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The Rational Clinical Examination
September 27, 2016

Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?

Author Affiliations
  • 1Department of Clinical Sciences Lund, Anesthesiology, and Intensive Care, Helsingborg Hospital, Helsingborg and Lund University, Lund, Sweden
  • 2Centre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
  • 3Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, Canada
  • 4Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, Canada
  • 5Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
  • 6Department of Radiology, University of British Columbia, Vancouver, Canada
  • 7Centre Health Evaluation and Outcome Sciences, Department of Medicine, Providence Healthcare, Vancouver, Canada
  • 8Respiratory Division, Department of Medicine, University of British Columbia, Vancouver, Canada
  • 9Division of Critical Care Medicine, Department of Medicine, St. Paul’s Hospital, Vancouver, Canada
  • 10Program in Critical Care Medicine, Vancouver General Hospital, Vancouver, Canada
  • 11Department of Anesthesiology, St. Paul’s Hospital, Vancouver, Canada
JAMA. 2016;316(12):1298-1309. doi:10.1001/jama.2016.12310
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.

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