This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone

1. Fluid Responsiveness in Critically ill Patients
Ubaidur Rahaman
Senior Resident, CCM, SGPGIMS
Lucknow, India

2. FLUID RESPSONSIVENSS
Definition:
fluid responsiveness denotes an increase in cardiac index
after infusion of a fluid either crystalloid or colloid.
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

3. FLUID RESUSCITATION
3 DIFFERENT SCENARIO
Patients in the ERS for acute blood losses or body fluid losses
No therapeutic dilemma regarding hypovolemia
Patients in the ERS for high suspicion of septic shock
EGDT- volume resuscitation mandatory in first 6 hours- mortality benefit
Patients in the ICU,
already resuscitated for several hours or days
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

4. Patients in the ICU, already resuscitated for several hours or days
• hemodynamic instability requiring therapy
• Cumulative fluid balance
• Risk of pulmonary oedema/ raised IAP
•? Fluid responsiveness
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

5. Cumulative fluid balance and mortality
Fluid resuscitation in septic shock: A positive fluid balance and elevated
central venous pressure are associated with increased mortality.
Crit Care Med 2011 Vol. 39, No. 2; John H. Boyd, Jason Forbes, MD; Taka-aki Nakada, Keith R. Walley,
James A. Russell,
retrospective review of the use of intravenous fluids during the first 4 days of care.
Patients: VASST study enrolled 778 patients
septic shock and receiving a minimum of 5 ug of norepinephrine per minute.
A more positive fluid balance both early in resuscitation and cumulatively over
4 days is associated with an increased risk of mortality in septic shock.
Central venous pressure may be used to gauge fluid balance <12 hrs into septic shock but
becomes an unreliable marker of fluid balance thereafter.
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

6. to give or not to give????
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

7. Assessment OF FLUID RESPONSIVENESS
PRELOAD DEPENDENCE
PRELOAD
CONTRACTILITY
CARDIAC INDEX
Both ventricles should be preload dependent
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

8. Assessment of PRELOAD is not
assessment of PRELOAD DEPENDENCE
normal heart
Stroke volume
preload-dependence
preload-
failing heart
preload-independence
preload-
Ventricular preload
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

9. ASSESSMENT OF FLUID RESPONSIVENESS
ASSESSMENT OF PRELOAD
•Filling pressures- CVP, Pawp
•Filling volumes- LVEDV/ RVEDV
•VENACAVAL DIAMETER- variation with respiration
•RAP - inspiratory fall
ASSESSMENT OF PRELOAD DEPENDENCE
•Response to fluid challenge
•Prediction of preload dependence:
PPV induced variation in CI parameters
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

10. ASSESSMENT OF PRELOAD
Filling pressures
oCentral Venous Pressure
oPulmonary artery Wedge Pressure
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

11. Central Venous Pressure
VR
CVP
Function of
CARDIAC PUMP
VR- function of
•MCFP
•Vs
•Venous resistance
VR- venous return; MCFP- mean capillary filling pressure
Vs- stressed volume

12. Mean Capillary filling pressure
(MCFP)
V
Vs
Vu
P
Vs- Stressed volume; Vu- unstressed volume
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

13. Central Venous Pressure
Venous function and central venous pressure. A physiologic story.
Simon Gelman. Anesthesiology 2008;108:735-48

14. C.O.
is determined by
intersection
RETURN FUNCTION
of
CARDIAC FUNCTION
Q
Q
Pra
Pra
Q
Pra
How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

15. CONCEPT OF LIMIT
Q
Limit of “RETURN FUNCTION”
Lowering Pra will not
increase VR
Limit of “CARDIAC FUNCTION”
Increasing Pra will not
Increase C.O.
Pra
How to use CVP measurements. Magder S. Current Opinion in Critical Care 2005, 11:264—270

16. Is CVP a misleading variable?
Body does everything to maintain homeostasis
adequate transmural pressure
MCFP
more accurate measurement of volume status- difficult to measure
Ppawp
is an even worse indicator than CVP as it is far removed from the action of MCFP
RAP and Ppaw
do not always reflect true transmural pressure in patients on PEEP, increased IAP
“The correlation between CVP and circulating blood volume has never been found
simply because it does not exist”
Venous function and central venous pressure. A physiologic story.
Simon Gelman. Anesthesiology 2008;108:735-48

17. Does Central Venous Pressure predicts fluid responsiveness?
A systemic review of literature and the tale of seven mares.
Paul E. Marik, M. Baram, B. Vahid. Chest 2008;134:172-178
Expansive literature search to identify all trials evaluating the relationship between
2.
1. CVP & blood volume
association between CVP or Δ CVP and fluid responsiveness
– 24 studies identified
– 5 comparing CVP with measured blood volume;
-19 studied relationship between CVP/ΔCVP & change in cardiac
performance after fluid challenge
Poor correlation between
•CVP and blood volume
•CVP or ∆CVP and homodynamic response to fluid challenge
overall 56% patients responded to fluid challenge

18. predicting fluid responsiveness in ICU patients: A critical analysis of evidences.
Frédéric Michard and Jean-Louis Teboul. Chest 2002;121;2000-2008
From medline (since 1966) Twelve studies were analyzed in which the parameters tested
were as follows:
(1) static Indicators: RAP, PAOP, RVEDV, LVEDA;
(2) dynamic parameters: inspiratory decrease in RAP, ddown, PPV, aortic blood
velocity(Vpeak)
Before fluid infusion, static indicators were not significantly lower in responders
than in nonresponders.
When a significant difference was found, no threshold value could discriminate
responders and nonresponders.
Before fluid infusion, inspiratory variation in RAP,SPV ddown, PPV, and Vpeak
were significantly higher in responders.
Positive predictive value: 77- 95%, negative predictive value: 81- 100%

20. ASSESSMENT OF PRELOAD
Filling Volumes
o RVEDV
o LVEDV

21. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
Spontaneous breathing
Negative pleural pressure---- increased VR---- collapse of IVC
Positive pressure ventilation
Positive pleural pressure---increased RA pressure---decreased VR
IVC- extrathoracic course--- increased transmural pressure---- distend
SVC- intrathoracic course--- decreased transmural pressure----collapse
This variation is affected by intravascular volume ( hydrostatic pressure)
Less intravascular volume--- more variation

22. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
SPONTNEOUS BREATHING Patient
IVC collapsibility index ≥ 50% is strongly associated with low CVP
Emergency department bedside ultrasonographic measurement of caval index for noninvasive
Determination of low central venous pressure.
Nagdev AD, Merchant RC, Murphy MC. Ann Emerg Med. 2010 Mar;55(3):290-5
In healthy subjects inspiration decreased IVC diameter by approx. 50%.
This cyclic change is abolished in high volume status, right ventricular failure, cardiac tamponade.
Applied Physiology in Intensive care Medicine. Pinsky, Mancebo. page 145
Could be affected by manner of respiration
Could be affected by raised IAP

23. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
IVC distensibility index ( DDIVC) ≥ 12% predictive of increase in C.I. by at least 15%
Positive predictive value- 93 %, negative predictive value- 92%
DDivc=(Dmax-Dmin)/ mean of 2 values
The respiratory variation in inferior venacava diameter as a guide to fluid therapy.
Feissel M, Michard F. Inten Car Med 2004;30:1834-7
IVC distensibility index (dIVC) ≥ 18% predictive of increase in C.I. of at least 15%
Sensitivity-90%, Specificity-90%
divc=(Dmax-Dmin)/ Dmin
Respiratory changes in inferior venacava diameter are helpful in predicting fluid
responsiveness in ventilated septic patients.
Barbier C, Jardin F. Inten Car Med 2004;30:1740-6

24. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
Could be affected by raised IAP

25. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
Could be affected by raised IAP

26. Assessment OF PRELOAD
Respiratory variation in VENACVAL DIAMETER
POSITIVE PRESSURE VENTILATED PATIENTS
SVC collapsibility index ≥ 36% identified preload responders.
Sensitivity- 90%, specificity- 100%
dSVC= (Dmax-Dmin)/ Dmax
Superior venacaval collapsibility as a gauge of volume status in ventilated
septic patients.
Vieillard Baron A, Chergui K, Rabiller A. Inten Care med 2004;30;1734-9
Not affected by raised IAP

27. Assessment OF PRELOAD
Inspiratory fall in right atrial pressure
Respiratory variation in RAP predicts the response to fluid challenge.
Magder S, Geoorgiadis G, Cheong T. J Crit Care 1992; 7:76-85
13 of 14 patients had no fall in RAPC.O. not increased with fluid challenge
16 of 19 patients who had a fall in RAP ≥ 1 mmHgC.O. increased by> 250 ml/ min with fluid challenge
Sufficient inspiratory effort to lower Ppaw by 2 mmHg

28. Assessment OF PRELOAD DEPENDENCE
FLUID CHALLENGE
PREDICTION BY PPV induced
RESPIRATORY VARIATION
IN
C.I. RELATED PARAMETERS
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

29. Assessment OF PRELOAD DEPENDENCE
Response to FLUID CHALLENGE
change in filling pressures- CVP, RAP, Pawp
change in perfusion markers- C.O., MAP, CFT, ABG, SCVO2, B. lactate
Disadvantages
pulmonary edema
excessive cumulative fluid balance
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

30. Assessment of PRELOAD DEPENDENCE
PREDICTION OF PRELOAD DEPENDENCE
Spontaneously breathing patients
PLR- ∆ stroke volume/ pulse pressure
Positive pressure ventilated patients
PLR- ∆ stroke volume/ pulse pressure
Respiratory cycle induced change in parameters related to cardiac indexSPV, SVV, PPV, pulse oxymetry plathysmography waveform variation,
Aortic blood flow velocity, aortic velocity time integral, aortic pre-ejection period
Respiratory systolic variation test ( RSVT)
end expiratory occlusion test

31. Assessment of PRELOAD DEPENDENCE
PREDICTION OF PRELOAD DEPENDENCE
PASSIVE LEG RAISING
Venous blood shift
(Rutlen et al. 1981, Reich et al. 1989)
1981,
45
°
Transient and reversible effect

32. Assessment of PRELOAD DEPENDENCE
PREDICTION OF PRELOAD DEPENDENCE
PLR
Passive leg raising predicts fluid responsiveness in the critically ill
Xavier Monnet, Mario Rienzo, David Osman, Nadia Anguel, C. Richard,
Michael R. Pinsky, Jean-Louis Teboul, Crit Care Med 2006; 34:1402–1407
71 mechanically ventilated patients considered for volume expansion.
31 patients had spontaneous breathing activity and/or arrhythmias.
homodynamic status assessed
at baseline, after PLR, after volume expansion (500 mL NaCl 0.9% infusion over 10 mins)
In both groups, PLR induced increase in aortic blood flow ≥10% predicted
volume expansion induced increase in aortic blood flow ≥15%
(sensitivity- 97%, specificity 94%)

33. Assessment of PRELOAD DEPENDENCE
PREDICTION OF PRELOAD DEPENDENCE- PLR
Immediate effect of PLR following induction of anesthesia for cardiac surgery in
18 patients
Baseline
PLR
Change
(%)
Cardiac output
( l/min)
4.5± 1.1
5.7 ± 1.1
23
PAOP ( mmHg)
12.9 ± 4.5
14.1± 4.8
10
SPV ( mmHg)
11.3 ± 5.1
5.9 ± 2.4
48
dDown ( mmHg)
7.5 ± 3.7
3.3 ± 2
56
Functional hemodynamic monitoring. Pinsky and Payen, page 318

34. PREDICTION OF PRELOAD DEPENDENCE
Positive pressure ventilation induced change in parameters related to
cardiac index
Paw
Ppl
PAlv
Palv
Transmural pressure
cardiac chambers/ great
vesseles
Filling gradient
of LV no effect
Transpulmonary
pressure
alveoli
Filling
gradient of RV
PVR
RV
preload
LV stroke
volume
Pulmonary
Transit time
Zone 3 to
zone 2/1
formation
RV
afterload
RV stroke
volume
Mainly responsible
for change in
stroke volume
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

35. PREDICTION OF PRELOAD DEPENDENCE
Positive pressure ventilation change in parameters related to
cardiac index
Paw
Ppl
Palv
Transmural pressure
Transpulmonary
pressure alveoli
cardiac chambers
LV afterload
squeezing of
blood out of
alveolar vesseles
LV preload
LV stroke
volume
Predominant mechanism
in LV systolic dysfunction
Predominant mechanism
in hypervolemia
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

36. PREDICTION OF PRELOAD DEPENDENCE
Positive pressure ventilation induced change in parameters related to
cardiac index
RV preload
RV ejection
Pleural
pressure
Pumonary
transit time
LV preload
RV afterload
LV ejection
transpulmonary
pressure
LV afterload
LV ejection
LV preload
Aortic velocity
Stroke volume
Systolic B.P.
Pulse Pressure
Aortic velocity
Stroke volume
Systolic B.P.
Pulse Pressure
MINIMUM AT END OF EXPIRATION
MAXIMUM AT END OF INSPIRATION
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

37. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
SYSTOLIC PRESSURE VARIATION- SPV
PROPOSED BY COYLE IN 1983
dup
inspiratory increase in systolic pressure:
increased LV Stroke volumeincreased preload
decreased afterload
Increase in extramural aortic pressure
Ddown
Expiratory decrease in systolic pressure:
decrease in LV stroke volumedecrease in preload

38. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
SYSTOLIC PRESSURE VARIATION- SPV
Systolic pressure variation as a guide to fluid therapy in patients with
sepsis induced hypotension
Taverneir B, Dupont J. Anesthesiology 1998, 89:1313-1321
ddown- threshold value of 5 mmHg was associated with
Increase in stroke volume ≥ 15%
Positive predictive value- 95%, Negative predictive value- 93%
dup- increase in hypervolemia and LVF
ddown-not increased in RVF despite hypovolemia
In the presence of large dup, the PPV, SPV and SVV will be less effective
in predicting fluid responsiveness
*cardiovascular monitoring Chapter 32, page 1327, Miller’s Anesthesia 7th edi

39. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
PPmax-PPmin
PPV=
PPmax+PPmin/2

40. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
Relation between Respiratory Changes in Arterial Pulse Pressure and Fluid
Responsiveness in Septic Patients with Acute Circulatory Failure
F. MICHARD, S. BOUSSAT, D. CHEMLA, NADIA ANGUEL, MICHAEL R. PINSKY, and JEAN-LOUIS TEBOUL
Am J Respir Crit Care Med Vol 162. pp 134–138, 2000
Baseline
VE
11o± 22
106 ± 21
MAP
69 ± 13
90 ± 13
Pra
9±3
12 ± 4
10 ± 3
14 ± 3
24 ± 6
29 ± 6
3.6 ±
0.9
4.0 ± 0.9
14 ± 10
7±5
9±6
6±4
HR
(beats/min)
(mmHg)
Pcwp
Ppa
CI
(mmHg)
(mmHg)
(l/min/m2)
∆PPV
∆SPV
(%)
(%)
Threshold value of 13% was
associated with increase in
C.I. ≥ 15% in response to
volume expansion
Sensitivity- 94%, specificity96%

41. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV

42. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
PULSE PRESSURE VARIATION- PPV
PPV better predictor than other SV derived variables
Inspiratory increase
in pleural pressure
increase in SPV
Increase in extra-mural
pressure
Equal increase in
Systolic pressure
And
Diastolic pressure
no change in PPV
Ubaidur Rahaman, S.R., CCM, SGPGIMS, Lucknow

43. PREDICTION OF PRELOAD DEPENDENCE
Respiratory cycle induced change in parameters related to cardiac index
RESPIRATORY SYSTOLIC VARIATION TEST ( RSVT)
RSVT slope 0.24 mmHg/ cmH2O
predicted
change in CI of 15%
RSVT slope
Predicting fluid responsiveness in patients undergoing surgery: functional haemodynamic parameters
including the Respiratory Systollic Variation Test and static preload indicators.
Preisman S, Kogan S, Berkenstadt H, et al Br J Anaesth 2005;95:746–55

44. “since during critical illness maintenance of the cardiac output
may depend upon right ventricular function, the clinician need to
be able to discern the presence of right ventricular dysfunction…”
William Hurford, 1988
Presence of fluid responsiveness is not an
indication by itself to administer fluids

45. It is commonly said that a teacher fails
if he has not been surpassed by his students
-Edmond H. Fischer

46. o PPV
Pulse pressure depends on stroke volume and arterial compliance
Change in compliance may affect degree of PPV induced by increase in
stroke volume
Elderly- stiff arteries--- small increase in stroke volume--- large PPV
Young healthy adult- large increase in stroke volume – relatively small PPV

47. CVP
o Effect of pleural pressure
o Effect of PEEP on pleural pressure
less than half of PEEP is transmitted to the pleural space
even less than that in pathological condition that require higher PEEP--- ARDS
PEEP – <=10 cm H2O = 8 mmHg----- change in pleural pressure—2-3 mmHg
but at PEEP>10 changes in pleural pressure at end expiration become significant
o Effect of forced expiration on pleural
pressure

48. Respiratory change in pleural
pressure
o Respiratory change in Pcwp
o Respiratory change in esophageal
pressure

49. Fluid challenge
o
o
o
o
Rapidity of fluid infusion is important- faster the fluid is given,
lesser the amount to be given
type of fluid- crystalloid or colloid does not matter
Change in CVP and not the volume of infusion that is important
Blood pressure is not a good guide as to whether C.O.
increased with fluid infusion
In ¾ patients in whom C.O. increased there was no increase in
B.P. ( Bafaqeeh F, Magder S. CVP and volume responsiveness of cardiac output. Am J
Respir Crit Car Med 2004, 169: A 343

50. Role of echocardiography
Assessment of inadequate resuscitation:
o
o
Volume status and responsiveness – fluid resuscitation
Cardiac contractility -- ionotrope

51. Effect of Positive Pressure Mechanical Ventilation on Hemodynamics
PULSE PRESSURE VARIATION- PPV
contribution of transmission of pleural pressure
effect on both systolic as well as diastolic pressure equally
Determination of aortic pressure variation during positive pressure ventilation in man.
Denault, Gasior, Pinsky, Gorscan, Mandarino. Chest 2000;116:176-186