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Assessment of Fluid Responsiveness

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Hemodynamic Monitoring

Part of the book series: Lessons from the ICU ((LEICU))

Abstract

Introduction: Volume expansion in patients with acute circulatory failure is the source of a therapeutic dilemma. On the one hand, it might improve oxygen delivery to the tissues; on the other hand, it might induce some fluid overload, of which deleterious effects have been well established. The problem is even more complex since all patients do not respond to fluid administration by a significant increase in cardiac output. Then, after the very initial phase and/or if fluid losses are not obvious, predicting fluid responsiveness should be the first step of fluid strategy. Results: For detecting preload responsiveness, it is today very clear that “static” markers of cardiac preload, such as central venous pressure, are not reliable. A number of dynamic tests have been developed over the last 15 years. The principle is that the response to volume expansion can be predicted by the effects on stroke volume and cardiac output of changes in cardiac preload, induced by mechanical ventilation, by a passive leg raise or the infusion of small amounts of fluid. Pulse pressure and stroke volume variations were first developed, but they are reliable only under strict conditions. The variations in venae cavae diameters under mechanical ventilation share many limitations with pulse pressure variation. The passive leg raising test is now supported by solid evidence and is more frequently used. The end-expiratory occlusion test is easily performed in ventilated patients. Adding its effects to those of an end-inspiratory occlusion increases changes in cardiac output in preload responsive patients, making the test more sensitive. Unlike the traditional fluid challenge, these dynamic tests do not lead to fluid overload. The tests are complementary, and clinicians should choose between them based on the status of the patient and the available cardiac output monitoring technique.

Conclusions: Several methods and tests are today available to identify preload responsiveness. All have some limitations, but they are frequently complementary. Along with elements indicating the risk of fluid administration, they should help clinicians take the decision to administer fluids or not in a reasoned way.

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Conflicts of Interest

Prof. Xavier MONNET and Prof. Jean-Louis TEBOUL are members of the Medical Advisory Board of Pulsion Medical Systems and have received honoraria for lectures from Masimo and Cheetah.

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Monnet, X., Teboul, JL. (2019). Assessment of Fluid Responsiveness. In: Pinsky, M.R., Teboul, JL., Vincent, JL. (eds) Hemodynamic Monitoring. Lessons from the ICU. Springer, Cham. https://doi.org/10.1007/978-3-319-69269-2_24

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  • DOI: https://doi.org/10.1007/978-3-319-69269-2_24

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