Assessing volume status and fluid responsiveness in the emergency department

David C Mackenzie, Vicki E Noble, David C Mackenzie, Vicki E Noble

Abstract

Resuscitation with intravenous fluid can restore intravascular volume and improve stroke volume. However, in unstable patients, approximately 50% of fluid boluses fail to improve cardiac output as intended. Increasing evidence suggests that excess fluid may worsen patient outcomes. Clinical examination and vital signs are unreliable predictors of the response to a fluid challenge. We review the importance of fluid management in the critically ill, methods of evaluating volume status, and tools to predict fluid responsiveness.

Keywords: Hemodynamics; Shock; Ultrasonography.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1.
Fig. 1.
(A) Frank-Starling curve. Static measures of preload reflect an individual’s cardiac output at a given time point, but cannot inform the clinician if the patient has preload reserve (points X and Y) or is preload independent (Z). (B) Tests of fluid responsiveness should challenge an individual’s FrankStarling relationship, and assess potential to advance along the curve (from 1 to 2).
Fig. 2.
Fig. 2.
Passive leg raise. To perform a passive leg raise, a patient is placed in a semi-recumbent position at 45°. The patient’s legs are then elevated to 45° and the hemodynamic variable of interest evaluated after 30−60 seconds.
Fig. 3.
Fig. 3.
Measurement of the inferior vena cava (IVC) caval index. (A) Long axis view of the IVC. The diameter is measured with M-mode 2−3 cm distal to the confluence of the hepatic vein and IVC. (B) M-mode tracing of the IVC demonstrating respirophasic changes in diameter.
Fig. 4.
Fig. 4.
Measurement of aortic velocity-time integral (VTI). (A) Apical 5-chamber view of the heart, demonstrating position for Doppler measurement of aortic blood flow. (B) Spectral Doppler tracing of aortic blood flow. The area under the curve is the VTI.

References

    1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637.
    1. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35:64–8.
    1. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37:2642–7.
    1. Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care. 2014;4:21.
    1. Wang CH, Hsieh WH, Chou HC, et al. Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies. Crit Care Med. 2014;42:954–61.
    1. Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008;12:R74.
    1. Jozwiak M, Silva S, Persichini R, et al. Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med. 2013;41:472–80.
    1. Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care. 2013;17:
    1. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39:259–65.
    1. Legrand M, Dupuis C, Simon C, et al. Association between systemic hemodynamics and septic acute kidney injury in critically ill patients: a retrospective observational study. Crit Care. 2013;17:
    1. Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care. 2014;29:700–5.
    1. Kaafarani HM, Velmahos GC. Damage control resuscitation in trauma. Scand J Surg. 2014;103:81–8.
    1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.
    1. ProCESS Investigators. Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683–93.
    1. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483–95.
    1. Maitland K, George EC, Evans JA, et al. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Med. 2013;11:68.
    1. Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011;1:1.
    1. Lansdorp B, Lemson J, van Putten MJ, de Keijzer A, van der Hoeven JG, Pickkers P. Dynamic indices do not predict volume responsiveness in routine clinical practice. Br J Anaesth. 2012;108:395–401.
    1. Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med. 2010;36:1475–83.
    1. Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34:1402–7.
    1. Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002;121:1245–52.
    1. Muller L, Toumi M, Bousquet PJ, et al. An increase in aortic blood flow after an infusion of 100 ml colloid over 1 minute can predict fluid responsiveness: the mini-fluid challenge study. Anesthesiology. 2011;115:541–7.
    1. Wu Y, Zhou S, Zhou Z, Liu B. A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness. Crit Care. 2014;18:
    1. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41:1774–81.
    1. Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004;32:691–9.
    1. Lichtenstein DA, Meziere GA, Lagoueyte JF, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136:1014–20.
    1. Prekker ME, Scott NL, Hart D, Sprenkle MD, Leatherman JW. Point-of-care ultrasound to estimate central venous pressure: a comparison of three techniques. Crit Care Med. 2013;41:833–41.
    1. Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med. 2010;55:290–5.
    1. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30:1834–7.
    1. Barbier C, Loubieres Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30:1740–6.
    1. Corl K, Napoli AM, Gardiner F. Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. Emerg Med Australas. 2012;24:534–9.
    1. Muller L, Bobbia X, Toumi M, et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Crit Care. 2012;16:
    1. Blehar DJ, Resop D, Chin B, Dayno M, Gaspari R. Inferior vena cava displacement during respirophasic ultrasound imaging. Crit Ultrasound J. 2012;4:18.
    1. Singer M, Clarke J, Bennett ED. Continuous hemodynamic monitoring by esophageal Doppler. Crit Care Med. 1989;17:447–52.
    1. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909–12.
    1. Monnet X, Rienzo M, Osman D, et al. Esophageal Doppler monitoring predicts fluid responsiveness in critically ill ventilated patients. Intensive Care Med. 2005;31:1195–201.
    1. Guinot PG, de Broca B, Abou Arab O, et al. Ability of stroke volume variation measured by oesophageal Doppler monitoring to predict fluid responsiveness during surgery. Br J Anaesth. 2013;110:28–33.
    1. Lee JH, Kim JT, Yoon SZ, et al. Evaluation of corrected flow time in oesophageal Doppler as a predictor of fluid responsiveness. Br J Anaesth. 2007;99:343–8.
    1. Blehar DJ, Glazier S, Gaspari RJ. Correlation of corrected flow time in the carotid artery with changes in intravascular volume status. J Crit Care. 2014;29:486–8.
    1. Lafanechere A, Pene F, Goulenok C, et al. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care. 2006;10:
    1. De Backer D, Heenen S, Piagnerelli M, Koch M, Vincent JL. Pulse pressure variations to predict fluid responsiveness: influence of tidal volume. Intensive Care Med. 2005;31:517–23.
    1. Yang SY, Shim JK, Song Y, Seo SJ, Kwak YL. Validation of pulse pressure variation and corrected flow time as predictors of fluid responsiveness in patients in the prone position. Br J Anaesth. 2013;110:713–20.
    1. Soubrier S, Saulnier F, Hubert H, et al. Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients? Intensive Care Med. 2007;33:1117–24.
    1. Mahjoub Y, Lejeune V, Muller L, et al. Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study. Br J Anaesth. 2014;112:681–5.
    1. Keller G, Cassar E, Desebbe O, Lehot JJ, Cannesson M. Ability of pleth variability index to detect hemodynamic changes induced by passive leg raising in spontaneously breathing volunteers. Crit Care. 2008;12:
    1. Cannesson M, Desebbe O, Rosamel P, et al. Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theatre. Br J Anaesth. 2008;101:200–6.
    1. Feissel M, Kalakhy R, Banwarth P, et al. Plethysmographic variation index predicts fluid responsiveness in ventilated patients in the early phase of septic shock in the emergency department: a pilot study. J Crit Care. 2013;28:634–9.
    1. Levitov A, Marik PE. Echocardiographic assessment of preload responsiveness in critically ill patients. Cardiol Res Pract. 2012;2012:819696.
    1. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119:867–73.
    1. Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med. 2007;33:1125–32.
    1. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med. 2007;33:1133–8.
    1. Dinh VA, Ko HS, Rao R, et al. Measuring cardiac index with a focused cardiac ultrasound examination in the ED. Am J Emerg Med. 2012;30:1845–51.
    1. Thom O, Taylor DM, Wolfe RE, et al. Comparison of a supra-sternal cardiac output monitor (USCOM) with the pulmonary artery catheter. Br J Anaesth. 2009;103:800–4.
    1. Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM) Anaesthesia. 2012;67:1266–71.
    1. Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients. Chest. 2013;143:364–70.
    1. Squara P, Denjean D, Estagnasie P, Brusset A, Dib JC, Dubois C. Noninvasive cardiac output monitoring (NICOM): a clinical validation. Intensive Care Med. 2007;33:1191–4.
    1. Dunham CM, Chirichella TJ, Gruber BS, et al. In emergently ventilated trauma patients, low end-tidal CO2 and low cardiac output are associated and correlate with hemodynamic instability, hemorrhage, abnormal pupils, and death. BMC Anesthesiol. 2013;13:20.
    1. Garcia X, Simon P, Guyette FX, et al. Noninvasive assessment of acute dyspnea in the ED. Chest. 2013;144:610–5.
    1. Lichtenstein D. FALLS-protocol: lung ultrasound in hemodynamic assessment of shock. Heart Lung Vessel. 2013;5:142–7.
    1. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28:29–56.
    1. Haydar SA, Moore ET, Higgins GL 3rd, Irish CB, Owens WB, Strout TD. Effect of bedside ultrasonography on the certainty of physician clinical decisionmaking for septic patients in the emergency department. Ann Emerg Med. 2012;60:346–58.
    1. Caltabeloti F, Monsel A, Arbelot C, et al. Early fluid loading in acute respiratory distress syndrome with septic shock deteriorates lung aeration without impairing arterial oxygenation: a lung ultrasound observational study. Crit Care. 2014;18:

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