending aortic blood flow measured by
esophageal Doppler monitoring has been demonstrated to predict fluid responsiveness.

Summary of methods predicting preload responsiveness with diagnostic

threshold and limitations
Method Threshold Limitations
Pulse pressure variation 13-15 % Cannot be used in case of
spontaneous breathing, cardiac
stroke volume variation 10 % arrhythmias, low tidal volume/
lung compliance

Inferior vena cava diameter variations 12-18% Cannot be used in case of

spontaneous breathing, low tidal
volume/lung compliance

Requires performing
Superior vena cava diameter variations 36 % transesophageal Doppler
Cannot be used in case of
spontaneous breathing

10% Requires a direct measurement of

Passive leg raising cardiac output

End-expiratory occlusion test 5% Cannot be used in non-intubated

patients
Cannot be used in patients who
interrupt a 15-s respiratory hold

Requires a precise technique for

“Mini”-fluid challenge (100 mL) 6% measuring cardiac output

Requires a direct measurement of

“Conventional” fluid challenge (500 mL) 15% cardiac output
Induces fluid overload if repeated