Fluid-

Responsiveness:
An ICU Phoenix
Darryl Stewart
Regional ICM Study Day
07/11/2013
Altnagelvin Area
Hospital
 Resuscitation
• Fluid administration remains the cornerstone of
immediate resuscitation

• Endless debate regarding timing, volume,

duration, targets & type
Goal-directed Therapy
 Fluid Balance & Mortality
• Rosenberg AL et al. Review of a large
clinical series: association of cumulative
fluid balance on outcome in acute lung
injury: a retrospective review of the
ARDSnet tidal volume study cohort. JICM
2009; 24:35-46
• Boyd JH et al. Fluid resuscitation in septic
shock: a positive fluid balance and
elevated central venous pressure increase
mortality.
CCM 2011; 39 (2): 259-61
• Bellomo R et al. An observational study
fluid balance and patient outcomes in the
Randomized Evaluation of Normal vs
Augmented Level of Replacement Therapy
trial. CCM 2012; 40 (6): 1753-60
Assessment
 Often the 1st step…
• Fluid administration is frequently initial response to
indicators of tissue hypoperfusion

• However, it is likely that only 50% of haemodynamically

unstable ICU patients are volume responsive

• Marik PE et al. Dynamic changes in arterial

waveform derived variables and fluid
responsiveness in mechanically ventilated patients.
A systematic review of the literature. CCM 2009; 37:
2642-2647
 Preload &
•
SV
Fluid should only be administered to augment
preload in the belief that this will increase stroke
volume & subsequently cardiac output
 Haemodynamic changes
with mechanical ventilation
Vascular Waveform Analysis

Morgan BC et al. Haemodynamic effects of intermittent positive pressure

ventilation. Anesthesiology 1966; 27: 584-90
Systolic Pressure Variation
• Accentuated in:
• Hypovolaemia
• Tamponade
• Constrictive Pericarditis
• LV dysfunction
• Massive PE
• Bronchospasm
• Dynamic Hyperinflation
• Pneumothorax
• Increased intra-thoracic pressure
• Increased intra-abdominal pressure
Volaemic Assessment
Parameters

Static Dynamic
CVP SV
PAOP V
RVED PP
V V
LVEDA SP
GEDV V
& ITBV
 CV
• P Scand 2007
Kastrup et al, Acta Anaes
• 90% German anaesthetists & intensivists used CVP to guide fluid
management (cardiac surgery & CSICU)

• McIntyre LA et al, Crit Care 2007

• 90% Canadian intensivists use CVP to guide fluid therapy in septic shock

Assumption

CVP → RAP → RV filling → LV preload →

CO
• Systematic review; 213 articles screened, 24 met inclusion criteria =
803pts
Overall 56 +/- 16% (mean +/- SD) of 803pts responded to fluid challenge
with pooled area under ROC curve 0.56. Pooled correlation between
ΔCVP & change in stroke index/cardiac index (7 studies) was 0.11 (95%
CI, 0.01 to 0.21). Baseline CVP (11 studies) was 8.7 +/- 2.3mmHg in
responders, compared to 9.7 +/- 2.2mmHg in non responders (p=0.3)

Therefore the likelihood that CVP can predict responsiveness (at any given
CVP) is no better than a coin toss!
Pts are equally likely to be fluid responsive with low or high CVP!
 CVP
• Fraud
The assumptions are overly tenuous
Changes in systemic & pulmonary venous capacitance

Changes in intrathoracic pressure

Changes in RV compliance & afterload

Changes in RV systolic function

Changes in LV compliance & filling

Assumption of NSR
 Chest 2002; 121 ( 6): 2008-
8

• Systematic review, 12 studies included, looking at predictive factors of

fluid responsiveness in ICU pts

• Assessed RAP, PAOP, RVEDV, LVEDA, + ΔRAP, Δdown, PPV & Δaortic
blood velocity

• RAP did not predict fluid responsiveness

• PAOP investigated in 10 studies; not significantly lower in responder

group in 7 studies, was significantly higher in responder group in 1
study & was significantly lower in responder group in 2 studies.
• RVEDV studied in 6 studies; 4 showed RVEDV was not
significantly lower in responder group; remaining 2 demonstrated
RVEDV was significantly lower in responder group.

• LVEDA studied in 2 studies only. No significant association

between LVEDA & fluid responsiveness.
 Problems with preload
indicators
• CVP & PAOP do not reflect ventricular end-diastolic volumes
• Ventricular diastolic compliance & filling is non-linear
• Don’t account for ventricular transmural filling pressures (afterload &
compliance)
• It is TRANSMURAL pressures not intracavity pressures that are related to
end-diastolic volumes (via compliance)
• RVEDV is strongly influenced by TR (very common in ICU)
• IMPORTANT: A patient can be fluid non-responder due to high
venous capacitance, poor ventricular compliance &/or poor ventricular
function
• Little wonder then that intracavity pressures & static chamber dimensions
to not predict fluid responsiveness
 Dynamic Parameters
• Numerous studies over last decade shown that
dynamic parameters can better predict fluid
responsiveness than static

• PPV - from analysis of arterial pressure

waveform

• SVV - from pulse contour analysis

• Pulse oximeter plethysmography

• 40 mechanically ventilated pts in septic shock

• Demonstrated higher variations in systolic pressure (15%

vs 6%) & pulse pressure (24% vs 7%) during respiration in
pts who were vol responders (increase 15% CI)

• Derived that cut-off value of 13% for PPV had sensitivity of

94% & specificity 96%.

• Also, variability in pulse pressure was superior to systolic

pressure variation in discriminating fluid responders.
Crit Care Med. 2009 Sep;37(9):2642-7. doi: 10.1097/CCM.0b013e3181a590da.

Dynamic changes in arterial waveform derived variables and fluid responsiveness

in mechanically ventilated patients: a systematic review of the literature.
Marik PE, Cavallazzi R, Vasu T, Hirani A.

• Meta-analysis of 29 clinical studies, 685 pts to evaluate utility of PPV & SVV in
predicting fluid responsiveness

• Correlation coefficient for baseline PPV & SVV, and changes in CI or SV in response to
volume expansion were 0.78 & 0.72 respectively.

• Area under ROC curve for PPV was 0.94, for SVV 0.86
• Included studies had remarkably consistent threshold PPV/SVV of 12-13% for defining
fluid responsiveness

• PPV found to be more reliable predictor than SVV (directly measured, no calculated
assumptions)
• NOTE: Appears to be “grey area” of PPV values (9-13%) were fluid
responsiveness cannot be reliably predicted

• Cannesson et al. Anesthesiol 2011; 115: 231-241

• This “grey zone” may affect up to 25% pts under GA

 Pulse Oximeter
Plethysmograph
• Less invasive y
alternative to SVV &
PPV
• Uses form of pulse pressure analysis to consider changes
in peak & amplitude of pleth waveform (assesses vol
changes)
• Numerous studies demonstrating significant correlation between
changes in pulse oximeter waveform & PPV & hence may
predict fluid responders

• “Pleth Variability Index” (Masimo, Irvine)

• Automatic measure of dynamic change in perfusion index (pulsatile:nonpulsatile blood flow)
during ventilation.

• Pleth variability index >14% is predictive that pt will be fluid responder with sensitivity 81%
 Dynamic Limitations
• Arrhythmias & spontaneous respiration may influence change in
PPV / SVV response to volume loading

• PPV / SVV varies with tidal volume, PEEP, chest wall compliance etc

• De Backer et al, ICM 2005, demonstrated tidal volume must be >

8 ml/kg to ensure accuracy

• Lansdorp et al, BJA 2012, demonstrated predictive value of SPV,

SVV & PPV were optimal when Vt >7ml/kg & patient in SR

• Requires optimum arterial trace

• PVI influenced by acute vasomotor

changes
Oesophageal Doppler
 Oesophageal Doppler
• Respiratory changes in aortic peak velocity may
used to estimate fluid responsiveness (Monnet X et
al, ICM 2005)

• Feissel et al, Chest 2001, demonstrated that a

change in aortic peak velocity with
respiration
>12% allowed discrimination between fluid
responders & non-responders with sensitivity of
100% & specificity 89%.
 IVC Collapse
• Intrathoracic pressure changes affect VR & therefore
diameter IVC

• Absolute diameter or Δdiameter have both been used

to assess col status

• Sefidbakht et al, Emer Radiol 2007, developed vena

cava collapsibility index (= (end-expiratory diameter -
end-inspiratory diameter) / end-expiratory diameter).
• Those who responded had greater collapsibility at baseline (25% vs
6%)
Intensive Care Medicine
September 2004, Volume 30, Issue 9, pp 1734-1739

Superior vena caval collapsibility as a gauge of volume status in

ventilated septic patients
Antoine Vieillard-Baron, Karim Chergui, Anne Rabiller, Olivier Peyrouset, Bernard Page, Alain Beauchet, François Jardin

• Studied 66 pts in medical ICU with “ALI”

• Used TOE Doppler to measure SVC collapsibility at

baseline and following 10ml/kg fluid (HES).

• Threshold SVC collapsibility of 36% allowed

discrimination between responders and non-
responders (defined by increase CI of at least 11%)
with a sensitivity of 90% & specificity of 100%
 Passive Leg Raise
• All previous techniques required sedated, ventilated
pts
• PLR can be used reliably in awake pts with cardiac
dysrhythmias
• Numerous studies demonstrating ability of PLR to predict
fluid responsiveness

• Cavallaro et al, ICM 2010, meta-analysis determined AUC for PLR in

determining fluid responsiveness was 0.95

• Should use CO monitor - FloTrac-Vigleo system can be used

to measure SVV with PLR where a 10% or greater increase in
CO predicts fluid responsiveness (Biais M et al, CC 2009)
Summar
y