Hard evidence for fluid responsiveness – JAMA Rational Clinical Exam
No physical findings predicted fluid responsiveness. This includes: “dry mucous membranes, dry axilla, decreased tissue turgor, capillary refill time greater than 2 seconds, tachycardia, and low jugular venous pressure.” Low CVP had a positive likelihood ratio (LR+) of 2.6; high CVP had a negative likelihood ratio (LR -) or 0.5. IVC respiratory variation on ultrasound in ventilated patients (distensibility index >15%) had LR+ 5.3; LR- 0.27 if the IVC was less distensible. But the strongest predictor of fluid responsiveness was increased cardiac output with passive leg raise of >10% (by Swan-Ganz thermodilution or echo), LR+ 11; LR- with no change in cardiac output was 0.13.
Spoon Feed
Physical findings to assess for fluid responsiveness are not reliable, IVC distensibility on ultrasound in ventilated patients is pretty good. Increased cardiac output with passive leg raise is the best marker of fluid responsiveness.
JAMA. 2016 Sep 27;316(12):1298-309. doi: 10.1001/jama.2016.12310.
Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?
Bentzer P1, Griesdale DE2, Boyd J3, MacLean K4, Sirounis D5, Ayas NT6.
Author information:
- 1Department of Clinical Sciences Lund, Anesthesiology, and Intensive Care, Helsingborg Hospital, Helsingborg and Lund University, Lund, Sweden2Centre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada.
- 2Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, Canada4Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, Canada5Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada10Program in Critical Care Medicine, Vancouver General Hospital, Vancouver, Canada.
- 3Centre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada5Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada9Division of Critical Care Medicine, Department of Medicine, St. Paul’s Hospital, Vancouver, Canada.
- 4Department of Radiology, University of British Columbia, Vancouver, Canada.
- 5Centre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada3Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, Canada5Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada11Department of Anesthesiology, St. Paul’s Hospital, Vancouver, Canada.
- 6Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, Canada5Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada7Centre Health Evaluation and Outcome Sciences, Department of Medicine, Providence Healthcare, Vancouver, Canada8Respiratory Division, Department of Medicine, University of British Columbia, Vancouver, Canada9Division of Critical Care Medicine, Department of Medicine, St. Paul’s Hospital, Vancouver, Canada.
ABSTRACT
IMPORTANCE:
Fluid overload occurring as a consequence of overly aggressive fluid resuscitation may adversely affect outcome in hemodynamically unstable critically ill patients. Therefore, following the initial fluid resuscitation, it is important to identify which patients will benefit from further fluid administration.
OBJECTIVE:
To identify predictors of fluid responsiveness in hemodynamically unstable patients with signs of inadequate organ perfusion.
DATA SOURCES AND STUDY SELECTION:
Search of MEDLINE and EMBASE (1966 to June 2016) and reference lists from retrieved articles, previous reviews, and physical examination textbooks for studies that evaluated the diagnostic accuracy of tests to predict fluid responsiveness in hemodynamically unstable adult patients who were defined as having refractory hypotension, signs of organ hypoperfusion, or both. Fluid responsiveness was defined as an increase in cardiac output following intravenous fluid administration.
DATA EXTRACTION:
Two authors independently abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality. A bivariate mixed-effects binary regression model was used to pool the sensitivities, specificities, and LRs across studies.
RESULTS:
A total of 50 studies (N = 2260 patients) were analyzed. In all studies, indices were measured before assessment of fluid responsiveness. The mean prevalence of fluid responsiveness was 50% (95% CI, 42%-56%). Findings on physical examination were not predictive of fluid responsiveness with LRs and 95% CIs for each finding crossing 1.0. A low central venous pressure (CVP) (mean threshold <8 mm Hg) was associated with fluid responsiveness (positive LR, 2.6 [95% CI, 1.4-4.6]; pooled specificity, 76%), but a CVP greater than the threshold made fluid responsiveness less likely (negative LR, 0.50 [95% CI, 0.39-0.65]; pooled sensitivity, 62%). Respiratory variation in vena cava diameter measured by ultrasound (distensibility index >15%) predicted fluid responsiveness in a subgroup of patients without spontaneous respiratory efforts (positive LR, 5.3 [95% CI, 1.1-27]; pooled specificity, 85%). Patients with less vena cava distensibility were not as likely to be fluid responsive (negative LR, 0.27 [95% CI, 0.08-0.87]; pooled sensitivity, 77%). Augmentation of cardiac output or related parameters following passive leg raising predicted fluid responsiveness (positive LR, 11 [95% CI, 7.6-17]; pooled specificity, 92%). Conversely, the lack of an increase in cardiac output with passive leg raising identified patients unlikely to be fluid responsive (negative LR, 0.13 [95% CI, 0.07-0.22]; pooled sensitivity, 88%).
CONCLUSIONS AND RELEVANCE:
Passive leg raising followed by measurement of cardiac output or related parameters may be the most useful test for predicting fluid responsiveness in hemodynamically unstable adults. The usefulness of respiratory variation in the vena cava requires confirmatory studies.
PMID: 27673307 [PubMed – in process]
