The document discusses methods for assessing fluid responsiveness in patients with acute circulatory failure. It finds that the end-expiratory occlusion (EEO) test can predict fluid responsiveness except in patients with strong spontaneous breathing. The passive leg raising (PLR) test is reliable when pulse pressure variation cannot be used, but requires starting from a semi-recumbent position and monitoring cardiac output. Non-invasive measures like changes in end-tidal carbon dioxide may also assess PLR effects. Both EEO and PLR have limitations and cannot be used in all cases.

1. Assessment of fluid responsiveness
Beyond PPV
French
Intensive
Care
Society
Prof. Xavier MONNET
Medical Intensive Care Unit
Paris-Sud University Hospitals
xavier.monnet@bct.aphp.fr

2. Link of interest
Member of the Medical Advisory Board
of Pulsion Medical Systems

3. PPV cannot be used in patients with spontaneous breathing, cardiac
arrhythmias and ARDS with low Vt and/or low lung compliance
1
2
3
4
The 4key-messages

4. PPV, SVV EEO test
acute circulatory failure
when to administer fluid?
SB, arrhythmias, ARDS?
yesno
How to monitor fluid therapy

5.  systemic venous return
End-expiratory occlusion test

6. 34 patients with acute circulatory failure
monitored by PiCCO device
End-expiratory occlusion test

7. Easier with a continuous measurement of cardiac output
Prediction of fluid responsiveness end-expiratory occlusion test

8. -10
0
10
20
30
40
50
Effects of end-expiratory occlusion
on continuous cardiac index
increase  5%
Se = 91%
Sp = 100 %
34 patients with acute circulatory failure
monitored by PiCCO device
NR R
Prediction of fluid responsiveness end-expiratory occlusion test

9. EEO test
PEEP level?
limitations

10. 0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sensitivity
Sensitivity 90%
Specificity: 86%
>6%
PEEP = 14±4 cmH2O
0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sensitivity
Sensitivity: 80%
Specificity: 88%
>5%
PEEP = 5±0 cmH2O
End-expiratory occlusion test
The EEO test is reliable whatever the level of PEEP
34 ARDS patients
EEO test at PEEP=5 cmH2O and Pplat=30 cmH2O

11. EEO test
Cannot be used in non-intubated patients
but do we need to predict fluid responsiveness in such patients?
limitations
Cannot be used patients who cannot sustain an expiratory hold
Easier to perfom with a continuous measurement of cardiac output
PEEP level?

12. PPV cannot be used in patients with spontaneous breathing, cardiac
arrhythmias and ARDS with low Vt and/or low lung compliance
The EEO test is reliable to predict fluid responsiveness provided that
the patient does not exhibit a strong spontaneous breathing activity
1
2
3
4
The 4key-messages

13. PPV, SVV
EEO
acute circulatory failure
when to administer fluid?
SB, arrhythmias, ARDS?
yesno
EEO
PLR testPLR test
How to monitor fluid therapy

14. → PLR is like a " self preload challenge "
Prediction of fluid responsiveness passive leg raising

15. ABF
PLR
Volume expansion
Prediction of fluid responsiveness passive leg raising test

16. PPV
0
20
40
60
80
100
0 20 40 60 80 100
100 - specificity
sensitivity
PLR effects
on aortic blood flow
31 patients with spontaneous
breathing of cardiac arrhythmias
Passive leg raising

17. Passive leg raising

18. PPV cannot be used in patients with spontaneous breathing, cardiac
arrhythmias and ARDS with low Vt and/or low lung compliance
The EEO test is reliable to predict fluid responsiveness provided that
the patient does not exhibit a strong spontaneous breathing activity
The PLR test can be considered as reliable for predicting fluid
responsiveness when PPV cannot be used
1
2
3
4
The 4key-messages

19. Meta-analysis of 8 studies with PLR
and volume expansion
A large base of evidence→
Prediction of fluid responsiveness passive leg raising test
2important points→

20. semi-recumbent position PLR position
45° 45°
45°
PLR positionsupine position
Prediction of fluid responsiveness passive leg raising

21. 0
25
12.5
37.5
% change in cardiac
index from baseline
35 patients
All responders to PLR
Prediction of fluid responsiveness passive leg raising

22. Prediction of fluid responsiveness passive leg raising
Starting PLR from the semi-recumbent position
provides a more sensistive test
→
2nd important point→

23. Eso Doppler
echo
echo
echo and arterial flow
Flotrac/vigileo USCOM
PiCCO
Eso Doppler
PiCCO
echo
bioreactance
Passive leg raising
echo

24. -40
-20
0
20
40
60
80
PLR-induced changes in
arterial pulse pressure
*
RNR
False-negative
cases
We need a real-time measurement of cardiac output for
assessing fluid responsiveness
→
Passive leg raising

25. Passive leg raising

26. Passive leg raising
Cannot be used in case of:
no real-time measurement of cardiac output
limitations

27. 40CO2 (mmHg)
30 sec
0
Prediction of fluid responsiveness passive leg raising test
65 pts receiving volume expansion
Monitoring of end-expiratory CO2
passive leg raising volume expansion

28. Prediction of fluid responsiveness passive leg raising test
65 pts receiving volume expansion
Monitoring of end-expiratory CO2
PLR-induced changes in cardiac index
PLR-induced changes in EtCO2
0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sensitivity
*
PLR-induced changes in arterial pulse pressure
Non-invasive assessment of the effects of the PLR test→

29. Passive leg raising
Cannot be used in case of:
no real-time measurement of cardiac output
intracranial hypertension
operating room
limitations

30. PPV cannot be used in patients with spontaneous breathing, cardiac
arrhythmias and ARDS with low Vt and/or low lung compliance
The EEO test is reliable to predict fluid responsiveness provided that
the patient does not exhibit a strong spontaneous breathing activity
The PLR test can be considered as reliable for predicting fluid
responsiveness when PPV cannot be used
PLR must start from the semi-recumbent position and must be
monitored with a direct measurement of cardiac output
1
2
3
4
The 4key-messages

31. EEO EEO
Acute circulatory failure
When to administer fluid?
PPV, SVV
SB, arrhythmias, ARDS?
yesno
PLRPLR
Optimal management of fluid therapy?