1. Fluid responsiveness Prof. Xavier MONNET xavier.monnet@bct.aphp.fr
Medical Intensive Care Unit
Paris-Sud University Hospitals

2. The 5 key-messages 1
Fluid overload is clearly deleterious in septic and ARDS patients 2 3 4 5

3. → Limit fluid administration in case of ARDS
The risk of volume expansion
200 pts with ARDS
EVLW measured by PiCCO device 20 40 60 80
100
EVLWImax > 21 mL/kg
EVLWImax ≤ 21 mL/kg
70%
42%
p =
Day-28 mortality (%) →
Limit fluid administration in case of ARDS

4. The risk of volume expansion
Cohort study
3,147 pts with sepsis →
Excessive fluid administration is deleterious in septic shock patients

5. The 5 key-messages 1
Fluid overload is clearly deleterious in septic and ARDS patients and must be avoided 2 
How to avoid fluid overload ? 3 4 5

6.  The concept of fluid responsiveness
Stroke volume a' b' a' b' 
All patients do not "respond" to fluid administration A B A B
Cardiac preload VE VE

7. The 5 key-messages 1
Fluid overload is clearly deleterious in septic and ARDS patients and must be avoided 2
Volume expansion does not always result in the expected increase in cardiac output 3  4
How could we predict fluid responsiveness? 5

8. The concept of fluid responsiveness
Stroke
volume b' a' b' a' A B A B
Cardiac preload
Low preload
High preload

9. The concept of fluid responsiveness
Stroke
volume
normal ventricular function
impaired ventricular function A B
Cardiac preload
static marker of preload

10. The concept of fluid responsiveness
Stroke
volume
normal ventricular function
impaired ventricular function A B
Cardiac preload
E/Ea
LVEDV
LVEDA

11. Static markers of preload with echo
24 pts with circulatory failure and SB
TTE before and after 500 mL saline
Static markers of preload are unable to predict fluid responsiveness

12. The 5 key-messages 1
Fluid overload is clearly deleterious in septic and ARDS patients and must be avoided 2
Volume expansion does not always result in the expected increase in cardiac output 3
A given value of preload is not indicative of fluid responsiveness. Preload is not preload responsiveness 4 
How could we predict fluid responsiveness? 5

13. Prediction of fluid responsiveness Respiratory variation of HD signals
Stroke
volume A B

14. Prediction of fluid responsiveness Respiratory variation of HD signals
5-chamber view
Stroke
volume

15. Prediction of fluid responsiveness Respiratory variation of HD signals
19 pts with septic shock
Systematic fluid loading
Respiratory variation of VTI allows predicting fluid responsiveness

16. → Prediction of fluid responsiveness
Respiratory variation of HD signals
19 pts with septic shock
Systematic fluid loading →
Respiratory variation of VTI allows to predict fluid responsiveness

17. Prediction of fluid responsiveness Respiratory variation of HD signals
limitations
Cannot be used in case of:
spontaneous breathing activity
3 frequent situations
in the ICU
cardiac arrhythmias
ARDS with low Vt / compliance

18. How to monitor fluid therapy
acute circulatory failure
when to administer fluid?
SB, arrhythmias, ARDS? no
yes
ΔVTI
respiratory variation of vena cava

19. Prediction of fluid responsiveness Respiratory variation of vena cava
central blood volume
central blood volume

20. Prediction of fluid responsiveness Respiratory variation of vena cava
sub-costal view RV
SHV
IVC RA
diaphragm
Δ VCI =
ΔVCI max – ΔVCI min
Δ VCI mean
0.57 cm
1 cm

21. Prediction of fluid responsiveness Respiratory variation of vena cava
39 septic shock pts with MV
Systematic fluid loading with 6mL/kg starch
Se = 93%
Sp = 92%
cut-off value : 12%

22. Prediction of fluid responsiveness Respiratory variation of vena cava
66 pts with MV
Systematic fluid loading with 10 mL/kg starch

23. Prediction of fluid responsiveness Respiratory variation of vena cava
66 pts with MV
Systematic fluid loading with 10 mL/kg starch

24. Prediction of fluid responsiveness Respiratory variation of vena cava
66 pts with MV
Systematic fluid loading with 10 mL/kg starch

25. How to monitor fluid therapy
acute circulatory failure
when to administer fluid?
SB, arrhythmias, ARDS? no
yes
ΔVmax
Spontaneous breathing no
yes
Respiratory variation of VC
Passive leg raising

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

27. Prediction of fluid responsiveness passive leg raising testB

28. Passive leg raising →
With echo ?

29. Prediction of fluid responsiveness
passive leg raising test

30. * Prediction of fluid responsiveness passive leg raising test 40 35 30
24 pts with circulatory failure and SB
TTE before and after 500 mL saline
PLR-induced changes in
sub-aortic VTI 40 35 * 30 25 20
Cut-off :12%
Se = 77%
Sp = 100 % 15 10 5 -5
nonresponders
responders

31. How to monitor fluid therapy
acute circulatory failure
when to administer fluid?
SB, arrhythmias, ARDS? no
yes
Δmax
Spontaneous breathing no
yes
Respiratory variation of VC
Passive leg raising

32. The 5 key-messages 1
Fluid overload is clearly deleterious in septic and ARDS patients and must be avoided 2
Volume expansion does not always result in the expected increase in cardiac output 3
A given value of preload is not indicative of fluid responsiveness. Preload is not preload responsiveness 4
Respiratory variation of VTI allows to predict fluid responsiveness but is not valuable in case of arrhythmias, spontaneous breathing and ARDS 5
Respiratory variations of vena cava predict fluid responsiveness except in case of spontaneous breathing. PLR test can be used in any cases.