Fluid responsiveness in spontaneously breathing patients: A review of indexes used in intensive care

Objective: In spontaneously breathing patients, indexes predicting hemodynamic response to volume expansion are very much needed. The present review discusses the clinical utility and accuracy of indexes tested as bedside indicators of preload reserve and fluid responsiveness in hypotensive, spontaneously breathing patients. Data Source: We conducted a literature search of the MEDLINE database and the trial register of the Cochrane Group. Study Selection: Identification of reports investigating, prospectively, indexes of fluid responsiveness in spontaneously breathing critically ill patients. All the studies defined the response to fluid therapy after measuring cardiac output and stroke volume using the thermodilution technique. We did not score the methodological quality of the included studies before the data analysis. Data Extraction: A total of eight prospective clinical studies in critically ill patients were included. Only one publication evaluated cardiac output changes induced by fluid replacement in a selected population of spontaneously breathing critically ill patients. Data Synthesis: Based on this review, we can only conclude that static indexes are valuable tools to confirm that the fluid volume infused reaches the cardiac chambers, and therefore these indexes inform about changes in cardiac preload. However, respiratory variation in right atrial pressure, which represents a dynamic measurement, seems to identify hypotension related to a decrease in preload and to distinguish between responders and nonresponders to a fluid challenge. Conclusions: Further studies should address the question of the role of static indexes in predicting cardiac output improvement following fluid infusion in spontaneously breathing patients.