Role of End-Tidal CO2 During Passive Leg Raising to Predict Fluid Responsiveness in ICU

Fluid management is the cornerstone of hemodynamic stabilization in ICU patients with circulatory failure. However, distinguishing between patients who will benefit from fluid (responders) and those who will not is vital to prevent the high mortality associated with inappropriate fluid administration.Static parameters (e.g., CVP, MAP) fail to reliably predict fluid responsiveness. Dynamic parameters are superior but have limitations, such as dependence on regular heart rhythm and specific ventilation settings. Consequently, interest has shifted toward non-invasive surrogates for cardiac output, such as End-Tidal CO2 (EtCO2), which tracks pulmonary blood flow changes under constant ventilation. This study investigates whether Delta EtCO2 during a PLR maneuver can accurately predict the response to a fluid challenge. The primary objective is to determine the diagnostic accuracy of Delta EtCO2 during PLR. Its predictive value will be validated against the hemodynamic response to a Mini Fluid Challenge (MFC), serving as the reference method. This prospective, single-center, observational cohort study includes adult patients in the ICU receiving mechanical ventilation who require fluid resuscitation.

Passive Leg Raising (PLR) Test: The patient starts in a semi-recumbent position (45°). They are then moved to a supine position with legs raised to 45° without manual handling to avoid sympathetic stimulation. This auto-transfuses blood from the lower body to the central circulation, increasing preload.

Mini Fluid Challenge (MFC): Following PLR, 100 mL of crystalloid fluid is infused intravenously over approximately 1 minute.

Definition of Fluid Responsiveness (Reference Standard): An increase in Left Ventricular Outflow Tract Velocity Time Integral (LVOT-VTI) of \>10% on echocardiography. If cardiac output/VTI cannot be assessed, responsiveness is defined as a Systolic Arterial Pressure increase of \> 4%, a Pulse Pressure variation decrease of \> 2%, or a Mean Arterial Pressure increase of \> 15%.

The sample size was calculated using G\*Power 3.1 software based on a pilot study of 6 patients. In the pilot study, Delta EtCO2 values were found to be 3.5±2.1 mmHg in the fluid responder group and 2.1±1.1 mmHg in the non-responder group. Based on these findings, with an effect size (Cohen's d) of 0.72, an alpha error level of 0.05, and a targeted power (1-beta) of 0.80, the required sample size was calculated. Accounting for a potential 10% attrition rate, the study is planned to be conducted with a total of 68 patients.

• Change in Arterial Blood Pressures (SAP, DAP, MAP) [Срок оценки: Measured between 60 to 90 seconds after the position change.]
• Change in Heart Rate (Delta HR) [Срок оценки: Measured between 60 to 90 seconds after the position change.]
• Change in Pulse Pressure Variation (Delta PPV) [Срок оценки: Measured between 60 to 90 seconds after the position change.]
• Change in Oxygen Saturation (Delta SO2) [Срок оценки: Measured between 60 to 90 seconds after the position change.]
• Change in Vena Cava Inferior (VCI) Distensibility Index [Срок оценки: Measured between 60 to 90 seconds after the position change.]
• Change in Left Ventricular Outflow Tract Velocity Time Integral (LVOT-VTI) [Срок оценки: Immediately following the 1-minute Mini Fluid Challenge.]