This presentation is an evidence based approach to discussing different methods in assessing whether the patient will respond to fluid boluses or not

1. Monitoring Fluid Responsiveness

2. Objectives
1. Recall the incidence of patients who fail to respond to fluid boluses in the
ICU
2. Discuss current controversies in fluid volume management
3. Recognize the value of measuring patient response to fluid administration

3. More than 50% of patients in which fluid loading was “clinically indicated” are
non-responders and are being loaded with fluids unnecessarily!
Jean Louis Tebaoul et al.

4. 1. Volume expansion 1st line of
therapy.
2. Only ½ of patients show an
increase in CO as a response to
fluid therapy (Defined as
responders).
3. Need a reliable means to
determine patient ability to
respond to fluids.
The Volume Problem

5. Is there danger in the water?

6. 2012 Meta-Analysis of Fluid Bolus in
Children:
Conclusions: “…fluid boluses were harmful compared to no bolus.
Simple algorithms are needed to…determine who could potentially
be harmed by the provision of bolus fluids, and who will benefit.”
Ford N, hargreaves S, shanks L (2012) mortality after fluid bolus in children with shock due to sepsis or severe infection: A systematic
review and meta-analysis. Plos ONE 7(8): e43953. Doi:10.1371/journal.Pone.0043953

7. Permissive Hypotension in Trauma
Resuscitation
IV fluids in hypovolemic shock:
No ↑ survival, some ↑mortality
Theories on IVF in trauma:
1. ↑ BP dislodges clots
2. ↑ BP = ↑ bleeding
IVF hemodilutes clotting factors
EMS/ED: allow SBP 90, MAP 50-60
DUCHESNE JC ET AL. DAMAGE CONTROL RESUSCITATION: FROM EMERGENCY DEPARTMENT TO THE OPERATING ROOM. THE AMER SURGEON. 2011; 77: 201-206.

8. Invasive vs Noninvasive BP Monitoring
CRIT CARE MED 2013; 41:34–40
27,022 simultaneous NIBP & A-line BPs in 4,957 patients at a university
teaching hospital ICU
 NIBP overestimated SBP in hypotension
 Mean from NIBP and A-line consistent
 MAP < 60 associated with AKI & death

9. Acute Kidney Injury: SBP

10. Acute Kidney Injury: MAP

11. System-based Approaches to sepsis: Early-Goal
Directed Therapy
INCLUSION = Sepsis AND [BP < 90 after fluid OR Lactate > 4]
Control Intervention EGDT
CVP 8-12 Fluids CVP 8-12
MAP > 65 Vasopressors MAP > 65
Transfusions
Dobutamine
ScvO2 > 70%
49% mortality
33% mortality
LOS 4 less days
$13-16,000 savings
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., Peterson, E., et al. (2001). Early goal-directed therapy in the treatment of severe sepsis
and septic shock. New England Journal of Medicine, 345(19), 1368–1377.
Do what you normally do.
We’ll be watching you!

12. Hospital-wide impact of a standardized order set for
the management of bacteremic severe sepsis
After
Before
THIEL, S. W., ASGHAR, M. F., MICEK, S. T., REICHLEY, R. M., DOHERTY, J. A., & KOLLEF, M. H. (2009). HOSPITAL-WIDE IMPACT OF A STANDARDIZED ORDER
SET FOR THE MANAGEMENT OF BACTEREMIC SEVERE SEPSIS*. CRITICAL CARE MEDICINE, 37(3), 819–824. DOI:10.1097/CCM.0B013E318196206B

13. Summary of Trials
Rivers 2001
RCT
Sebat 2005
Before-After
Nguyen 2007
Complete or Not
Thiel 2009
Before-After
Levy 2011
Before-After
Goals
CVP >8
MAP > 65
ScVO2 >70%
HCT >30
MAP > 70
SaO2 > 92
UOP > 30ml/h
SvO2 > 60
CI > 2.5
ABX in 4 h
CVP > 8, MAP > 65,
ScVO2 > 70%, HCT >
30
Check Lactate
Steroids
Appropriate ABX in 4 h,
CVP > 8, MAP > 65,
ScVO2 > 70%
Early ABX, Blood
Cultures, Appropriate
ABX, CVP > 8, MAP >
65,
SvO2 > 70%
Specific
Interventions
Fluids, Blood, Pressors
ABX, Fluids
Pressors
ABX, Fluids, Blood,
Pressors
ABX, Fluids, Pressors,
Steroids, Xigris, Other
Supportive Care
ABX, Fluids, Pressors,
Steroids, Xigris, Other
Supportive Care
System
Interventions
ED-based Sepsis Team
Screening, Education,
Shock Team, Protocols
Education, In-services,
Protocols
Education, In-services,
Order Set, Protocols
Screening, Education,
Order Sets
Absolute Change in
Mortality -16% -12% -19% -16% -7%

14. Sepsis Guidelines 2012
Dellinger RP, levy MM, rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock:
2012. Critical care medicine 2013;41(2):580–637.
During the first 6 hrs of resuscitation, the goals of initial resuscitation of sepsis-induced
hypoperfusion should include all of the following as a part of a treatment protocol
(grade 1C):
1. CVP 8-12 mm Hg
2. MAP ≥ 65 mm Hg
3. Urine output ≥ 0.5 mL/kg.hr
4. Scvo2 70% or SVO2 65%

15. Drilling Into EGDT and SSC 2012:
The potential risks associated with individual elements:
◦ Dobutamine does not improve microvascular perfusion
◦ Transfusion to hematocrit of 30% appears harmful
Uncertainty about the external validity of the original trial
Uncertainty about the infrastructure and resource requirements for implementing EGDT.
Strong evidence exists only for:
1. Quickly restoring perfusion
2. Early blood cultures
ProCESS ARISE

16. ProCESS (60d))
EGDT 21%
PB-ST 18.2%
UC 18.9%
A Randomized Trial of Protocol-Based Care for
Early Septic Shock
ARISE (90d))
EGDT 18.6%
UC 18.8%
Process: published on march 18, 2014, at NEJM.Org.
Arise: nejm october 1, 2014

17. Continuous cardiac output monitoring is the gold
standard to monitor the response to a fluid challenge.
Response to Fluid Challenge

18. What hemodynamic monitoring do you routinely use for the management of high-risk surgery patients?

19. What are your indicators for volume expansion in patients undergoing high-risk surgery?

20. While only 47% of intensivists believed that CVP
should guide resuscitation, 86% used it because of the
Surviving Sepsis Campaign Guidelines.

21. Arterial Pulse Cardiac Output (APCO)

22. Hemodynamics During Positive Pressure
Ventilation: SVV and PPV
PPV=
𝑷𝑷𝒎𝒂𝒙−𝑷𝑷𝒎𝒊𝒏
𝑷𝑷𝒎𝒆𝒂𝒏Normal <13%

23. Determine success of fluid by the response
in stroke volume/index and SvO2
24
Stroke Volume
End-Diastolic Volume
D < 10%
D > 10%
D 0%
Fluid Responders
Fluid Non-Responders

24. Arterial Pressure Based Technologies
Technologies that use the arterial
pressure to determine cardiac output
can be affected by the quality of the
arterial pressure tracing.
Note the impact of an overdamped
tracing on the LiDCO cardiac output
value.
Jansen & van den berg 2005

25. “There is growing evidence that the pulse contour method is not the solution
to providing reliable CO monitoring at the bedside.”

26. Pleth Waveform
PVI is a percentage from 1 to 100%: 1 - no pleth variability 100 - maximum pleth variability

27. 2011 Radical-7

28. Fluid Administration Challenges
Fluid administration is critical to optimizing oxygen delivery by optimizing
cardiac output 1
Unnecessary fluid administration may be harmful2
Traditional methods to guide fluid administration often fail to predict fluid
responsiveness
◦ Accurate only 50-60% of time 3
Newer dynamic methods that can predict fluid responsiveness are invasive,
complex, and/or costly 4
◦ Many patients are not candidates for this level of monitoring
1 perel A. Anesth analg. 2008; 106 (4):1031-33 2 bundgaard-nielsen M et al. Acta anaesthesiol scand. 2007; 51(3):331-40
3 michard F et al. Chest. 2002; 121(6):2000-08 4 joshi G et al. Anesth analg. 2005; 101:601-5

29. Preload
Stroke
Volume
0
0
Higher PVI = More likely to respond to fluid administration
24 %
10 %
Lower PVI = Less likely to respond
to fluid administration
PVI to Help Clinicians
Optimize Preload / Cardiac Output
Frank-Starling Relationship

30. PVI to Help Clinicians Assess Fluid Responsiveness During
Surgery: Similar to Stroke Volume Variation / Superior to CVP
Zimmermann M, et al. Eur J anaesthesiol. 2010;27(66):555-561.

31. CO
PPV
PVI
PVI to Assess Fluid Responsiveness in the ICU
Similar to Pulse Pressure Variation / Superior to
Cardiac Output
Loupec T et al. Crit care med 2011 vol. 39, no. 2

32. PVI to Help Clinicians Predict Hypotension
During Surgery
Tsuchiya M et al. Acta anaesthesiol scand. 2010.

33. PVI to Help Clinicians Predict
Hemodynamic Instability by PEEP
Desebbe O et al. Anesth analg 2010;110:792–798.

34. PVI to Help Clinicians Improve Fluid
Management and Reduce Patient Risk
Forget P et al. Anesth analg 2010.

35. Clinical Evidence:
Predicting Fluid Nonresponders
Adapted from cannesson M. Et. Al. Br J anesth 2008;101(2):200-206
Similar to Arterial Pulse Pressure / Superior
to CI, PCWP, CVP

36. SVV or PVI and Fluid Status
High variability = volume depletion (“high is dry”)
◦ Ability to observe and intervene in real time
50% of patients are fluid non-responders
◦ The ventricle more
sensitive to respiratory
changes is more
responsive to preload
1. Who needs fluid
2. Who will respond

38. InSpectraTM StO2 Systems
Ardolic, ann emerg med. 2010;56:s131. Cohn, J trauma. 2007;62:44. Moore, int proc TSIS 2007;111.

39. What is StO2?
SaO2 and SpO2
measure O2
saturation in
the arteries.
ScvO2 measures O2
saturation in the
superior vena cava.
SvO2 measures O2
saturation in the
pulmonary artery.
StO2 measures O2 saturation in the
microcirculation where O2 diffuses to tissue cells. StO2 is a measure of tissue
oxygenation and is a sensitive indicator of tissue perfusion status.
InSpectra StO2
SaO2
SpO2
ScvO2
SvO2
StO2 = hemoglobin oxygen saturation of the microcirculation
Cohn, J trauma. 2007;62:44

41. Passive leg raising (PLR)
Self-volume challenge, reversible: 200 – 300 ml volume
Increases the left cardiac preload and thus challenge the Frank-Starling curve.
Effects < 30 sec., not > than 4 minutes
Assess for a 10% increase in stroke volume (cardiac output monitor) or using a surrogate such as pulse pressure (using an arterial
line)

42. Diagnostic Accuracy of Passive Leg Raising for Prediction of
Fluid Responsiveness in Adults: Systematic Review and Meta-
analysis of Clinical Studies.
Meta-analysis 9 studies
PLR changes in CO predicts fluid
responsiveness
Regardless of ventilation mode and
cardiac rhythm
Difference in CO of 18%
distinguished responder from NR
The pooled sensitivity and specificity of PLR-CO were
89.4% (84.1-93.4%) and 91.4% (85.9-95.2%) respectively
AUC= 0.96
Cavallaro, F. Et al. Intensive care med. 2010 sep;36(9):1475-83

43. Intensive Care Med. 2013 Jan;39(1):93-100

44. Collapsibility Index =
𝑰𝑽𝑪 𝒎𝒂𝒙
−𝑰𝑽𝑪𝒎𝒊𝒏
𝑰𝑽𝑪 𝒎𝒂𝒙
>12% = responders
(PPV 93% and NPV92%).

45. Collapsibility Index =
𝑰𝑽𝑪 𝒎𝒂𝒙
−𝑰𝑽𝑪𝒎𝒊𝒏
𝑰𝑽𝑪 𝒎𝒂𝒙
<12% = non-responders
(PPV 93% and NPV92%).

46. Ultrasonographic Measurement of the Respiratory Variation in the Inferior
Vena Cava Diameter is Predictive of Fluid Responsiveness in Critically Ill
Patients: Systematic Review and Meta-analysis
Total of 8 studies/235 Pts
ΔIVC measured is of great value in predicting fluid responsiveness,
particularly in patients on controlled mechanical ventilation
Zhongheng zhang, xiao xu, sheng ye, lei xu. Ultrasound in medicine and biology. Volume 40, issue 5, pages 845–853, may 2014

47. How should we monitor preload and
fluid responsiveness in shock?

49. The Hemodynamic Puzzle
O2ER
NIRS
SVV SvO2
ScvO2
Heart Rate
Urine Output
Mental Status
OPSI
GEDV
P(cv-a)CO2
Lactate
SV
CVP

50. Summary
We need to rethink why we’re giving fluids
◦ Important to identify who will benefit
Restoration of circulation is the goal
◦ Assess cardiac function and perfusion markers
◦ When fluids are not immediately effective – use pressors
Give fluids only when needed, and no more than needed (Could
2 liters be the limit?)
◦ No value in non-responders, likely harmful
Standardized approaches improve outcomes
◦ Continual attention to effects of individual interventions

52. Overall Conclusions:
Clinical Utility of PVI
• Fluid administration is critical to optimizing patient status
• Traditional methods to guide fluid administration are not
sensitive or specific 1
• Newer methods to improve fluid administration may
improve patient outcomes but are impractical, invasive, or
costly 2
• PVI is noninvasive and proven to predict fluid
responsiveness in mechanically ventilated patients in the
OR and ICU 3,4
• PVI improves fluid management and reduces patient risk
as evidenced by lower lactate levels 5
1 Michard F, Teboul JL. Chest. 2002 Jun;121(6):2000-8. 2 Joshi G. et al. Anesth Analg. 2005; 101:601. 3 Cannesson M
et al. Br J Anaesth. 2008 Aug;101(2):200-6. 4 Feissel M et al. Critical Care. 2009;13(1):P219.
5 Forget P et.al. Critical Care. 2009; 13(1):P204.