ICU Cases · Resuscitation
Hot case — the bedside: is this patient fluid-responsive?
A CICM hot case — a bedside encounter testing the fluid-responsiveness assessment: the bedside physical signs, the pulse-pressure variation (ventilated), the passive leg raise with a flow measure, and the principle of giving fluid only to the responsive patient.
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Prompt
At the bedside of a ventilated patient in septic shock, two hours into resuscitation, who remains hypotensive on noradrenaline with a borderline lactate. Assess whether he will respond to further fluid and manage the next step.
Presentation
You are taken to the bedside of a 58-year-old man who is two hours into the resuscitation of a septic shock from a pneumonia. He is intubated and ventilated (adapted, in sinus rhythm, tidal volume 8 mL/kg), on noradrenaline at 0.3 micrograms/kg/min for a mean arterial pressure of 66, and the lactate has fallen from 4.2 to 2.6 but is not yet normal. He has received 2 L of balanced crystalloid. The team asks: should we give more fluid?
[2]References5ShowHide
- [1]Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest, 2008.PMID 18628220
- [2]Michard F, Boussat S, Chemla D, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. American Journal of Respiratory and Critical Care Medicine, 2000.PMID 10903232
- [3]Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Critical Care Medicine, 2006.PMID 16540963
- [4]Meco M, Giustiniano E, Nisi F, et al. Predicting Fluid Responsiveness in Mechanically Ventilated Adults: An Umbrella Review of Diagnostic Accuracy Meta-Analyses. Anesth Analg, 2026.PMID 42461688
- [5]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.