Prof. Xavier MONNET

Medical Intensive Care Unit

Paris-Saclay University Hospitals

xavier.monnet@aphp.fr

How do we assess fluid

responsiveness ?

Pulsion Medical Systems

(Member of the medical advisory board)

Cheetah Medical

(Lecturer)

Baxter

(Lecturer)

Links of

interest

yes

no

Should I

give fluid?

?Obvious fluid loss?

First 60-90’of sepsis?

?Fluid !

Is CO too

low ?

?

?

+ Fluid !

No fluid !-

4IVC/SVC

PPV, SVV…

PLR test

EEO/EIO tests

Fluid challenge

Mini-fluid challenge

Recruitment manoeuvers

By detecting preload responsivenessPersonalised fluid management

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PPV, SVV…

PLR test

EEO/EIO tests

Fluid challenge

Mini-fluid challenge

Recruitment manoeuvers

What’s new in 2019 ?

Studies published during

the last 12 months

What’s new in 2019 ?

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PPV, SVV…

PLR test

EEO/EIO tests

Mini-fluid challenge

Recruitment manoeuvers

Requires a direct

measurement of CO

DrawbacksAdvantages

Easy to perform

Induces fluid overload

Fluid challenge

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PPV, SVV…

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge Requires a precise

measurement of CO

DrawbacksAdvantages

Less fluid

overload (100-150 mL)

More and more

positive studies

39 patients with acute circulatory failure

monitored by echocardiography

100 mL HES over 1 min followed by 400 mL

39 patients with acute circulatory failure

monitored by echocardiography

100 mL HES over 1 min followed by 400

… that must be detected

by echo

small changes

in preload

small changes

in CO…

Mini-fluid challenge Is echo preciseenough ?

Least significant changeof VTI measurements

100 stable patients

16% in 1F, 54% under MV

0

20

40

60

80

100

Different operator Same operator

15%10%

Mini-fluid challenge Issue of the precision of CO monitoring

Echo hardly detects

changes in VTI ≤10%

100-mL

challenge

50-mL

challenge

44 patients before neurosurgery

Minifluid challenge with 100 mL

Pulse contour analysis (ProQT/Pulsioflex)

Mini-fluid challenge Issue of the precision of CO monitoring

Monitored with pulse

contour analysis

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PPV, SVV…

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge Requires a precise

measurement of CO

DrawbacksAdvantages

Less fluid

overload

More and more

positive studies

Still requires fluid

infusion…

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge

PPV, SVV…

Cannot be used in

case of:

DrawbacksAdvantages

Very well

established

Automatically

measured

Arrhythmias

Spontaneous breathing

Low lung compliance

Low Vt

80-90% of

patients !

83 patients with

circulatory failure

The Applicability of Fluid Responsiveness Indices in Circulatory failure (AFRIC study)

SHI Rui, DE VITA Nello, GAVELLI Francesco, TEBOUL Jean-Louis, PAVOT Arthur, MONNET Xavier

In preparation

Interpretable

(16%)

Low Vt

(27%)

Several causes

(51%)

Spontaneous

breathing (12%)

PPV/SVV Conditions of use

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge Cannot be used in

case of:

DrawbacksAdvantages

Very well

established

Automatically

measured

Arrhythmias

Spontaneous breathing

Low lung compliance

PPV, SVV…

Low Vt

A solution ?

30 measurements in 20 pts

Increase in Vt from 6 to 8 mL/kg

Vt challenge

PPV6

PPV8

4PPV = (PPV8 -PPV6)

PPV6

PPV8

30 measurements in 20 pts

Increase in Vt from 6 to 8 mL/kg

The Vt challenge predicts

fluid responsiveness

Threshold :

Increase in PPV by 3.5%

Vt challenge

40 pts, elective neurosurgery

CO monitoring: MostCare

Vt challenge

Threshold :

Increase in PPV by ≈1%

The Vt challenge predicts

fluid responsiveness

BUT !

Patients with

normal lungs

We need more studies!

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-

4IVC/SVC

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge Cannot be used in

case of:

DrawbacksAdvantages

Very well

established

Automatically

measured

Arrhythmias

Spontaneous breathing

Low lung compliance

PPV, SVV…

Low Vt

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge

Requires skills in echo

DrawbacksAdvantages

No need for CO

monitoring

Likely less reliable

4IVC/SVC

↗ in cas of preload

responsiveness

↗ in case of low blood

volume

2 mechanisms

Variations

of CVP

Compliance

of the IVC

Less reliable than the other tests4IVC/SVC

540 pts

Less reliable than the other tests4IVC/SVC

One large ‘disappointing’ study→

Less reliable than the other tests4IVC/SVC

AUROC (SE) 0.75 (0.08)

Sensitivity (95%CI) 0.79 (0.67-0.86)

Specificity (95%CI) 0.70 (0.63-0.76)

Less reliable than the other tests4IVC/SVC

→

One large ‘disappointing’ study→

Many ‘disappointing’ meta-

analyses

23 studies

1574 pts

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

EEO/EIO tests

Recruitment manoeuvers

Fluid challenge

Mini-fluid challenge

Requires skills in echo

DrawbacksAdvantages

No need for CO

monitoring

Likely less reliable

4IVC/SVC

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

EEO/EIO tests

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers

DrawbacksAdvantages

Easy to assess

RM ↘ stroke volume less

in non-responders

RM ↘↘ stroke volume

more in responders

28 patients during anaesthesia

RM with 30 cmH2O for 30s

ProAQT to detect changes in SV

Recruitment manoeuvers

Interesting… but

needs confirmation

!

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

EEO/EIO tests

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers

DrawbacksAdvantages

Easy to assess Only in patients in whom

sighs are indicated

Requires a measurement

of CO

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers DrawbacksAdvantages

Easy to assessRespiratory occlusion tests

34 patients with shock

monitored by PiCCO device

� cardiac preload

A 15-sec EEO…

� cardiac output in case of

fluid responsiveness

→

What is it ?Respiratory occlusion tests

-10

0

10

20

30

40

50

Effects of end-expiratory occlusion

on continuous cardiac index

NR R

↗ in cardiac index

during EEO ≥ 5%

34 patients with shock

monitored by PiCCO device

Se = 91%

Sp = 100%

ReliabilityRespiratory occlusion tests

With echocardiography ??

15-sec EEO testWith pulse

contour analysis

Threshold: 5%

increase in cardiac output

ReliabilityRespiratory occlusion tests

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

PLR test

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers DrawbacksAdvantages

Several studiesRespiratory occlusion tests

13 studies

530 patients

End-expiratory occlusion test to predict fluid responsiveness: a

systematic review and meta-analysis

GAVELLI Francesco, SHI Rui, TEBOUL Jean-Louis, MONNET Xavier In preparation

Sensitivity

1-specificity0 0.2 0.4 0.6 0.8 1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

AUROC = 0.95 ± 0.01

Sensitivity = 0.87 (0.82-0.91)

Specificity = 0.91 (0.87-0.94)

ReliabilityRespiratory occlusion tests

With echocardiography ??

End-expi

hold

Inspi

hold

30 patients with shock

Inspiratory and expiratory occlusions

Tidal

ventilation

↗ SV ↘ SV+Larger in fluid

responders ?

Larger in fluid

responders ?

Larger in fluid

responders ?

Respiratory occlusion tests With echocardiography ?

30 patients with shock

Inspiratory and expiratory occlusions

4 VTI (%) induced by

end-expi hold

Threshold =

4%Threshold=

15%

0 20 40 60 80 100

0

20

40

60

80

100

100-Specificity

Se

nsi

tivi

ty

0 20 40 60 80 100

0

20

40

60

80

100

100-Specificity

Se

nsi

tivi

ty

4 VTI (%) induced by end-

expi + end-inspi hold

AUC = 0,865

p = 0,004

AUC = 0,952

p < 0,0001Requires less

precision

Threshold=

15%

Respiratory occlusion tests With echocardiography ?

0

2

4

6

8

10

12

14

16

-14

-12

-10

-8

-6

-4

-2

Fluid

non-responders

Fluid

responders

% variation of CIDoppler

0

2

4

6

8

10

12

14

16

-14

-12

-10

-8

-6

-4

-2

% variation of CIPiCCO

Fluid

non-responders

Fluid

responders

Incr

ea

ses

ind

uce

db

y E

EO

De

crea

ses

ind

uce

db

y EIO

28 patients with shock

Inspiratory and expiratory occlusions

Respiratory occlusion tests With oesophageal Doppler ?

Similar results with

oesophageal Doppler !

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

Passive leg raising test

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers DrawbacksAdvantages

Easy to assessRespiratory occlusion tests Impossible if too strong

respiratory efforts

Requires a measurement

of CO

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers

Respiratory occlusion tests DrawbacksAdvantages

Passive leg raising test Requires a real-time

measurement of CO

Well

demonstrated

Which techniques

of CO monitoring ?

?

EV 1000PiCCO

PulsioflexVigileo

LidCO rapid

Changes in pulse

contour-derived CO

Oeso Doppler

Changes in aortic

blood flow

Echo

Changes

in VTI

Capnography

Changes

in EtCO2

Changes

in flow

Vascular Doppler

Starling SV

Changes in

CO

Plethysmography

Changes in

perfusion index

Passive leg raising test Which techniques of CO monitoring ?

With plethysmographyPassive leg raising test

Non-pulsatile portion

Pulsatile portion

Non-pulsatile portion

Pulsatile portion

With plethysmographyPassive leg raising test

Perfusion index (PI)

Non-pulsatile portion

Pulsatile portion

Non-pulsatile portion

Pulsatile portion

=

2 determinants

Vasomotor tone

Stroke volume

Automatically measured by

Radical 7® (Masimo®)

With plethysmographyPassive leg raising test

Responder

Volume

expansion

5 10

PI (%)

5

0

PLR CI (L/min/m²)

5

4

3

2

2

0

CI

PI

Non-responder

Time (min)5 10

5

4

3

5

0

2

2

0

CI (L/min/m²)

PLR Volume

expansion

PI (%)

CI

PI

72 ICU patients

Monitoring of PI (Radical7, Masimo®)

With plethysmographyPassive leg raising test

100- specificity

0

20

40

60

80

100

0 20 40 60 80 100

Se

nsi

tivi

ty

Ability of PI changes to

detect a positive PLR test↗ in PI during PLR

≥ 9%

3 excluded because no signal

3 excluded because unstable signal

72 ICU patients

Monitoring of PI (Radical7, Masimo®) !

With plethysmographyPassive leg raising test

Se = 100%

Sp = 76%

EV 1000PiCCO

PulsioflexVigileo

LidCO rapid

Changes in pulse

contour-derived CO

Oeso Doppler

Changes in aortic

blood flow

Echo

Changes

in VTI

Capnography

Changes

in EtCO2Changes

in flow

Vascular Doppler

Starling SV

Changes in

CO

Plethysmography

Changes in

perfusion index

With plethysmographyPassive leg raising test

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers

Respiratory occlusion tests

Passive leg raising test

Requires a real-time

measurement of CO

DrawbacksAdvantages

Well

demonstrated

Many techniques

are available

Less reliable during intra-

abdominal hypertension ?

Intra-abdominal hypertensionPassive leg raising test

False negativesPLR test

Fluid responders

0

5

10

15

20

25

30

35

40

45Changes in

cardiac index

(%)

*

30 patients with IAP > 12 mmHg

30 patients without IAH

IAHNo IAH

PLR VEPLR VE

Less ↗ in CI in case of IAH

False negatives

30 patients with IAP > 12 mmHg

30 patients without IAH

15/20N=30

Fluid responders Fluid non-responders

PLR+ PLR- PLR+ PLR-

N=9N=21

N=6 N=15 N=1 N=8

TRUE + FALSE- FALSE+ TRUE -

IAH+

15/20N=30

Fluid responders Fluid non-responders

PLR+ PLR- PLR+ PLR-

N=15N=15

N=14 N=1 N=0 N=15

TRUE + FALSE- FALSE+ TRUE -

IAH-

!PLR test

False negatives to PLR

in case of IAH

yes

no

Obvious fluid loss?

First 60-90’of sepsis?

Fluid !

?

+ Fluid !

No fluid !-PPV, SVV…

Fluid challenge

Mini-fluid challenge

4IVC/SVC

Recruitment manoeuvers

Respiratory occlusion tests

Passive leg raising test

Requires a real-time

measurement of CO

DrawbacksAdvantages

Well

demonstrated

Many techniques

are available

Less reliable during intra-

abdominal hypertension ?!

What’s new?

Prof. Xavier MONNET

Medical Intensive Care Unit

Paris-Saclay University Hospitals

xavier.monnet@aphp.fr

How do we assess fluid

responsiveness ?