Chest
Volume 121, Issue 6, June 2002, Pages 2000-2008
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Critical Care Reviews
Predicting Fluid Responsiveness in ICU Patients: A Critical Analysis of the Evidence

https://doi.org/10.1378/chest.121.6.2000Get rights and content

Study objective

To identify and critically review the published peer-reviewed, English-language studies investigating predictive factors of fluid responsiveness in ICU patients.

Design

Studies were collected by doing a search in MEDLINE (from 1966) and scanning the reference lists of the articles. Studies were selected according to the following criteria: volume expansion performed in critically ill patients, patients classified in two groups (responders and nonresponders) according to the effects of volume expansion on stroke volume or on cardiac output, and comparison of responder and nonresponder patients' characteristics before volume expansion.

Results

Twelve studies were analyzed in which the parameters tested were as follows: (1) static indicators of cardiac preload (right atrial pressure [RAP], pulmonary artery occlusion pressure [PAOP], right ventricular end-diastolic volume [RVEDV], and left ventricular end-diastolic area [LVEDA]); and (2) dynamic parameters (inspiratory decrease in RAP [ΔRAP], expiratory decrease in arterial systolic pressure [Δdown], respiratory changes in pulse pressure [ΔPP], and respiratory changes in aortic blood velocity [ΔVpeak]). Before fluid infusion, RAP, PAOP, RVEDV, and LVEDA were not significantly lower in responders than in nonresponders in three of five studies, in seven of nine studies, in four of six studies, and in one of three studies, respectively. When a significant difference was found, no threshold value could discriminate responders and nonresponders. Before fluid infusion, ΔRAP, Δdown, ΔPP, and ΔVpeak were significantly higher in responders, and a threshold value predicted fluid responsiveness with high positive (77 to 95%) and negative (81 to 100%) predictive values.

Conclusion

Dynamic parameters should be used preferentially to static parameters to predict fluid responsiveness in ICU patients.

Section snippets

Selection of Studies To Be Evaluated

We collected studies investigating the predictive factors of fluid responsiveness in critically ill patients by doing a search in MEDLINE (from 1966). Studies were selected according to the following criteria: volume expansion performed in critically ill patients, patients classified in two groups (responders and nonresponders) according to the effects of volume expansion on stroke volume or on cardiac output, and comparison of responder and nonresponder patients characteristics before volume

Results

There were 406 fluid challenges in 334 patients (Table 1). Most of the patients were septic (55%) and receiving mechanical ventilation (84%). The decision of volume expansion was based on criteria listed in Table 2. Fluid administration was performed using colloid solutions (albumin, fresh frozen plasma, or hydroxyethylstarch) in 253 instances, and crystalloid solutions (serum saline solution or Ringer's lactate) in 153 instances (Table 1). In nine studies, the volume infused was predetermined

Discussion

The present analysis emphasizes the minimal clinical value of ventricular preload indicators and the higher value of dynamic parameters (testing the cardiovascular response to respiratory changes in pleural pressure) in predicting fluid responsiveness in critically ill patients. It has been suggested that a beneficial hemodynamic effect of volume expansion cannot be expected in critically ill patients with a RAP > 12 mm Hg17 and/or a PAOP > 12 mm Hg or > 15 mm Hg.15,18 In this regard, RAP and

ACKNOWLEDGMENT

The authors thank Dr. Denis Chemla for helpful discussion.

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