Status Volume Evaluation

and Fluid Responsiveness

dr. Ingrid M. Pardede. Sp.JP, FIHA
Siloam Hospitals Lippo Village
Department of Cardiology University of Pelita Harapan
Hemodynamic problem in critical
care
Hemodynamic failure is a common problem in the
intensive care unit
Hypovolemia may suspected in many clinical
situations frequent cause of shock
Volume loading often first-line therapy to improve
hemodynamic status
Only 40-70% response to fluid challenge
Significant disadvantages to inappropriate fluid
administration
Dellinger RP. Critical Care Med. 2013
Michard F. Chest. 2002
Wiedeman HP. NEJM. 2006
 Proposed algorithm of simplified step-
wise haemodynamic approach

Ashraf Roshdy et al. Echo Res Pract 2014;1:D1-D8

2014 The authors

Diagnostic algorithm based on use of
echocardiography

Vincent et al. Critical Care 2011, 15:229

Basic Volume Status Assessment

Easy in severe hypovolemia

Easy in clear volume overload
Difficult in less severe hypovolemia or in
significant cardiac disease
Consider pre-existing cardiac disease
Consider respiratory status
 Aim of Fluid Responsiveness
Assessment
Todetermine which patients with circulatory failure
that will get benefit from fluid administration
To predict which patients with acute circulatory
failure will respond to fluid by a significant increase
in cardiac output
Must answer key question:
should the patient receive additional volume
infusions?

Monnet, Teboul. Critical Care, 2013 17:217.

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Key Principles
Cardiac output =
Heart Rate x Stroke
Volume
Increase in venous return
(preload)
Increase in stroke volume
(Frank-Starling Curve) until
some extend
Concept of Preload
reserve vs No preload
Sherwood. Human Physiology, 7th Ed. 2010
reserve Monnet, Teboul. Critical Care, 2013 17:217
 Frank-Starling Curve:
Preload reserve vs No preload reserve

Not every fluid administration always result in a significant increase of Stroke

Volume
Monnet, Teboul. Critical Care, 2013
Preload optimization

Traditional parameters estimating blood volume,

central venous pressure or pulmonary artery systolic
pressure have not been proven reliable in predicting
fluid responsiveness
Echocardiography may offer useful parameters to
determine the critical patients preload and volume
status assessment: ventricular volume changes,
respiratory changes in inferior vena cava or superior
vena cava (with TEE) or respiratory changes in aortic
flow velocity
Marik P, et al. Chest 2008, 134; 172-178
Bermejo et al. Current Cardiology Reviews, 2011, 7, 146-
156
Charron C. Current Opinion Critical Care 2006
Adverse Effect of Fluid Administration in
fluid non- responsive patients
Increasing hydrostatic pressure pulmonary edema
Respiratory failure
Prone to infection
Fluid extravasation to interstitial compartment
Diffuse peripheral edema compromise tissue oxygenation
Cerebral edema
Disorder of electrolytes
LV compression in acute cor pulmonale cases

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.2009

Methods to Asses Fluid
Responsiveness
Clinical parameter: heart rate, blood pressure,
capillary refill time
Laboratory: blood lactates, mixed vein
saturation
Invasive technique
Central venous pressure
PCWP (with Swan Ganz catheter)
Non-invasive technique
Monnet, Teboul. Critical Care, 2013 17:217
Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness. 2009
Marik, Lemson. Br J Anaesth. 2014;112(4):617-620
Invasive methods
Central venous pressure (with central venous
catheter)
PCWP (with Swan Ganz catheter)

Image courtesy of clinicalgate.com and Adam

PCWP (Pulmonary Capillary Wedge
Pressure)
PCWP or PAOP (pulmonary artery occlusion pressure)
obtained from Swan Ganz catether reflects cardiac filling
pressure
Changes in PCWP was also believed to be predictor of
fluid responsiveness recent studies showed no
correlation
PCWP is not generally useful in predicting volume
responsiveness...except in patients with very low
value of PCWP (very rarely encountered in ICU)

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness. 2009

Coudray, Romand, Treggiari. Crit Care Med. 2005; 33:27572762
Marik PE, Baram M, Vahid B. Chest 2008;134:172-178
Marik PE, Cavallazzi R. Crit Care Med 2013;134:1774-81
Kumar A, Anel R, et al. Crit Care Med 2004;31:691-699
Non-Invasive Methods
Performed with ultrasound/echocardiography by
cardiologist/intensivist
Methods:
Changes of inferior vena cava (IVC) diameter during
mechanical ventilation distensibility index
Variation of velocity-time integral with respiration
Passive leg raising (PLR) test
Mini fluid challenge test
End-expiratory occlusion test
Mandeville JC, Colebourn CL. Critical Care Research and Practice.
doi:10.1155/2012/513480
Left Ventricular Study in
hypovolemia
The visualization of left
ventricular end systolic
obliteration kissing
papillary muscle sign
TTE parasternal short axis
view at the level of the
papillary muscles
Or TEE trans-gastric view
at level of the papillary
muscle
Leung, et al. Anesthesiology 1994;81:1102-1109
Beaulieu Y, Marik PE. Chest 2005;128;881-895
Left Ventricular Study in
hypovolemia

Small left ventricular size
LV end diastolic area (LVEDA)
< 5.5cm/m2 (Body Surface
Area) TTE normal values
13 2 cm2/m2 (10-18)
or < 10 cm2 (Normal
population values: 5.2
18.8 cm2)
Leung, et al. Anesthesiology 1994;81:1102-1109
Beaulieu Y, Marik PE. Chest 2005;128;881-895
Schiller NB, Shah PM, Crawford M, et al. J Am Soc Echocardiogr 1989; 2:358 367
LVEDA variation with respiration

Assessed LV diastolic area (LVEDA) changes by

TEE from short- axis view
In mechanically ventilated patients
16% respiratory variation of LVEDA between
inspiration and expiration predicted fluid
responsiveness with a sensitivity of 92% and a
specificity of 83%

Cannesson M, Slieker J, et all. Crit Care. 2006;10:R171

LVEDA variation with loading

Decrease of 3
cm2 = 10% EBV
loss

Range for value of normal LVEDA in the short axis are from
9.5 to 22 cm2 Cheung, et al. Anesthesiology 1994;81:376-387
Schiller NB, et al. J Am Soc Echocardiogr 1989; 2:358
367
Changes in stroke volume and IVC diameter caused by mechanical
ventilation

Mandeville JC, Colebourn CL. Critical Care Research and Practice.

doi:10.1155/2012/513480
Respiratory changes in Cava Veins
Analysis: Superior Vena Cava

Superior vena cava was recorded from TEE longitudinal view at

90 100

Collapsibility index: Maximal diameter on expiration minimal

diameter on inspiration)/maximal diameter on expiration

Cutoff values of 36% for SVC collapsibility index (sensitivity 90%,

specificity 100%) were found to accurately separate responders
and non-responders

Significant superior vena cava

collapsibility

Vieillard-Baron A, Augarde R, Prin P, et al. Anesthesiology. 2001;95:1083

1088
Respiratory changes in Cava Veins
Analysis: Inferior Vena Cava
IVC diameter analyzed from a
longitudinal subcostal view and
recorded by using M- mode
Measured 12 cm distal to the
junction of the right atrium.
Small diameter was: 1.2 cm
Normal diameter: 1.2 cm and 1.7
cm
Dilated diameter 1.72.5 cm,
markedly dilated > 2.6 cm

Breitkreutz L, Walcher F, et al Eur J Trauma Emerg Surg 2009;35:34756

Lang RM, Bierig M, et al J Am Soc Echocardiogr 2005;18:1440 63
Respiratory changes in Cava Veins
Analysis: Inferior Vena Cava
In spontaneously breathing
patients, the following
measurements suggest a
patient is likely to be fluid
responsive:
IVC measuring < 2 cm in
diameter
IVC collapse > 40-50% with The image on the left depicts substantial
each breath 70% sensitivity respiratory variations in IVC diameter suggestive
of volume responsiveness. The patient on the right
and 80% specificity is unlikely to positively respond to volume
resuscitation
Barbier C, Loubi`eres Y, Schmit C, et al. Intensive Care Med. 2004;30:17401746
Muller L, Bobbia X, Toumi M, et al.. Crit Care 2012; 16:R188
Evans D, Ferraioli G. J Ultrasound Med 2014; 33:37
Respiratory changes in Cava Veins
Analysis: IVC collapsibility index
Vena cava collapsibility index
predict hemodynamic response
to fluid challenge patients with
septic shock who are not
mechanically ventilated
Measurement using TTE
IVC collapsibility index: 15% or
greater fluid responsiveness
(positive predictive value 62%
and negative predictive value, Vena cava collapsibility index
100%)
Lanspa MJ, Grissom CK. Shock. 2013; 39: 155-160
Respiratory changes in Cava Veins Analysis:
Distensibility index of IVC

IVC diameter changes during

mechanical ventilation were
measured to predict fluid
responsiveness.
Accurately separate responders
and non-responders of fluid
infusion in mechanically
ventilated patients
Significant inferior vena cava distensibility
in a mechanically ventilated patient

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness. 2009

PV: positivepredictivevalue, NPV: negativepredictivevalue, r: correlation coefficient, PLR:Passivelegraising, SI: singleinv
likelihoodratio, PPV:positivepredictivevalue,NPV:negativepredictivevalue,r:correlationcoefficient,PLR:Passivelegraising,SI:singleinvestiga
t, SV:CO:
strokevolume,
cardiac output, dVF: changein dVF:
SV: strokevolume, femoral artery
changein velocity
femoral asmeasured by Doppler,
arteryvelocityasmeasured byDoppler,SVI: strokevolumeindex,
SVI: LVEDAI
strokevolumeindex, LVEDAI: left
E/Eaend-diastolicarea,
: mitral E-wavevelocity/mitral annulus E velocity
E/Ea: mitral E-wavevelocity/mitral annulusEmeasured by tissueDoppler,
velocitymeasured bytissueDoppler, DD : changein
IVCIVC IVCdiameter
: changein IVC diameter(D) (D)
asca
(Dmax(D+Dmax ), IVC
Dmin
min DI:
)/0.5(D maxIVC distensibilityindexcalculated
+Dmin by(Dmax Dmax
), IVC DI: IVC distensibilityindexcalculatedby(D min)/D
Dmin
min)/D. min.
Respiratory changes in Cava Veins Analysis:
Distensibility index of IVC
t of 3.3.
Fluid Responsive
Assessment nessResponsiveness
of Fluid through Rethrough
spiratory
Respiratory Barbier et al.etused
Barbier adistensibilityindex
al. usedadistensibilityindex ca
calcula
C Diame ter. ofTwo
Variation studiesbyBarbier
IVC Diameter.
Cutoff Two values et al. andet al. and
studiesbyBarbier
of 18% (by (D(Dmax Dmin) )
ed respiratory variation of thediameter of the max Dmin ,
Feissel et al. usedrespiratoryvariation
using of thediameter of the a
maxmin/min) DDmin ,
t fluid responsiveness [17,
IVC to predict fluidsensitivity 18]. Both
responsiveness [17, studies
18]. Both studies min
mechanically ventilated patients, and specificity
without of
whereasFeissel et al. corrected themean of thet
included only mechanically ventilated patients, without whereasFeissel et al. correctedthemean of thetwo
espiratory effort. 90%
Each study
(1) compared the
spontaneous respiratory effort. Each study compared the (D(Dmax Dmin) )
minimum diameter of the IVC
Cutoff just distal
values of to
12% (by max Dmin .
maximum and minimum diameter of theIVC just distal to 0.5(Dmax +Dmin) .
n: Dmax and Dmin, respectively
using (seeFigure1).
maxmin/mean 0.5(D max +Dmin)
thehepatic vein: Dmax and Dmin, respectively (seeFigure1).
xpressed thedistensibility of theIVC asaper- Barbier et al.showedasensitivityandspecificity
Both studiesexpressed thedistensibilityof
value) high sensitivitytheIVC asaper- 93%
Barbier etal.showedasensitivityandspecificityof9
using a cut-off distensibility index of 18 percen
centageindex. and specificity 92% (2) using acut-off distensibility index of 18 percent to
(1) Barbier C, Loubi`eres Y, Schmit C, et al. Intensive Care Med. 2004;30:17401746
(2) Feissel M, Michard F, Faller JP, et al. Intensive Care Med. 2004;30:18341837
Respiratory variations of maximal aortic blood flow velocity

Evaluation by TTE and

TEE: Apical 5-chamber
view with spectral Doppler
gates set at 5 mm within
the LVOT in measure the
LVOT velocity time integral

Evans D, et al. J Ultrasound Med 2014; 33:37

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Respiratory variations of maximal
aortic blood flow velocity

Maximal aortic blood flow VTI variation measured

with TEE or TTE in a mechanically ventilated patient
Predicts increases in cardiac output after fluid
infusion in patients with shock high sensitivity,
specificity, and predictive value
Variation of maximal velocity (Vmax) with respiration
responder vs non-responder:
A cutoff value of 12% for maximal velocity
Feissel M, Michard F. Chest. 2001;119:867873
Charron C, Fessenmeyer C, Cosson C, et al. Anesth Analg. 2006; 102:15111517
Respiratory variations of maximal aortic
blood flow velocity

Presence of significant respiratory variations of Vmax. (1.29 1.09/1.19 =

17%. Same patient after volume expansion, regression of the respiratory
variations (1.37 1.32/1.34 = 4%)
Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Respiratory variations of aortic
blood flow velocity VTI
Aortic blood flow VTI variation measured with TEE
or TTE predicts increases in cardiac output after
fluid infusion in mechanically ventilated patients
with shock
High sensitivity, specificity, and predictive value
Variation of VTI with respiration responder vs non-
responder
A cutoff 20% for respiratory cycle changes of
aortic VTI
Feissel M, Michard F. Chest. 2001;119:867873
Charron C, Fessenmeyer C, Cosson C, et al. Anesth Analg. 2006; 102:15111517
Respiratory variations of aortic blood
flow velocity VTI

Presence of significant respiratory variations of VTI: (VTImax VTImin/[VTImax

+ VTI min/2] (20.7 17.3/19 = 18%). Same patient after volume expansion,
regression of the respiratory variations: VTI (23.5 22.3/22.9 = 5%)
Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Passive Leg Raising (PLR) test

PLR rapidly mobilizes about 300 mL of blood

from the lower limbs to the intrathoracic
compartment and reproduces the effects of
volume expansion
It is reversible and devoid of any risks of
volume expansion
In spontaneous breathing and mechanically
ventilated patients
Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness. 2009
Boulain T, Achard JM, Teboul JL, et al. Chest. 2002;121:12451252
Lafanech`ere A, P`ene F, Goulenok C, et al. Crit Care. 2006;10:R132
Passive Leg Raising (PLR) test

Mandeville JC, Colebourn CL. Critical Care Research and Practice.

doi:10.1155/2012/513480
Passive Leg Raising (PLR) test
Percent change is [(stroke volume after passive leg
raising stroke volume before passive leg
raising)/stroke volume after passive leg raising] 100%
A threshold of 10 to 15 percent increment of stroke
volume or cardiac output
All studies showed good sensitivity (77 to 100 %) and
specificity (88 to 99 %)
PLR predicted the correct response to volume
expansion in patients with arrhythmia
Mandeville JC, Colebourn CL. Critical Care Research and Practice.
doi:10.1155/2012/513480
Thiel SW, Kollef MH. Critical Care, vol. 13, no. 4, article R111, 2009
The End-expiratory Occlusion
Test
During mechanical ventilation, inspiration
cyclically decreases the left cardiac preload. An
end-expiratory occlusion may prevent the cyclic
impediment in left cardiac preload and may act
like a fluid challenge
A 15-second end- expiratory occlusion test in
ventilator patient followed by 500 ml saline
infusion increased the arterial pulse pressure or
the pulse contour-derived cardiac index

Monnet, Teboul. Critical Care, 2013 17:217.

Monnet X, Osman D, Ridel C et al. Crit Care Med 2009, 37: 951-956
The End-expiratory Occlusion
Test
During the end-expiratory occlusion, fluid
responsiveness was predicted by:
an increase in pulse pressure >5% with a
sensitivity of 87% and a specificity of 100%
an increase in cardiac index >5% with a
sensitivity of 91% and a specificity of100%
This test can also be used in patients with
spontaneous breathing activity

Monnet, Teboul. Critical Care, 2013 17:217.

Monnet X, Osman D, Ridel C et al. Crit Care Med 2009, 37: 951-956
 The 'mini' Fluid Challenge
Give mini (small) amount of fluid (100 cc) vs classical
fluid challenge (300-500 cc)
It consists of administering 100 ml of colloid over 1
min and observe the effects of this 'mini' fluid
challenge on stroke volume, as measured by the sub
aortic velocity time index using TTE
An increase in the velocity time index of more than
10% predicted fluid responsiveness with a sensitivity
of 95% and a specificity of 78%
Small volume of fluid is unlikely to induce fluid
overload Monnet, Teboul. Critical Care, 2013 17:217
Muller L, Toumi M, Bousquet PJ, et al. Anesthesiology 2011, 115: 541-
547
Significant methodological limitation determination of volume
responsiveness using echocardiography

All require that the patient be on mechanical

ventilation and passive in their interaction with the
ventilator.
The patient can make no spontaneous breathing
effort during the measurement and must be in a
regular heart rhythm.
The degree of respiratory variation is contingent on
the change of intrathoracic pressure.
Tidal volume and positive end-expiratory pressure
(PEEP) levels are known to influence pulse pressure
variation
Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Decision-making process in fluid administration

Monnet, Teboul. Critical Care, 2013 17:217

Which Methods to Use?

Which methods we should use?

Depend of patient condition
Spontaneous breathing vs mechanically
ventilated

Monnet, Teboul. Critical Care, 2013 17:217

Slama, Maizel, Mayo. Echocardiographic Evaluation of Preload Responsiveness.
2009
Take Home Message
Volume status and fluid responsiveness assessment in critically ill
patients using echocardiography is applicable, safe and accurate.
Dynamic parameters determined by echocardiography are superior to
static measurements of preload for the determination of volume
responsiveness.
Inferior vena cava diameter and trans-aortic Doppler signal changes
with the respiratory cycle or passive leg raising has strong predictive
power.
Limitations of the technique relate to patient tolerance of the
procedure, adequacy of acoustic windows, and operator skill.
Thank you
Echo findings in severe
hypovolemia
Left ventricular study
Reduced LV end diastolic area
End systolic LV obliteration (kissing walls)
Small IVC diameter
Spontaneous respiration end expiratory dimension < 9mm
Mechanical ventilation end expiratory dimension < 15 mm
IVC respiratory variation
Spontaneous respiration: > 50 %
Mechanical ventilation > 18%
Mean right atrial pressure according to
respiratory changes in inferior cava vein
Central Venous Pressure
Central venous pressure (CVP) =P
CVP can reflect a volume increase in RA pressures or decrease in RV
contractility
can be both.
Need to be monitored in conjunction with other monitors
(CVP&MAP)
The main limitations of CVP monitoring:
(a) it does not allow to measure cardiac output
(b) it does not provide reliable information on the status of the
pulmonary circulation in the presence of left ventricular dysfunction
Characteristic of all included studies
Critical CareResearch and Practice 5

Tabl e2: Characteristicsof studiesselected.

Time Response
Study Technique Patient group Selection Ventilation Rhythm Volumeand type
(min) criteria
Shock (sepsis) and >15%
Barbier et al. [17] IVC DI Mixed ICU All mand Any 7mL/kgcolloid 30
acutelunginjury CO TTE
>15%
Feissel et al. [18] DIVC Medical ICU Shock (sepsis) All mand Any 8mL/kgcolloid 20
CO TTE
Shock (sepsisor Regular >15%
Lamiaet al. [14] PLR Medical ICU All spont 500mL crystalloid 15
hypovolaemia) SR, or AF SV TTE
Shock >12%
Maizel et al. [13] PLR Mixed ICU All spont Regular SR 500mL crystalloid 15
(unspecified) CO TTE
Shock (sepsisor >15%
Biaiset al. [15] PLR Surgical ICU All spont Any 500crystalloid 15
haemorrhage) SV TTE
Post-operative 20mL/kg/m2 >15%
Biaiswt al. [19] SVV Surgical ICU All mand Regular SR 20
(liver surgery) colloid CO TTE
Shock 500mL crystalloid >15%
Thiel et al. [16] PLR Medical ICU Mixed Any Unspec
(unspecified) or colloid SV TTE
Shock (sepsisor >15%
Pr
eau et al. [12] PLR Medical ICU All spont Regular SR 500mL colloid <30
acutepancreatitis) SV TTE
Selection: inclusion criteria summary, PLR: passive leg raising, spont: spontaneous respiratory effort whether or not on mechanical ventilation, mand:
ventilator givingmandatorybreathsonlyandpatientfullyadaptedtoventilator, SR: sinusrhythm, AF:atrial fibrillation, TTE: transthoracicechocardiography,
SV: strokevolume, CO: cardiacoutput, DIVC changein IVC diameter adjustedbythemean (seetext), IVC DI: IVC distensibilityindex(seetext), and unspec:
unspecified time.
Mandeville JC, Colebourn CL. Critical Care Research and Practice. doi:10.1155/2012/513480
Tabl e3: Collated resultsof all included studies.
Biaiswt al. [19] SVV Surgical ICU All mand Regular SR 20
(liver surgery) colloid CO TTE
Shock 500mL crystalloid >15%
Thiel et al. [16] PLR Medical ICU Mixed Any Unspec
(unspecified) or colloid SV TTE
Shock (sepsisor >15%
Pr
eau et al. [12] PLR Medical ICU All spont Regular SR 500mL colloid <30
acutepancreatitis) SV TTE
Selection: inclusion criteria summary, PLR: passive leg raising, spont: spontaneous respiratory effort whether or not on mechanical ventilation, mand:

Collated result of all included studies

ventilator givingmandatorybreathsonlyandpatientfullyadaptedtoventilator,SR: sinusrhythm, AF:atrial fibrillation, TTE:transthoracicechocardiography,
SV: strokevolume, CO: cardiacoutput, DIVC changein IVC diameter adjustedbythemean (seetext), IVC DI: IVC distensibilityindex(seetext), and unspec:
unspecified time.

Tabl e3: Collated resultsof all included studies.

Number Resp Intra-obs Inter-obs AUC

Study Predictivetest Threshold Sens Spec PLiR NLiR PPV NPV r
of tests % % % (ROC)
PLR SVI or
Lamiaet al. [14] 24 12.5% 54 2.8 2.2 3.2 2.5 0.96 0.04 77 99 77 0.23 0.79
CO rise
Maizel et al. [13] 34 PLR CO rise 12% 50 4.2 3.9 6.5 5.5 0.90 0.06 63 89 5.73 0.42 85 76 0.75
PLR SV rise 12% 4.2 3.9 6.2 4.2 0.95 0.04 69 89 6.27 0.35 83 73 0.57
Biaiset al. [15] 34 PLR SV rise 13% 67 SI 0.96 0.03 100 80 5.00 0.00
Thiel et al. [16] 102 PLR SV rise 15% 46 SI 0.89 0.04 81 93 11.57 0.20 91 85
Pr
eau et al. [12] 34 PLR SV rise 10% 41 SI 0.90 0.04 86 90 8.60 0.16 86 90 0.74
PLR dVF rise 8% 0.93 0.04 86 80 4.30 0.18 75 89 0.58
Biaiset al. [15] 30 SVV 9% 47 SI 0.95 100 88 8.33 0.00 0.80
Barbier et al. [17] 23 IVC DI 18% 41 8.7 9 6.3 8 0.91 0.07 90 90 9.00 0.11 0.90
Feissel et al. [18] 39 DIVC 12% 41 3 4 SI 93 92 0.82
Threshold: cut-off between responders and nonresponders, Resp: proportion responding to fluid load, Intra-obs: intraobserver variability, Inter-obs:
interobserver variability,AUC(ROC): areaunder thereceiver-operator curve, Sens: Sensitivity,Spec: Specificity,PLiR: positivelikelihoodratio, NLiR: negative
likelihoodratio, PPV: positivepredictivevalue, NPV: negativepredictivevalue, r: correlation coefficient, PLR: Passivelegraising, SI: singleinvestigator/reader,
CO: cardiac output, SV: strokevolume, dVF: changein femoral artery velocity asmeasured by Doppler, SVI: strokevolumeindex, LVEDAI: left ventricular
end-diastolic area, E/Ea: mitral E-wavevelocity/mitral annulus E velocity measured by tissueDoppler, DIVC: changein IVC diameter (D) as calculated by
(Dmax Dmin)/0.5(Dmax +Dmin ), IVC DI: IVC distensibilityindex calculated by(Dmax Dmin)/Dmin.

3.3. Assessment of Fluid Responsiveness through Respiratory Barbier et al. used adistensibilityindex calculated by
Variation of IVC Diameter. Two studiesby Barbier et
Mandeville JC,al.Colebourn
and CL. Critical Care Research and Practice. doi:10.1155/2012/513480
(Dmax D min)
Feissel et al. used respiratory variation of thediameter of the , (2)
Dmin