FLUID RESPONSIVENESS

R2 Varittha Borirajdechakul
 OUTLINE

-Background
-Frank-Starling curve & Cardiac function curve & Venous return curve
-Preload monitoring
-Heart&Lung interaction
BACKGROUND
 FLUID ADMINISTRATION

Indication for fluid administration

(a) Augmentation perfusion
(b) Increase cardiac output (CO) in response to fluid administration (“fluid responsive”)

Very initial phase of septic shock and/or obvious fluid loss:

First line of treatment : Volume expansion

Azriel Perel; Using Dynamic Variables to Guide Perioperative Fluid Management. Anesthesiology 2020; 133:929–935
Only 50% of critical ill patients receive
benefit from fluid responsiveness

Increase cardiac output and oxygen delivery

Fluid overload

-Increase cardiac filling pressure & hydrostatic pressure

-Aggravating lung and tissue edema
-Hemodilution >> decrease oxygen delivery
 FRANK-STARLING CURVE
CARDIAC FUNCTION CURVE
VENOUS RETURN CURVE
FRANK-STARLING CURVE

- Frank-starling curve : changes in

stroke volume in response to
changes in venous return and
subsequent preload and right
atrial pressure (RAP)
- Fluid responder : Fluid >>
increase SV steep portion of the
curve
- Fluid non-responder : Fluid >>
not effective; flat portion of that
curve
- The shape of the Frank- Starling
curve is dependent on preload,
contractility, afterload.
CARDIAC FUNCTION CURVE

- Cardiac function curve : Right atrial pressure

(RAP) & Cardiac output
- Increasing RAP as a reflection of increased
ventricular preload, myocyte stretching increases
the sarcomere length with an augmentation in
force generation and subsequent increase of
stroke volume.
- The shape of the cardiac function curve is directly
affected by heart rate, preload, contractility,
afterload.
 VENOUS RETURN CURVE
- Major portion of our blood volume resides in capacitance veins, which are highly distensible
- The volume that does create a transmural pressure above zero is called the stressed volume
>> the mean systemic filling pressure (MSFP)

Fluid

Venous return = MSFP − RAP

Rv

MSFP : Mean systemic filling pressure

RAP : Right atrial pressure
Rv : Resistance venous flow

Limit lowering RAP, Critical pressure (Pcrit) at which the great veins at the thoracic inlet start to
collapse causes a subsequent increase in Rv, preventing a further increase in venous return
 THE VENOUS RETURN CURVE
ON THE CARDIAC FUNCTION CURVE

III >> V : Fluid responsive I >> II : Fluid unresponsive

a rise in MSFP upon fluid loading
is accompanied by a similar increase in RAP
>> not an increase in venous return and cardiac output
PRELOAD MONITORING
 PRELOAD MONITORING
-Static hemodynamic parameters :
- Pressure : CVP
- Diameter : IVC diameter
-Dynamic hemodynamic parameters :
-Mechanical Ventilation-induced variations stroke volume-derived parameter
- Systolic pressure variation
- Pulse pressure variation
- Stroke volume variation
- Tidal volume challenge
- Mini-fluid challenge
- Plethysmography
-Mechanical Ventilation-induced variations non-stroke volume-derived parameter
- IVC variability Index & distensibility index
-Preload-redistributing maneuvers
- Passive leg raising
- End expiratory occlusion test
- Respiratory systolic variation test
- Dynamic arterial elastance
STATIC HEMODYNAMIC
PARAMETERS
STATIC HEMODYNAMIC PARAMETERS
Poor predictors of fluid responsiveness : 3 mechanisms

-1. Cardiac filling pressures : Intramural pressures ( not fully reflecting transmural
pressures )
-2. Varying ventricular compliance between patient ( The combination of
cardiac filling pressures with ventricular end-diastolic radius determines preload,
which is dependent on ventricular compliance varying largely between patients
and within patients when critically ill.)
-3. Low cardiac filling pressures do not imply that a patient is fluid responsive
Eg.
-Pressure : CVP
-Diameter : IVC diameter
Neth Heart J (2013) 21:530–536
DYNAMIC HEMODYNAMIC
PARAMETERS
DYNAMIC HEMODYNAMIC PARAMETERS

Combination of preload-modifying maneuver (e.g., mechanical breath)

&
Measurement of its immediate hemodynamic response (e.g., change in SV)
 HEART-LUNG INTERACTION
2-4
Decrease venous return
Heartbeats

RV SV LV SV

Decrease transmural pressure

Alveolar pressure - Intrapleural pressure

LV SV

Teboul JL, et al. Arterial Pulse Pressure Variation with Mechanical Ventilation. Am J Respir Crit Care Med. 2019 Jan 1;199(1):22-31
 DYNAMIC VARIABLES INDUCED BY
MECHANICAL VENTILATION
- The increase in intrathoracic pressure during a mechanical breath has direct effects on all heart chambers and transient
decrease in venous return that may be regarded as a preload-modifying test of fluid responsiveness

Fluid-responder
- Mechanical breath will be associated Non fluid-responder
with a transient reduction in venous return - Mechanical breath will not produce
and decrease in left ventricular SV any significant reduction in the left
ventricular SV

Perel A. Using Dynamic Variables to Guide Perioperative Fluid Management. Anesthesiology. 2020 Oct 1;133(4):929-935
 MECHANICAL VENTILATION
-INDUCED VARIATIONS
STROKE VOLUME-DERIVED PARAMETER
- Systolic pressure variation
- Pulse pressure variation
- Stroke volume variation
- Tidal volume challenge
- Mini-fluid challenge
- Plethysmography
 SYSTOLIC PRESSURE VARIATION

Interpretation

Difference between the maximal and minimal values - The systolic pressure variation is normally about 8 to
of the systolic arterial pressure during one 10 mmHg in normotensive anesthetized patients
mechanical breath who are ventilated with tidal volume of 8 ml/ kg
 PULSE PRESSURE VARIATION

Yang X, Du B. Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta‐analysis. Crit Care. 2014;18:650.
 STROKE VOLUME VARIATION

Interpretation

SVV reflects the respiratory-induced

changes in the left ventricular SV during - 9-12% - Need cardiac output monitoring
one mechanical breath
 LIMITATIONS OF PPV

Limitations Mechanisms of failure Type of failure

Irregular variations in intrathoracic pressure >>

variation in stroke volume cannot correlate with False positive
Spontaneous breathing activity
preload dependency

Cardiac arrhythmias Variation in stroke volume False positive

Mechanical ventilation using low Too small variations in intrathoracic pressure to to

tidal volume (<8 ml/kg) produce significant changes in the intrathoracic False negative
pressure

Low lung compliance Insufficient transmission of changes in alveolar False negative

pressure to the intrathoracic structures

ARDS
- Low tidal volume
False negative
- Low lung compliance

Myatra et al.Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation. Critical Care (2017) 21:60
 LIMITATIONS OF PPV

Limitations Mechanisms of failure Type of failure

No change in intrathoracic pressure during the

Open thorax (Cardiac surgery) respiratory cycle False negative

Increased intra‐abdominal pressure

Excessively high TV and PEEP
Threshold values of PPV will be elevated False positive
Air-trapping
Prone position
Low HR/RR ratio < 3.6 (severe If the RR is very high, the number of cardiac
bradycardia or high frequency cycles per respiratory cycle may be too low to False negative
ventilation) allow variation in stroke volume

Increase in right ventricular afterload during False positive

Right side heart failure mechanical insufflation

Myatra et al.Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation. Critical Care (2017) 21:60
 PRACTICAL USE OF PPV

Teboul JL, et al. Arterial Pulse Pressure Variation with Mechanical Ventilation. Am J Respir Crit Care Med. 2019 Jan 1;199(1):22-31
 TIDAL VOLUME CHALLENGE

Methods Interpretation Advantages Limitations

-
- Spontaneous breathing
- Transient 1-min increase in - A ΔPPV ≥ - Increases the reliability of
- Cardiac arrhythmias
-
6-8

tidal volume from 6 to 8ml/ 3.5% or SVV ≥ PPV during low tidal volume Open chest
kg predicted body weight 2.5% ventilation ex. ARDS - Raised intra-abdominal
pressure
 MINI-FLUID CHALLENGE

Methods Interpretation Advantages Limitations

- Requires a very precise cardiac

- Rapid fluid challenge - 6% increase in
- Low-tidal-volume ventilation
output monitoring system :
with 100 mL of colloid stroke volume non-invasive pulse contour
analysis devices
 PLETHYSMOGRAPHIC VARIABILITY INDEX

Methods Interpretation Advantages Limitations

- Non-invasive - Affected by a changing

- Displays by pulse Cut-off value : 14% - Able to reflect even mild vasomotor tone (e.g.,
oximeters decreases in circulating blood hypothermia,
volume intraoperatively vasoconstriction).
DYNAMIC (CONTINUOUS) PARAMETER

Perel A. Using Dynamic Variables to Guide Perioperative Fluid Management. Anesthesiology. 2020 Oct 1;133(4):929-935
 MECHANICAL VENTILATION
-INDUCED VARIATIONS
NON-STROKE VOLUME-DERIVED PARAMETER

- Variation of IVC
VARIATIONS OF VENA CAVAL DIMENSIONS

In inspiration Fluid responsiveness

In Spontaneous ventilation
Spontaneous ventilation : the IVC collapses
IVC collapsibility index = IVC max - IVC min x 100 > 50%
IVC max
De Backer D, et al. Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc. 2014 Jan;11(1):129-36
VARIATIONS OF VENA CAVAL DIMENSIONS

In inspiration Fluid responsiveness

In controlled ventilation
IVC variability Index = IVC max - IVC min x 100 > 12%
Mechanical ventilation : the IVC dilates IVC mean
IVC distensibility index = IVC max - IVC min x 100 > 18%
IVC min
De Backer D, et al. Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc. 2014 Jan;11(1):129-36
 VARIATIONS OF VENA CAVAL DIMENSIONS

Furtado S, Reis L. Inferior vena cava evaluation in fluid therapy decision making in intensive care: practical implications. Rev Bras Ter Intensiva. 2019 Jun 27;31(2):240-247
VARIATIONS OF VENA CAVAL DIMENSIONS

Limitations
-Increase intra-abdominal pressure
-Factors affect intrathoracic pressure
-
High PEEP
-
TV < 8 ml/kg
-
Respiratory effort
-Impair venous return
-
RV dysfunction
-
Cardiac tamponade
PRELOAD-REDISTRIBUTING MANEUVER
- Passive leg raising
- End expiratory occlusion test
- Respiratory systolic variation test
- Dynamic arterial elastance
 PASSIVE LEG RAISING

Methods Interpretation Advantages Limitations

- Require continuous
- Transferring a patient from the semi- measurement of - Spontaneous
recumbent position at 30–45° to a Cardiac output ( arterial ventilation - Intracranial hypertension
position in which the trunk is pulse contour analysis, - Arrhythmia - Intra- abdominal hypertension
horizontal and the lower limbs raised echocardiography, - Reversible fluid (compresses the splanchnic territory,
at 30–45° esophageal Doppler) or when returned to the probably hinders blood transfer from
- Volume around 300 mL from the lower change in ETCO2 semi-recumbent the lower limbs) >> False negative
body toward the right heart - CO 10+-2% position

Ann Transl Med 2020;8(12):790

 END-EXPIRATORY OCCLUSION TEST

Methods Interpretation Advantages Limitations

- -
Interrupting the ventilator at end-
expiration for 15 secs
- Cardiac output by pulse
- Spontaneous breathing - Not suitable for patients without
- Decrease Intrathoracic pressure
contour analysis
- Cardiac arrhythmia mechanical ventilation.
- Increase RV- stroke volume
Increase > 5%
- Can't tolerate a 15-s respiratory hold
- Increase LV preload
Gavelli et al. Critical Care (2019) 23:274
 RESPIRATORY SYSTOLIC VARIATION TEST

Methods Interpretation Advantages Limitations

- Three consecutive
RSVT slope - Need mechanical ventilation
mechanical breaths with
increasing airway pressure
threshold > 0.51 - Independent of tidal volume - Normal sinus rhythm
>> Decrease SBP

British Journal of Anaesthesia 95 (6): 746–55 (2005)

 DYNAMIC ARTERIAL ELASTANCE
- Pulse pressure is not only a direct measure of stroke volume, but also depends on arterial
compliance.
- Noninvasive Eadyn, predicted the arterial blood pressure increase to fluid administration in
spontaneously breathing, preload-dependent patients.
- Baseline value >= 0.89

Eadyn = PPV
SVV

Hypovolumia

Hypotension
In preload-dependent patients :
High Eadyn (pressure-responder) : Fluid alone, vasopressor should be delayed
Loss of arterial tone Low Eadyn (non pressure-responder) : Initiate vasopressor + Fluid
Anesth Analg 2015;120:76–84
García et al. Critical Care 2014, 18:626
 CONCLUSION
- Do not delay fluid administration
in obvious fluid loss/initial phase of septic shock
Do not delay fluid - Only 50% of critical ill patients : fluid responsiveness
resuscitation - Dynamic hemodynamic parameters : more accuracy