Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification

Jon-Émile S Kenny; Ross Prager; Philippe Rola; Korbin Haycock; John Basmaji; Glenn Hernández

doi:10.1097/CCE.0000000000001022

Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification

Crit Care Explor. 2023 Dec 12;5(12):e1022. doi: 10.1097/CCE.0000000000001022. eCollection 2023 Dec.

Authors

Jon-Émile S Kenny^{1

2}, Ross Prager³, Philippe Rola⁴, Korbin Haycock⁵, John Basmaji³, Glenn Hernández⁶

Affiliations

¹ Emerging Areas of Clinical Research, Health Sciences North Research Institute, Sudbury, ON, Canada.
² Flosonics Medical, Toronto, ON, Canada.
³ Division of Critical Care Medicine, Western University, London, ON, Canada.
⁴ Division of Intensive Care, Santa Cabrini Hospital, Montreal, QC, Canada.
⁵ Department of Emergency Medicine, Riverside University Health System Medical Center, Moreno Valley, CA.
⁶ Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

Abstract

Point of care ultrasound (POCUS) is a first-line tool to assess hemodynamically unstable patients, however, there is confusion surrounding intertwined concepts such as: "flow," "congestion," "fluid responsiveness (FR)," and "fluid tolerance." We argue that the Frank-Starling relationship is clarifying because it describes the interplay between "congestion" and "flow" on the x-axis and y-axis, respectively. Nevertheless, a single, simultaneous assessment of congestion and flow via POCUS remains a static approach. To expand this, we propose a two-step process. The first step is to place the patient on an ultrasonographic Diamond-Forrester plot. The second step is a dynamic assessment for FR (e.g., passive leg raise), which individualizes therapy across the arc of critical illness.