open access

Vol 50, No 2 (2018)
Review articles
Published online: 2017-11-28
Submitted: 2017-10-14
Accepted: 2017-11-13
Get Citation

Assessment of hypovolaemia in the critically ill

Jan Van der Mullen, Robert Wise, Griet Vermeulen, Pieter-Jan Moonen, Manu L.N.G. Malbrain
DOI: 10.5603/AIT.a2017.0077
Pubmed: 29182211
Anaesthesiol Intensive Ther 2018;50(2):141-149.

open access

Vol 50, No 2 (2018)
Review articles
Published online: 2017-11-28
Submitted: 2017-10-14
Accepted: 2017-11-13


Assessment of the intravascular volume status of patients is one of the most challenging tasks for the intensive care clinician. It is also one of the most important skills in intensive care management as both hypervolaemia and hypovolaemia lead to increased morbidity and mortality. The assessment of hypovolaemic patients is aided by several clinical signs, laboratory investigations, and a multitude of haemodynamic monitoring systems. This review aims to outline the definitions, pathophysiology, and various assessment techniques (both old and new) employed by intensivists on the critically ill patient.


Assessment of the intravascular volume status of patients is one of the most challenging tasks for the intensive care clinician. It is also one of the most important skills in intensive care management as both hypervolaemia and hypovolaemia lead to increased morbidity and mortality. The assessment of hypovolaemic patients is aided by several clinical signs, laboratory investigations, and a multitude of haemodynamic monitoring systems. This review aims to outline the definitions, pathophysiology, and various assessment techniques (both old and new) employed by intensivists on the critically ill patient.

Get Citation


fluids, therapy, resuscitation, hypovolaemia, monitoring, biomarkers, preload, hydration, underfilling, fluid responsiveness, passive leg raising

About this article

Assessment of hypovolaemia in the critically ill


Anaesthesiology Intensive Therapy


Vol 50, No 2 (2018)



Published online






Bibliographic record

Anaesthesiol Intensive Ther 2018;50(2):141-149.


fluid responsiveness
passive leg raising


Jan Van der Mullen
Robert Wise
Griet Vermeulen
Pieter-Jan Moonen
Manu L.N.G. Malbrain

References (74)
  1. Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006; 97(6): 755–757.
  2. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A rational approach to perioperative fluid management. Anesthesiology. 2008; 109(4): 723–740.
  3. Malbrain ML, Huygh J, Dabrowski W, et al. The use of bio-electrical impedance analysis (BIA) to guide fluid management, resuscitation and deresuscitation in critically ill patients: a bench-to-bedside review. Anaesthesiol Intensive Ther. 2014; 46(5): 381–391.
  4. Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery. 1962; 51(2): 224–232.
  5. Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best Pract Res Clin Anaesthesiol. 2014; 28(3): 261–273.
  6. Jacob G, Robertson D, Mosqueda-Garcia R, et al. Hypovolemia in syncope and orthostatic intolerance role of the renin-angiotensin system. Am J Med. 1997; 103(2): 128–133.
  7. Duchesne JC, Kaplan LJ, Balogh ZJ, et al. Role of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: adjuncts to damage control resuscitation to prevent intra-abdominal hypertension. Anaesthesiol Intensive Ther. 2015; 47(2): 143–155.
  8. Malbrain ML, Marik PE, Witters I, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014; 46(5): 361–380.
  9. Pruvost I, Dubos F, Chazard E, et al. The value of body weight measurement to assess dehydration in children. PLoS One. 2013; 8(1): e55063.
  10. Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011; 1(1): 1.
  11. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013; 369(18): 1726–1734.
  12. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016; 20: 100.
  13. Arai S, Stotts N, Puntillo K. Thirst in critically ill patients: from physiology to sensation. Am J Crit Care. 2013; 22(4): 328–335.
  14. Saugel B, Ringmaier S, Holzapfel K, et al. Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial. J Crit Care. 2011; 26(4): 402–410.
  15. Padhi S, Bullock I, Li L, et al. National Institute for Health and Care Excellence (NICE) Guideline Development Group. Intravenous fluid therapy for adults in hospital: summary of NICE guidance. BMJ. 2013; 347: f7073.
  16. Van Beaumont W. Evaluation of hemoconcentration from hematocrit measurements. J Appl Physiol. 1972; 32(5): 712–713.
  17. Liamis G, Filippatos TD, Elisaf MS. Correction of hypovolemia with crystalloid fluids: Individualizing infusion therapy. Postgrad Med. 2015; 127(4): 405–412.
  18. Baron S, Courbebaisse M, Lepicard EM, et al. Assessment of hydration status in a large population. Br J Nutr. 2015; 113(1): 147–158.
  19. Armstrong LE. Assessing hydration status: the elusive gold standard. J Am Coll Nutr. 2007; 26(5 Suppl): 575S–584S.
  20. Perrier E, Rondeau P, Poupin M, et al. Relation between urinary hydration biomarkers and total fluid intake in healthy adults. Eur J Clin Nutr. 2013; 67(9): 939–943.
  21. Morissette MP. Colloid osmotic pressure: its measurement and clinical value. Can Med Assoc J. 1977; 116(8): 897–900.
  22. Gattinoni L, Carlesso E. Supporting hemodynamics: what should we target? What treatments should we use? Crit Care. 2013; 17 Suppl 1: S4.
  23. Kalantari K, Chang JN, Ronco C, et al. Assessment of intravascular volume status and volume responsiveness in critically ill patients. Kidney Int. 2013; 83(6): 1017–1028.
  24. Lichtenstein D, van Hooland S, Elbers P, et al. Ten good reasons to practice ultrasound in critical care. Anaesthesiol Intensive Ther. 2014; 46(5): 323–335.
  25. Vincent JL, Rhodes A, Perel A, et al. Clinical review: Update on hemodynamic monitoring--a consensus of 16. Crit Care. 2011; 15(4): 229.
  26. Stawicki SPA, Adkins EJ, Eiferman DS, et al. Prospective evaluation of intravascular volume status in critically ill patients: does inferior vena cava collapsibility correlate with central venous pressure? J Trauma Acute Care Surg. 2014; 76(4): 956–63; discussion 963.
  27. Moore CL. Does Ultrasound Improve Clinical Outcomes? Prove It. Crit Care Med. 2015; 43(12): 2682–2683.
  28. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011; 364(8): 749–757.
  29. Kelly N, Esteve R, Papadimos TJ, et al. Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations. Eur J Trauma Emerg Surg. 2015; 41(5): 469–480.
  30. Kent A, Bahner DP, Boulger CT, et al. Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index. J Surg Res. 2013; 184(1): 561–566.
  31. Stawicki SP, Braslow BM, Panebianco NL, et al. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J Am Coll Surg. 2009; 209(1): 55–61.
  32. Pasquero P, Albani S, Sitia E, et al. Inferior vena cava diameters and collapsibility index reveal early volume depletion in a blood donor model. Crit Ultrasound J. 2015; 7(1): 17.
  33. Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care. 2016; 6(1): 111.
  34. Monnet X, Marik P, Teboul JL. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med. 2016; 42(12): 1935–1947.
  35. Monnet X, Teboul JL. Passive leg raising: five rules, not a drop of fluid! Crit Care. 2015; 19: 18.
  36. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002; 121(6): 2000–2008.
  37. Poelaert JI, Schüpfer G. Hemodynamic monitoring utilizing transesophageal echocardiography: the relationships among pressure, flow, and function. Chest. 2005; 127(1): 379–390.
  38. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth. 2005; 19(2): 155–159.
  39. Melamed R, Sprenkle MD, Ulstad VK, et al. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009; 135(6): 1416–1420.
  40. Stec S, Zaborska B, Sikora-Frac M, et al. First experience with microprobe transoesophageal echocardiography in non-sedated adults undergoing atrial fibrillation ablation: feasibility study and comparison with intracardiac echocardiography. Europace. 2011; 13(1): 51–56.
  41. Vieillard-Baron A, Slama M, Mayo P, et al. A pilot study on safety and clinical utility of a single-use 72-hour indwelling transesophageal echocardiography probe. Intensive Care Med. 2013; 39(4): 629–635.
  42. Toole BJ, Slesnick TC, Kreeger J, et al. The Miniaturized Multiplane Micro-Transesophageal Echocardiographic Probe: A Comparative Evaluation of Its Accuracy and Image Quality. J Am Soc Echocardiogr. 2015; 28(7): 802–807.
  43. Vermeiren GLJ, Malbrain ML, Walpot JM. Cardiac Ultrasonography in the critical care setting: a practical approach to asses cardiac function and preload for the "non-cardiologist". Anaesthesiol Intensive Ther. 2015; 47 Spec No: s89–104.
  44. DiCorte CJ, Latham P, Greilich PE, et al. Esophageal Doppler monitor determinations of cardiac output and preload during cardiac operations. Ann Thorac Surg. 2000; 69(6): 1782–1786.
  45. Lichtenberger M, DeBehnke D, Crowe DT, et al. Comparison of esophageal Doppler monitor generated minute distance and cardiac output in a porcine model of ventricular fibrillation. Resuscitation. 1999; 41(3): 269–276.
  46. Stawicki PS, Braslow B, Gracias VH. Exploring measurement biases associated with esophageal Doppler monitoring in critically ill patients in intensive care unit. Ann Thorac Med. 2007; 2(4): 148–153.
  47. Kyle UG, Bosaeus I, De Lorenzo AD, et al. ESPEN. Bioelectrical impedance analysis-part II: utilization in clinical practice. Clin Nutr. 2004; 23(6): 1430–1453.
  48. Laher AE, Watermeyer MJ, Buchanan SK, et al. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. Am J Emerg Med. 2017; 35(9): 1335–1347.
  49. Kupersztych-Hagege E, Teboul JL, Artigas A, et al. Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients. Br J Anaesth. 2013; 111(6): 961–966.
  50. Samoni S, Vigo V, Reséndiz LI, et al. Impact of hyperhydration on the mortality risk in critically ill patients admitted in intensive care units: comparison between bioelectrical impedance vector analysis and cumulative fluid balance recording. Crit Care. 2016; 20: 95.
  51. Armstrong LE, Ganio MS, Klau JF, et al. Hydration assessment techniques. Nutr Rev. 2005; 63(6 Pt 2): S40–S54.
  52. de Tombe PP, ter Keurs HE. Cardiac muscle mechanics: Sarcomere length matters. J Mol Cell Cardiol. 2016; 91: 148–150.
  53. Hofkens PJ, Verrijcken A, Merveille K, et al. Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review. Anaesthesiol Intensive Ther. 2015; 47(2): 89–116.
  54. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013; 41(7): 1774–1781.
  55. Marik PE, Baram M. Noninvasive hemodynamic monitoring in the intensive care unit. Crit Care Clin. 2007; 23(3): 383–400.
  56. Malbrain ML, De Waele JJ, De Keulenaer BL. What every ICU clinician needs to know about the cardiovascular effects caused by abdominal hypertension. Anaesthesiol Intensive Ther. 2015; 47(4): 388–399.
  57. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007; 35(1): 64–68.
  58. Shah MR, Hasselblad V, Stevenson LW, et al. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. 2005; 294(13): 1664–1670.
  59. De Backer D, Fagnoul D, Herpain A. The role of invasive techniques in cardiopulmonary evaluation. Curr Opin Crit Care. 2013; 19(3): 228–233.
  60. Reuter DA, Huang C, Edrich T, et al. Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg. 2010; 110(3): 799–811.
  61. Sakka SG, Rühl CC, Pfeiffer UJ, et al. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med. 2000; 26(2): 180–187.
  62. Marx G, Schuerholz T, Sümpelmann R, et al. Comparison of cardiac output measurements by arterial trans-cardiopulmonary and pulmonary arterial thermodilution with direct Fick in septic shock. Eur J Anaesthesiol. 2005; 22(2): 129–134.
  63. Morélot-Panzini C, Lefort Y, Derenne JP, et al. Simplified method to measure respiratory-related changes in arterial pulse pressure in patients receiving mechanical ventilation. Chest. 2003; 124(2): 665–670.
  64. Jardin F, Farcot JC, Gueret P, et al. Cyclic changes in arterial pulse during respiratory support. Circulation. 1983; 68(2): 266–274.
  65. Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009; 37(9): 2642–2647.
  66. Maizel J, Airapetian N, Lorne E, et al. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med. 2007; 33(7): 1133–1138.
  67. Poelaert J. Assessment of loading conditions with cardiac ultrasound. A comprehensive review. Anaesthesiol Intensive Ther. 2015; 47(5): 464–470.
  68. Monnet X, Osman D, Ridel C, et al. Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients. Crit Care Med. 2009; 37(3): 951–956.
  69. Kara A, Akin S, Ince C. Monitoring microcirculation in critical illness. Curr Opin Crit Care. 2016; 22(5): 444–452.
  70. Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005; 9 Suppl 4: S13–S19.
  71. Gruartmoner G, Mesquida J, Ince C. Fluid therapy and the hypovolemic microcirculation. Curr Opin Crit Care. 2015; 21(4): 276–284.
  72. De Backer D, Orbegozo Cortes D, Donadello K, et al. Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence. 2014; 5(1): 73–79.
  73. Ince C. Hemodynamic coherence and the rationale for monitoring the microcirculation. Crit Care. 2015; 19 Suppl 3: S8.
  74. Hofer CK, Cannesson M. Monitoring fluid responsiveness. Acta Anaesthesiol Taiwan. 2011; 49(2): 59–65.

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

VM Media sp. z o.o. VM Group sp.k., Grupa Via Medica, Świętokrzyska 73 St., 80–180 Gdańsk

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail: